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OFFICE MANAGEMENT – 5/13/09
*** Grading: Midterm project and final exam ***
5/15/09
Business Costs
Fixed: Costs don‘t change from month to month (rent, salaries, etc.)
Floating: Costs change monthly (toilet paper, computer paper, ink cartridges, etc.)
Examples of Business Costs:
Rent, Utilities, Leasing Equipment, Electronic Billing, Malpractice, Postage, Promotion and Marketing, Office Supplies, Web Site, Telephone, Yellow Page Adds, X-Ray supplies, Miscellaneous, Taxes, Unemployment Taxes, Staff, CPA-Accountant, Food, Credit Cards, Insurance, Clothing, Gas, Entertainment, Miscellaneous, Student Loans Repayment
Taxable Income – Earned Income
Most chiropractors owe money to the federal government (IRS). Get disciplined about taxes. Deductions are rent, utilities, equipment leases (all of these are 100% deductible for taxes). Deductions mean that you don’t pay taxes on the income. Business expenses to start your practice are deductible.
Deductible/Deductions
Mortgage Interest (interest is stacked up front early, and later in the mortgage more money goes to principle and less to interest), Contributions to charity, Interest may be deducted from student loans (not principle, up to a maximum of 2500 per year),
Example: 100,000 (your income earned per year)...After expenses are paid = 50-60,000 (after overhead is paid, taxable income)…Interest Deductions on loan (12,000)…Child Care Deductions (?)…1200 (?),
100,000 (income earned) - 40,000 (operating expenses) = 60,000 (total income after expenses paid)
60,000 (total income after expenses are paid) – 12,000 (interest on student loans) -1200 (child care deductions or other deductions) = 30,000 (Taxable Income)
Self employed tax & FICA (sole proprietors have to take 15% of the first 88,000 of taxable income). FICA is for social security, Medicare, etc. You’ll pay 15%, so roughly 7,000 yearly.
Federal Income Tax is based on percentage. On 30,000 the tax is 10-15%. You will have to pay quarterly. 15% of 30,000 is roughly 4,000 quarterly. This is 16,000 yearly.
State income Tax: 700-800 per month depending on the state.
Bottom line is how to know much are we spending and how do we spend less than we want. The responsibility is to pay the lowest amount of taxes that we can. That forces the government to be frugal. Pay as minimal amount of tax as possible to force the government to use restraint.
National Health Care
Unfortunately, the paradigm may include medical referral for chiropractic care
Extra Tax Tidbits
Personal Property Tax: Taxes on motorized vehicles or trailers (bigger cars and vehicles more tax)…Farm Animals may also be taxed.
Business Property Tax:
Real Estate Tax: Tax that the county you live in imposes. The tax goes to fire, police, sewers, waste management). The tax is based on appraised value of your home. Every 2 years they do an appraisal. The tax is added on to your mortgage payments. The more upper class the area, the higher the area tax rate. The more lower class the area the lower the tax, usually.
Un-employment tax: Paid for employees and for you.
Typically, Around 62% of the income you bring home at the end of the year is taxable.
If you take home 100,000 you’ll spend 37% on fed, 15% on self employment taxes, state income taxes 7-8%.
5/18/09
Key Questions to Ask
#1. Are you financially able to run an office of your own?
#2. Are you mentally ready to run/open an office of your own?
Chiropractic Profiles
We all fit into a category within chiropractic. Some are liberal and some are conservative. There are 2 major thinking processes that describes who you are. Most chiropractors fit into 2 camps, with just a little overlap.
Some tend to be conservative (hands on, traditional, subluxation based). The other group is a newer model of chiropractic (therapies, exercise, etc.). There is a particular construct, philosophy that draws us to what we think. Most people are prominent voters on 1 issue. That is how patients are. They have 1 major issue that draws them to chiropractic care or medical care. Patients come to your office because of something that you do, a practice style, fee structure, or something else, but it occurs because of 1 specific reason.
The most dangerous place to be is the middle of the road. Either be mechanistic or innate, because those practices do well. Moving to the extremes is better because it will attract patients of similar mindset, whereas
Mechanistic Model of Chiropractic Care
Diagnosis dictates treatment.
Stresses evidence based, outcomes assessment and clinical studies.
Full body diagnosis is indicated.
Present objective findings to determine future care.
It requires contemporary philosophy, which requires clinical diagnostic abilities and treatment protocols.
Condition based care is at the core of this model.
Maintenance and preventative care is determined on the basis of the patient’s condition as it relates to the condition. Asymptomatic conditions are not significant.
Wellness is typical clinical goal, rather than a treatment phase or desired outcome.
Innate Based Model of Chiropractic Care (Subluxation Based)
Vitalistic, holistic concept of functional neurology and anatomy.
There is an inherent ability to be stable within themselves and environment.
The nervous system controls and coordinates activities.
It is associated that interference with the nervous system’s ability causes perceptional dis-relationship between nervous system and cells.
Basic sciences are important to understand limitation of matter and to understand the abilities of innate intelligence. Traditional philosophy and subluxation based model ensues.
Maintenance and preventative care are emphasized.
Condition based care is a significant makeup, but wellness care is the direction care is headed to.
A top priority is to identify what it is to be healthy and live that lifestyle.
Our professions future will depend on what model we will choose.
16 Reasons What Causes New Practices to Fail
Dr. Hillgartner’s Def: A new practitioner is less than 5-7 years.
1. Choosing to operate an all cash practice = In 4-5 years from now, your skills, your communication skills, diagnostic skills, etc. will improve. You’ll improve while getting on the job training (practice). All cash practices are pay at the time of service. Cash can be money, check, or credit card. Patients with insurance have co-pays and deductibles. You bill the insurance company and await payment. You will lose part of your practice if you went all cash.
Patients feel that someone else should pay for their health care costs. This is a cultural thing. Patients feel that someone else should pay for their health care premiums (employers, mom, dad and/or the government). Patients have grown up in culture, where they shouldn’t have to pay for their health care and they shouldn’t pay for their benefits. The predicament is that some people want their patients to pay cash, while they don’t want to pay cash for their own service. Patients want 1 visit, at no charge, with their problem fixed yesterday.
You increase the probability of your patients staying with you, if you charge insurance. A good place to be is to pick and choose which insurances you want to be in. People prefer to use insurance rather than cash. If your reputation is good enough, you may be able to do it one day, but not when you start. Make your recommendations of care based on needed treatment and not money.
Health insurance premiums have gone up in the past couple of years. Benefits have gone down in the past couple years. Deductibles have gone up, co-pays have gone up, and reimbursement has gone down. The out of network providers may not have the amount applied to the deductible. The patient would rather use the co-pay for an in network provider to have the amount applied to the deductible.
Chiropractic practices are procedurally based and personality driven.
2. Not performing an effective consultation, chiropractic exam, and ROF before you accept the patient and begin treatment = It is vital that this chemistry occurs for an ongoing relationship to be formed and for patient compliance. Without this chemistry, this is not going anywhere. Never accept a patient to be treated as a patient until you have accepted them as a patient. Don’t offer to solve their problems, till you give them a solution. The solution is based on the power of choice.
Considerations
#1 = You need a chemistry with the patient
#2 = You should not give chiropractic care to a patient unless there is context to it. …Patients should understand that they are part of a plan to help them. Compliance is mandatory to the outcome.
5/20/09
Charges
A cost for a service (ex. $45). What you get reimbursed is different than the cost of a service. You charge the insurance $45, but the insurance “allowed charge” may be less ($36). There are charges, write offs, and “real charges” for the day.
Discount
Payment at the time of Service (cash only….PATS) = Offer the same thing to cash patients and insurance companies, discount at the time of service... If you offer it to the insurance companies, have them electronically deposit the funds in your account the same night. Insurance companies aren’t set up to do that, but you have to offer if you do that for insurance companies
3. Lack of implementation of proven office procedures and policies = You want standardizes office procedures and policies so that when you are not in the office, everything flows
4. Inability to effectively communicate chiropractic to people = Start with the structural problem and venture out. Use the 5 component model (kinesiopathology, neuropathology, biochemical, histopathology and myopathology) and break it down to the patients. Effective communication is your ability to get the patient to “get it.” You may constantly need to remold them to your idea, because patients are allopathically oriented.
5. Going into practice, under financed
6. Purchasing the newest, most expensive, most technically advanced equipment (too much initial investment debt) = This is not consumer debt, but investment debt. Sales people will say that it is only 1 extra patient per week and it will pay for itself. Don’t buy into it.
a. Example: Decompression tables can run over 100,000. Sales people will use data to try to sell the table, stating it will generate revenue for you. Consider the hidden costs of the table: marketing the table, paying for the table, expensive packages (may be tough to afford), table upkeep. In the long run, it may not be worth it.
7. Partnering with a best friend
a. This relationship hardly works
b. There can be only 1 leader
c. It destroys practices and friendships
d. Usually done for security
e. Usually both people are on the lease and both people are responsible for the full amount…A big problem is that typically 1 doctor does well and the other doesn’t. When rent comes or expenses are paid, there can be hard feelings.
8. Choosing the wrong office site
a. Second floor office without elevator
b. Rent is too much or too little
c. Office is in the rear of the building
d. Competition from other DC’s or other health care providers
e. Dead town
9. Practicing Part-Time
a. Waiting for growth, will lead to no growth
b. You have to be aggressive and work full time
c. There is no self validation
d. Your competition will beat you out. They have a full time mentality and office hours convenient to see patients.
10. Join every HMO and PPO that would accept them (Do the research)
a. You can drop out any time you want to
b. When you get to your area, PPO’s are geographical. Research by talking to other chiros in your area. Each area of your county and city is different with regards to you reimbursement, so do your research.
Process for PPO’s
1. Get Credentialed (yearly)
2. Answer the questions are medically oriented as possible
3. Look at the upfront costs and yearly fees
4. What are the kickbacks? (example: 10% of your fees)
5. Reduction of Fees and Charges, Down coding, etc. (UHC will down code)
6. Treatment Plan Restriction: UHC gives 6-8 visits normally
7. Profit and Loss Margin: Write offs can be 20-25% for Blue cross Blue Shield
8. Coordination of Benefits: Insurance companies are trying to negotiate state statues to fix prices and discount services under
11. Lacking effective new patient acquisition procedures/programs (relates to #4)
a. Your first couple years you need to do a lot of marketing.
b. Often the marketing is for long term growth…Patients may need to see the ad or speak to you many times over the years to become a patient. It can take money to grow your business, because of the competition factor
12. Making no serious effort to personally meet/know the people in their community
13. Untrained Staff/No Staff/Over Staffed
a. Do you have too many people that work there?
b. When is the time to hire a CA? When can you afford to hire a CA? If you don’t have someone there to start, get them there part time to start with.
c. A one man or one woman show is not necessarily a good thing. Patients may think that you can’t afford a CA, because you don’t have patients. They don’t like this
14. Providing routine services that have no chance of being reimbursed by the insurance plan or the patient.
a. You have to write off the balance of services for services that aren’t reimbursed well
b. You may to restrict paying someone to use the modalities (a tech)
15. Purchasing personal high ticket items (expensive cars, new homes, toys, trips, etc) before the practice income could comfortably support it.
16. No ongoing practice management, consulting or coaching after graduation and opening practice.
a. this should be considered a top priority
b. You need to get people in the door before we can deliver the goods
c. You need to learn the tools that will help you grow
Deduction for student loans- a deduction is allowed for interest paid on certain student loans. Individual taxpayers who are legally obligated to make interest payments under the terms of a qualified education loan may deduct a portion of the interest paid as an above-the-line deduction. The maximum amount allowed as an interest deduction is $2,500.
5/27/09
Practice Advice
Right now, we have a model of clinical competency. The more competent you are clinically, the more you will succeed. This is not the actual case in practice. Practice is procedurally based and personality driven. The question is how to implement this in your practice?
12 Things to Read in Text – “12 Keys to Read for Chiropractic Greatness”
1. Manage your time
2. Have Goals
3. Fall in love with chiropractic
4. Become a chiropractic specialist
5. Have an advisor or mentor (coach, consulting group, etc.)
6. Have a strong procedurally based practice
7. Improve management skills
8. Read
9. Save Money
10. Pay Yourself First
11. Defeat Your Debt
12. Invest in Your Clinic
15 Points to Ultimate Practice Management
1. Have courage to make decisions
2. Be Accountable for your actions
3. (He didn’t finish reading the list in class)
Management By Statistics
Many consulting firms teach this. Look over your stats weekly. Go over the stats to plan your next month, next quarter and next calendar year.
Procedures
Start with consultation, step by step procedures, chiropractic exam and final reports. If you master these areas you will build a practice. There is a science and an art to doing a great chiropractic exam, consultation and report of findings.
5/29/09
Types of Care
1. Maintenance/Preventative: These patients routinely will come back when they need to or based on your suggestion. You can “retard” the progression of that condition.
2. Condition Care
3. Wellness Care: “There is no wellness care”….Wellness is the intent and not the treatment. Structure of the body, spinal column, affects the nervous system. There can be imperceptible problems with innate responses. Wellness care takes very effective communication. The average new graduate doesn’t own the concept of wellness to talk about it.
James Chestnut
*** Writes good information about physiology, chiropractic and adjustments ***
What works and doesn’t work is highly dependent on personality. We will start as condition based in our careers, with the goal getting towards wellness care.
Flow Chart
Relief Care --- Stabilization/Correction Care ---- Maintenance/Preventative Care
6/1/09
A patient will show up in your office for a condition. You goal is to help them and transition the patient to wellness based care.
Category 1
???
Category 2
Insurance
Category 3
Cash
Category 4
Insurance-Medicare (in particular) and certain PPO’s and HMO’s…Each state is different. Reimbursement is based on state and location.
Medicare (can be cash or insurance). It may be wise to be a non-par provider so you can bill the patient directly and get paid on the spot. You can submit the claim for the patient so they can get reimbursed from the federal government. MACC (max allowable chiropractic claim)…The government will tell you the max you can charge. You can still charge for other services to your patient, but not bill Medicare for that. Geographics (location) will determine what you get paid by Medicare.
Medicare covers nothing but adjustment. Take a hard look if you want to participate or not. You still have to follow federal guidelines whether you participate or not participate. If you are a non-par provider, you can on a case by case basis choose to participate.
2 VISIT PROCEDURES
You can do back to back days or 2 visits in 1 day. You need to have a report of findings meeting to give options to the patient. You and patient must have a meeting to go over what will occur and establish a relationship.
FIRST VISIT
1. Patient is greeted: Have the CA take the upper hand to meet and greet the patient. Patients like to be greeted when first walking into the office. Don’t have them do the paperwork at the front counter.
2. Patient gets paperwork: Paperwork is done sitting down in the waiting room, not at the front counter. Have the patient come in 15 minutes early in regular cases and 30 minutes early in a personal injury/auto/worker’s compensation case.
3. Patient goes to consult room or exam room
4. Doctor greets patient
5. New patient watches video
6. Dr. gives physical exam
7. Dr. takes X-rays
8. Dr. dismisses patient/or treats patient in an emergency
9. Collect Fees
10. CA makes next appointment
Patient Into Letter – Dr. Hilgarnter’s Form
Welcome to our office. We realize that his is your first visit to our office, and our past experiences have shown us that new patients have many unanswered questions on their minds. Our staff will attempt to do everything possible to make you feel at ease, and to answer any questions that you may have.
To insure your first visit with use is a pleasant one, here are the procedures you can expect during this visit.
1. Consultation
2. Video: To acquaint you with our office and explain how we help our patients regain their health, most patients see a short 8 minute video
3. Examination: Standard physical, orthopedics, neurological, and chiropractic tests will be performed to determine the causes of the problem.
4. X-rays
5. Future Visits
Business Arrangement Policy – Dr. Hilgartner’s Form
We are committed to providing you with the best possible care. If you have health insurance, w are anxious to help you receive your maximum allowable benefits. IN order to achieve these goals, we need your assistance and your understanding of our payment policy.
Many times the expenses incurred by an individual for health care are paid by insurance companies. Recognizing this, it is our policy to accept assignment for health care rendered to our patients under the following circumstances
1. Personal or Group Health Insurance (partial credit): It is the office policy to ask you to pay the portion of the bill that your insurance company does not pay.
2. Auto Accident/Insurance Coverage: partial to complete credit with chiropractic insurance coverage
3. Work Injury/Compensation Coverage: With employer authorization partial to complete credit
We must emphasize that as health care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a service that we perform for our patient all charges are your responsibility from the date the services are rendered.
If there is no health insurance coverage which reimburses you for our services, arrangements will be made with you that will allow you to receive the needed care and take care of expenses on a daily, weekly, or monthly basis.
We hope this serves as an introduction that explains and answers some of your questions. We sincerely believe that the best doctor/patient relationship exists when there is complete understanding of treatment and financial???
Consultation and ROF
Consultation and ROF are the 2 most important meetings with the patient. It sets the stage for the relationship to be formed and care to proceed. There is another reason to do consultation other than getting patient information on LOPPQRST.
Pre-consultation
Have the CA do this in a sit down area. It is preferred to do in an office and not in a treatment setting. The purpose of the pre-consultation:
1. Categorize the Patient Correctly: Insurance, Cash, etc.
2. Explain how the category works in the office: When you bill the patient, what forms will be received, co-pay amounts and deductibles.
It takes about 30-45 seconds to do the pre-consultation. Often the CA hands the patient the filled out form with insurance coverage amount, person talked to at the insurance company (their name) and goes over the insurance process. On the bottom of the form there is a note that states we have verified your benefits for you; however we advise you to contact your insurance company to make sure this information is correct.
The CA leaves the room and sets the file for you to go over before the doctor enters the room. The folder has their filled out information, pain drawings, outcomes assessments, etc. so you get a clinical picture before you walk in the room and can easily link your diagnosis to a CPT code.
Rapport
You must build a relationship with the patient. This is done with your consultation and ROF. You want your patient after the consultation and before the exam to say “good guy” or “good gal” or “I like my doctor.” This says nothing about your clinical skills and speaks about personality. One of the best things to help build rapport is to become a good listener.
A good trick is to set your file down and look at them and just listen to the patient. Don’t interrupt the patient, let them talk. When you want them to stop, pick up your pen and summarize what you said to them. The summary becomes what you will write down in your notes.
For some people, you can represent that you are the first physician that actually listened to them. Listen intently by not writing and just listening. Make the patient understand that you are listening by repeating the content back to them. This will help develop chemistry.
Patient Encounter Tidbits
When you meet a new person, get close to them and shake their hands. Get in their 3 foot space and get it to overlap.
1. Get in their 3 foot space
2. Touch them
3. Eye to Eye contact and use the patient’s name (make sure to pronounce it correctly and spell it correctly)…Simple things like spelling a patient’s name correctly shows that you care
4. Mention the referral if there has been a referral.
6/3/09
Perceived Value
The patient’s perception of the importance of chiropractic is critical. When a patient perceives value, compliancy multiplies. The patient has to come to this conclusion and perceive that your care is important.
Functional Indexes
It is good to ask the patient about how their condition affects their work life and personal life. You do this for them to get the perceived value of what your care will do for them.
1. Work Life: How does this problem affect your abilities at work?
2. Personal Life: How does this problem affect your personal life (including recreational, social and family life)?
Address the perceived value in the consultation and report of findings. PERCEIVED VALUE OF WHAT IS IN IT FOR ME (the patient) IS IMPORTANT TO ADDRES. You need to be able to address quality of life and perceived value.
Confrontation Analysis – Confrontation Skills
Confrontation is important to build a practice. There is good confrontation and bad confrontation.
Bad Confrontation = Acknowledge that you heard what they said, “duck it” and move on. These situations may be patients that are control freaks.
In some cases, if you are insulted as a “quack” you’ve got 2 choices: 1). Attack Them (get drawn into the conversation) 2). Acknowledge It, Duck It and Move On.
Good Confrontation = You’ve got to able to hold people accountable so they can make agreements. When patients don’t hold to agreements, make them feel accountable. If it isn’t worth the patient’s time, why did you schedule them? If it happens several times, it is time to confront them. You want to be eye to eye with them. Say to the patient if you can’t keep to the treatment plan, we are going to have to change your plan or you are going to have to follow the plan. Wait for the response. Offer the patient a safe venue and opportunity to return if they follow your recommendation. State that you are under the umbrella of relief care, until the plan no longer works. When it no longer works, you need to change the plan or refer them somewhere else.
Opening Statement and Closing Statement
Closing: I want to go into another room and examine your spine (back, neck, etc.)
Patient Transition from Consultation to Exam
1). Have your CA do it 2). Watch the Video on Chiropractic Care.
6/5/09
Consult to Exam Room
Typically a good time to do a video is the transition period between consult and exam. Some chiropractic consultants see the video before consultation. Usually the video should be 7-8 minutes long. The video can save time later, by explaining chiropractic. We learn more from our eyes than by our ears. The video adds context to what you will do.
After the video, have the patient get into a gown and perform your exam. Do a chiropractic exam. Work on your chiropractic exam and analysis. Emphasize spinal analysis, motion palpation, and static palpation. Do a chiropractic exam, unique to your practice. You want to do an exam that other doctors don’t do.
Only 79% of the people in private practice use an X-ray according to Chiro Economics. The trend is not to X-ray patients now. X-ray can be used to give a good chiropractic exam.
1. A talking exam = So people know that you are clinically proficient. This is not a report of findings or a lecture, this is a short synopsis of what you found, when you found it.
2. Put a third party, high tech instrument on them during the exam (ex. Thermoscope, Surface EMG’s, X-ray, etc.)…This allows you to be more objective
6/8/09
You need to do something so unique in your office and with your exam so the patient feels chemistry. Develop an exam that is unique and personal, so that it has an impact. Make sure the exam is done in an examination room. In the room, have the equipment available to do the exam (grease pen, flat screen TV, X-ray view box, orthopedic and neurological tools, etc.). Sit the patient on the table and summarize after your exam.
Radiographic Exam
After your physical, orthopedic and chiropractic exam send to another room for X-rays.
After the Radiographic Exam
Say to the patient, “We are done with the exam; I’ll review all the tests and X-rays at the next visit. I’ll review all of your options at that time.” It is critical to say t o them, “If I feel that I can help you, I will accept you as a patient.”
Next Visit
The next visit can be later that day or within a couple of days. It is important to separate out the visits so that you can review their findings and determine if you can help them and whether you can accept them as a patient.
Common Reasons Doctors Adjust the Patient On the First Visit
1. Patient’s expect it
2. Start the healing
3. Validates Chiropractic
4. Shows you care
5. I’ve always done it
Downside to Adjusting on the First Visit
1. Unable to give adjustment context = What, how and why an adjustment is given is neglected, reducing the value and perceived difficulty
2. One visit miracle = Patient’s will say they want the “one crack” Again, lack of context is present.
3. Patient may feel worse = The patient can feel disappointed and leave care. You didn’t inform them, that they might feel more sore after the first visit, but this can be a normal process/procedure.
4. Nothing happens =
5. Salutes how they feel = It makes them appear you are only interested in symptoms and discontinue care once they feel better.
Ultimately the procedure you use should reflect the patient relationships you want.
If the patient is acute, you can treat them on the first day at the second visit. Give them the option of treating them later the first day towards the end of the day, or say that I’ll see you tomorrow. Give the patient the power of choice. Make them figure out what they want to do and choose
Components of the First Visit
1. History
2. Consult
3. Exam
4. Procedures after the first exam
You compliance will be measured by how many times you adjust the patient before the end of the 1st visit. The more you do it, often the worse the compliance.
SECOND VISIT
The key to a final report is preparation. Do not shoot from the hip, be prepared.
3 Things to do during the Final Report
1. Video: The video explains chiropractic and chiropractic procedures
2. Written Final Report: It is suggested to hand write the written final report to give it a personal touch.
3. Verbal/Oral Final Report: Explain the key points to get an understanding
Keys to Success During a Final Report
1. Be organized
2. Have all the tools in place (X-rays, spine, laminated charts, thermograph reports, video machine)
3. Use an environment conducive to a final report (ex. your office)
A good typical final report takes about 15 minutes and an 8 minute video (23 total minutes). Most doctors give too much time in a final report. 10-15 minutes is ideal to give the final report. The goal is to introduce them that day to your plan and treatment as well as teach them over the next several weeks.
The 10% of your patients that stay after 5 years will provide you 80% of their income.
Report of Findings
The report of findings addresses 2 major findings:
1). What the patient wants to know?:
a). What do I have?
b). What do I need to do about it?
c). Why is it important for me to do this?
d). What are my options?
Other questions are: What will it cost? How long?
2). What you want to accomplish?
Tape your final report and listen to it. This can help you give better final reports based on the feedback from the tape.
Consultants refer to the idea of “noise.” Noise is patient chatter. To limit the chatter, have the patient read the final report before you give it to them, orally.
Report of Findings
*** Document on Overhead ***
Important: No selling – just present (Selling will create pressure…Presenting leads to no pressure…Present the patient options, so at the end even if they don’t pick your option, you know where they stand)
Be prepared – allow sufficient time to prep
1. Patient Watched “Report Video – 8 minutes
a. CA instructions: Example…”There will be a test after this video…or…Pay special attention to the video and stages of degeneration.”
b. The CA turns off the video and hands the patient a written or typed final report with 4 questions. The doctor fills in by hand the answers to those questions.
2. Doctor Presentation
a. You have watched the video and have seen your X-rays & now, let me review your exam findings with you. I have put your findings in a folder for you, so you can take a copy with you. You will not have to remember everything we talk about today.
Let me review what we found on your exams. The doctor then explains what these findings mean, discusses the treatment recommendations with you and your options of care. I’ll answer any questions you have before we begin care.
3. X-rays & Discussion
4. List the structural problems; number them 1, 2, 3, etc.
5. Follow this format (or similar) to cover the important points
P ------- Problem Fixable No Fixable
C ------ Components
P ------- Phase (1-2-3) (Prevent Progression)
T ------- Treatment (How long – How much) – (STAB)
A ------- Alternatives (options) – Relief – Choice
Important: Patient Responsibility/Commitment
Vs.
Do not begin STAB (stabilization care) – relief only
Do not talk after you often them the choice, wait till you hear their response.
***Patient Form – On Screen ***
You are being accepted as chiropractic patient because your examinations reveal evidence of a structural spinal disorder. This is interfering with normal spinal and neurological functioning and appears to be the underlying cause of your problem. Chiropractic treatments are given to restore normal positioning and movement of your spine and correct the neurological and soft tissue involvement. Our past experience with similar patients with similar problems…
How you will respond to treatment depends primarily on your vitality. Of course your age, duration and severity of the condition and delay in seeking proper care and any past injuries accidents or surgeries will have their affect. We recommend that plans to be made to proceed with the average treatment plan required in conditions similar to ours. We will discuss your treatment plan and schedule with you, as well as your spinal care options. Naturally, all of the treatment you receive will be non-invasive, no drugs or surgery.
A. Acute Care???
B. Relief Care
(On the back of the form)
1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?
4. What are my options?
Problem A: Example L5 disc
Problem B: Example C7 nerve root
1. Components:
1. Abnormal Vertebral Alignment/Motion (Kinesiopathology)
2. Nerve Irritation (Neuropathophysiology)
3. Muscle Imbalance/Spasm/Tone (Myopathology)
4. Disc and Joint Decay(Ligaments Weak – Unstable (Histopathology)
5. Calcification Fusion (Pathophysiology)
Phase: Spinal and Joint Decay
Phase 1 Phase 2 Phase 3
2. What Do I Need to Do?
Treatment Goals: Pain Relief Stabilization/Rehab Stop the progression to Phase 2 or Phase 3
Corrective Care Treatment (Pain Relief, Stabilization and Rehab)
Spinal Adjustments/Manipulation
Manual Therapy (Trigger Point Therapy and Manual Traction)
Rehabilitation Therapy (Flex/Ext Traction, Decompression, Diathermy, Deep Heat)
Chiropractic Re-exam and Thermography Studies
_________ # Sessions/Treatments ________ # Weeks
3. Why is it Important for me to do this?
Blank section and you (the doctor) fill in this part of the form
4. What are my treatment options?
a. Relief Care Only
b. Test/Trial Period of Care
c. Pharmaceuticals/Drugs/Orthopedic/Neurological Consult
d. Maintenance Care Only – Condition Beyond Rehabilitation
6/10/09
*** Article: 100% Compliance ***
It is better to present a final report than sell a final report. Give them enough information to be an informed consumer and have them make the choice. They are more likely to be compliant.
Talking to Patients
Always tell patients what you think they need, document it, and let them make their choice.
“Compliance refers to following through with a prescribed course of care for restoration and maintenance of health. Compliance ties to the patients need and benefit. While the reasons for noncompliance vary greatly, the majority occurs on the second office visit with the report of findings. Present with a ROF specific to patient’s needs and concerns. Include e a brochure, with levels of subluxation, spinal health care class, schedule of care. A written ROF will minimize the chance that the doctor will give into the “patient’s noise.” Convey to the patient that your services are more valuable to the patient. Convey the consequence of treatment vs. no treatment
#1.What are the consequences of the care vs. no care. Mention this to the patient. Use another source if necessary (journal articles)
#2. ???
#3. Loss of ADL to their condition or daily health
A health void is an activity, sport or etc. that would be lost to the condition. The perception of value can change under different circumstances. An example is a glass of water. IF you asked someone to give you $1,000 for a glass would you? Probably not, but if you were in the desert for 3 days, then you probably would. Perception is everything. Conveying value to the patient is critical to perceived value.
Don’t spend significant time with insignificant opportunity. It is the DC’s belief system regarding patient care that dictates the type of care presented, such as symptomatic care, wellness care, etc. If boils down to the DC’s.
Working on acceptance and approval causes us to lose focus. Focus on purpose over potential rejection. Recognize that a person that won’t accept 50 visits, won’t accept 10 visits. Concentrate on the process rather than the results.
Crystal Ball Syndrome: Noise includes, insurance coverage or lack of, patients opinions or comments, my insurance only covers, I don’t want to be on a schedule, I’m a once a month chiropractor only….Noise impacts care. The louder the noise, the less the chance for acceptance/approval, and the more the chance for your recommendations to fail. Make required professional recommendations, regardless of what the patient will accept. The golden rule is to tell patients what they need and let them choose what they want and treat them like they want to be treated. Stop listening to noise. Your patient’s compliance grows when you base care on clinical need. If a patient wants a patch work solution, offer them that and also offer them a safe harbor to return. Always recommend to patients optimal comprehensive care, but share with them temporary relief of pain.
Give patients choices. Patient choice takes all the pressure off the doctor. Self imposed anxiety diminishes with this strategy. 99% of people are followers, but the catch is they are particular about who they follow.
“Some will
Some won’t
So what – Next Patient”
Closing the Final Report
1. Define better. The term can mean reduction of symptoms, improved motion or function, improved stability.
2. Base your recommendations on what you think they need and power of choice.
Second Visit & Adjusting
When done adjusting the patient, walk the patient back and have them meet the CA. Transfer authority. The patient is listening while you instruct the CA on what to do. Have the CA walk the patient to the front and make the appointment. Collect all funds. This is also a time for open conversation. Let the patient go with the CA. If there are therapies, have the patient and CA do the therapy. Appointment first and payment second is the strategy. Hand the patient get a card with their appointment. If the patient is there for relief care, make sure the CA knows they are there for relief care.
When the patient has a question about insurance or billing, the CA takes care of it via the transfer of authority. The CA has a script to use for the first couple of visits.
End your second visit by summarizing to your CA verbally what you and the patient decide to do.
6/15/09
RELIEF PHASE
Top Priority: Pain relief (reduce nerve irritation)
Schedule of Treatment: Days to weeks, to completion of this phase. Adjustments 1-2 days apart
CORRECTIVE PHASE/STABILIZATION PHASE
Top Priority: Correct dysfunction and stabilization of joint function (adjunctive therapies are pain oriented)
Schedule of Treatment: Begin to lengthen the time between visits (we are not cutting back…We are making progress; we are getting stability)…Adjunctive therapies are corrective and stabilizing
WELLNESS PHASE
Top Priority: Supportive care of spine and nerves in the spine
Schedule of Treatment: Begin to lengthen time between visits to allow for support of the of the neuro-mechanical components (usually monthly)…Adjunctive therapies are supportive in nature
3 Categories of Patients
How to process patient and get paid for care is important
1. PI: State statutes dictate what can be done. The area includes car accidents, workers compensation, malpractice claims, etc. State statutes may be different for auto vs. worker’s compensation.
a. The term is mostly for MVA (motor vehicle accident). You may or may not enjoy this type of care. They want your help for treatment and liability settlement. This is a part of marketing your practice and getting patient satisfaction. The average lay person does not understand how the insurance company system and personal injury system works. You can help them understand this practice and help
b. Fault vs. No Fault States: It’s about 50/50 between states. A fault state (like Missouri) says that you are at fault if you run into somebody. This determines who pays the bill. A no fault state says that no fault is attributed unless a certain threshold is met. The state that the accident occurs determines how the claim will be processed (particularly in a no-fault state). The state of your license and title doesn’t matter, only the state in which accident occurred. Illinois is a no fault state. A no fault state is simple.
2. Insurance: How do you process in network and out of network benefits? Even patients that do not have insurance may still want the paperwork done.
3. Cash
Fault State (Like Missouri) – Example
Another way of saying fault state is a non-no-fault state. The victim comes to your office. You do a comprehensive exam that includes ortho, neuro, chiropractic, physical exam, X-ray and others. Your bill may be over $700. How do you get this from the patient? You need to have a script in place for cash and non-cash payment with clear instructions to the patient what to do and what to expect. .
Know what to do for hardship cases. You can reduce your charges on a case by case basis for hardship or reduced level services.
The biggest concern with this case, is will you get paid? Some insurances are better than others to pay for PI. It often takes 12-15months or longer to get paid. In some cases, you’ll need to say, the only way I’ll treat you is going to an attorney that I will refer you to or pay cash. If they want to use their own attorney, say to them that it won’t work.
If you want to get paid from an insurance company:
*** We are going to assume full coverage for this class in all examples ***
GEICO (Auto) and Blue Cross/Blue Shield (Health) – For the Victim…Wife has Prudential (Health)
Progressive (Auto) and United Health Care (Health) – For the Culprit…Wife has Aetna (Health)
Example: The bill is $700. The question is where is the bill sent and which one will pay the quickest?
The victim owes you the bill. This is why you put this in the paperwork and make them sign it, that the patient is responsible for the bill. The patient knows that it is not a free clinic and your services are worth it.
6/17/09
ACCIDENT EXAMPLE – FAULT STATE
The example is in a non-no fault state (also called fault state). Missouri is a fault state. Mike runs into Roy. Roy comes into your office for consultation.
UC/RN
Usual and customary (UC) means what it typically done in a geographic location. The UC applies to the service and the fee. Reasonable and necessary (RN) refers to is the code, charge and service reasonable and what is needed to perform. Are the services rendered compatible with objective findings?
In the example, you have a $700 charge. Do you make the patient pay or do you charge insurance? How do you allow Roy to come into the office for treatment and get paid for care? The injury occurred in a fault state. The categorization of a fault vs. no fault state, determines who is liable in paying this bill. The bottom line is Roy is liable for the bill, but he is protected legally.
Key Ideas and Concepts
#1. Get Roy’s signature in writing and have Roy sign the paperwork that you will bill the insurance, but ultimately Roy is liable for the bill when it is all said and done.
#2. What is the greatest probability of getting paid quickly?
Where do we send the $700 bill? The quickest place to go is:
#1. Roy = Quickest way to get paid. Roy has full coverage. Bill Roy’s coverage and let them coordinate the benefits. Send it to Roy’s MEDICAL PAYMENT (MED-PAY) benefit. In this case, the bill goes to Geico and Blue Cross/Blue Shield. Most people have MED-PAY benefits. MED-PAY pays 100% of usual and customary, reasonable and necessary (UC/RN). You will get a check from this within 30-45 days for Roy’s Care. 100% of UC/RN is paid according to the insurance’s UC/RN rates. Whatever their criteria is for UC/RN, they will pay for. You will have to call the MED-PAY, verify the benefits, and get a claim number.
Roy also has Blue Cross/Blue Shield. If you are in network in the PPO, of the $700 you will roughly get $150. They will coordinate benefits between Blue Cross and Geico. You will get a $700 check from Geico and $150 from Blue Cross. Blue Cross has limited reimbursement per visit.
Roy’s Spouse has Prudential and may have some benefits. Even though Roy is not primary on Prudential, Prudential may pick up 50% because of state statute. Whatever Blue Cross and Geico don’t pay, Prudential may pay for. You will have to send them the bill and EOB.
It usually takes 2 insurance companies to equal 1 payment. If you treat Roy several times and his bill accumulates to $1900. The bill will be submitted and reimbursed to a certain point or percentage. You bill 2 insurance companies for a percentage of the $1900.
#2. Mike’s Auto Liability (Progressive): Logical, accurate and legal….Don’t send Progressive the bill because it will take too long. You will wait months to years to get paid from Progressive.
Why don’t you bill Progressive? They won’t pay a dime until Roy is released from care. It is a simple rule to follow: WHEN POSSIBLE, ALWAYS BILL A MED-PAY AND A MAJOR MEDICAL, BECAUSE IT IS THE QUICKEST RETURN ON THE DOLLAR.
Progressive may also pay at the time of settlement. When Roy starts care, SEND A LEIN VIA CERTIFIED MAIL. Make them sign for it. Make sure the state has a chiropractic lein law. The lein law says that the insurance company must send you the money (not elsewhere) when care is completed and the case is settled.
Once Roy is done, send a letter of release to Progressive. Progressive will now send a letter of settlement to Roy. You will wait to be paid for care.
ANYTHING COLLECTED ABOVE THE TOTAL AMOUNT BILLED, HAS TO BE SENT BACK TO THE PATIENT. IT IS A STATE LAW TO DO SO!
Settlement
Roy hires an attorney and acts on his behalf. The attorney will collect the paperwork when Roy is nearing the end of care. He may ask for a narrative. The attorney will sit with a claims adjuster from Progressive (mike’s insurance) and pound out a settlement. The typical settlement is 3x the medical expense. The attorney will ask for 1/3. Between Roy and everyone else, the rest is divided up. Settlement is 9,000, attorney takes 3,000 and the remainder is 6,000. The 6,000 is now disbursed to settle your bill, with the rest going to the patient.
Buy MED-PAY for yourself, because it covers you and everyone in your car. MED-PAY is cheap. MED-PAY IS BASED ON CONTRACT (WITH INSRUANCE COMPANY) AND NOT ON FAULT. Roy can use Med-Pay even if he is at fault (he hits someone), because it is based on contractual obligations.
6/19/09
Auto Accident
Easiest way to get reimbursed is Roy’s (accident victim’s) MedPay and Personal Health Insurance. Look over the bills to make sure the EOB’s come in correctly. You need cash flow so bill the MedPay and Personal health Insurance.
If Blue Cross/Blue Shield has in network benefits only, then you can try Prudential. Roy’s insurances will coordinate benefits.
Progressive (Mike’s) insurance will be the liability insurance. After Roy’s insurance is used, Mike’s liability via Progressive will be the next best place for reimbursement. Often times, the liability is the last to pay, because they wait for the settlement.
The rule: Always bill the Med Pay and the Major Medical. The greatest likelihood of getting paid occurs, and it is legal. Geico is MedPay and Blue Cross is major medical (in this example).
If Blue Cross were removed (the patient did not have it), you would bill Prudential (his wife’s insurance). Prudential would be the major medical to bill, keeping the rule of billing a MedPay and Major Medical.
If the patient doesn’t have MedPay, you will have to bill major medical only. You can also check for the spouse’s major medical – coinsurance. For the rest, you can bill the patient directly or in an agreement with Roy, place a lein on the case and await a settlement from Progressive. You need an iron clad script to the patient on who you will bill and why, especially if it includes billing the patient directly.
If Mike does not have insurance, Roy is still responsible for his bill. You would bill Blue Cross and Geico. Roy can get an attorney and file a lawsuit against Mike. If Roy wins the lawsuit, the attorney will garnish Mike’s wages (taking some of Mike’s wages). Mike is responsible to Roy and Roy is responsible to you.
In some cases, many medical practitioners don’t get involved in personal injury. Consultants have found that MedPay is first come, first serve. Get your bill in first. Bill the MedPay and major medical 2-3 times per week, so you get paid. Waiting once a month to bill is a bad idea, and then you lose cash flow that is vital to your practice.
IN Missouri, you have 2 years post accident to get care and 5 years to settle.
EXAMPLE #2: MIKE’S CASE
Mike sees you after the accident. Mike has a $700 bill. How do you get pad from Mike?:
1). Ask Mike directly = You probably won’t get paid, but he is responsible for his bill
2). The Rule = ALWAYS BILL THE MED PAY AND MAJOR MEDICAL WHEN THEY EXIST. They are the greatest likelihood of getting paid.
a). Med Pay = Progressive ($700)
b). Major Medical = UHC ($700)
3). Wife’s Insurance = Aetna
Mike can use Med Pay even though he was at fault. Med Pay is always based on contract and not on fault.
If Mike doesn’t have Med Pay, you would then bill major medical (UHC). You will get back $60 from UHC. UHC is a bad insurance to deal with. Maximum allowable reimbursement from UHC in St. Louis, is $44. You have to write the rest of the funds off.
Roy can get a disability or impairment settlement because he was not at fault. Mike cannot get the disability or impairment settlement, because he was at fault. Remember this is a fault state example.
6/22/09
NEW SCENARIO – PASSENGERS IN EACH CAR
*** Same Scenario as above except passengers are under care ***
*** Ian is a passenger in Roy’s Care…He has State Farm Insurance (Auto), Cigna Health Insurance, and his wife has Humana Health Insurance ***
Patient in the Victim’s Vehicle – Ian’s
Ian has been hurt. This is a fault state, so Mike is responsible for Ian’s injury. Mike ran into Roy and Ian. Mike is responsible to Ian and Roy. The rule ALWAYS BILL A MED PAY AND MAJOR MEDICAL, WHEN POSSIBLE! In this scenario, state statutes dictate who you bill. The state of Missouri says you can bill the Med Pay and Major Medical. The insurance on Roy’s Car is Med Pay. Med Pay covers ROY and any passenger in Roy’s Car. You then try for Ian’s major medical.
You can also bill Mike, because Mike hurt Roy and Ian. You can bill Mike, but you get paid when the case settles over time.
EX: Ian was in the hospital due to the accident. Ian has disability and/or impairment rating. He has a personal injury and liability coming to him. Mike is at fault and Mike owes money to Roy and Ian. Ian and Roy will have to negotiate a lump sum settlement. Ian and Roy would want an attorney to try to procure a settlement. Often the attorney, wants 1/3 of a settlement.
Ex: $2,000 of Med Pay is bought…Ian is coming to see you. Ian’s bill is over 3,000. You have been billing Med Pay and major medical. They coordinate benefits and it is legal. You have collected some money from Geico for Med Pay (covers anyone in the car) and some money from Cigna. What do you do with Ian because he has 3,000 of care? Geico has paid 2,000 and that is all you get from them because you have exhausted the limit. Where does the extra 1,000 of care and reimbursement come from? State statutes allow for STACKING. You can now go to Ian’s Med Pay, but you have to show that the 2,000 from Roy’s MedPay has been maxed out. The 1,000 of care will go to State Farm (Ian’s Med Pay) to get reimbursed.
In this scenario, Geico is Primary Med Pay. State Farm is Secondary Med Pay. Med Pay in the car you are in is primary. Med Pay not applicable to the car is secondary Med Pay. Roy’s Med Pay is first, and Ian’s is second. You must max out Roy’s before you max out Ian’s because it was Roy’s car involved in the accident.
The 2,000 is for every person in the car and is per person and per accident. So if there was an accident in the same car next week with another passenger, the 2,000 would be applicable to everyone in the car and all over again.
Ex: If Ian doesn’t have Med Pay?
Patient in Mike’s Car
Brandon is a passenger in Mike’s car. Brandon needs care. The rule is a Med Pay and major medical, because you have the greatest probability of getting paid. State statutes determine who you will bill. The insurance follows the car. For Brandon’s bill, you will bill the Med Pay of Progressive. The major medical will be Health Link (his major medical health insurance). Whatever Health Link doesn’t pay, you can try for Mercy (his wife’s health insurance).
Stacking = You can take the extra fees not paid for by Med Pay, and sent it to All State (his secondary insurance). His primary is the Med Pay of the car he was in (Mike’s Car and Mike’s Progressive Med Pay). Brandon’s secondary Med Pay is via All State.
Mike is responsible for Brandon’s care if Brandon is disabled. Brandon can sue Mike for lost wages and disability. If the case doesn’t get settled, then it will go to court to judge and jury.
You need a claim number to start and go through the whole process. 2 years for treatment and up to 5 years to settle your claim. The treatment has got to be compatible with the diagnosis. It has to be compatible with usual and customary, reasonable and necessary.
All of the people are entitled up to 2,000 of reimbursed expenses (because we have arbitrarily said 2,000 for Med Pay in the examples). But within the 2,000 the fees are reimbursed in reasonable and necessary and usual and customary.
Resubmit or ask for a different claims adjuster if your bill/claim is denied.
Medicare
MACC: Maximal allowable chiropractic charge…This is geographic. Anything after the adjustment is covered by the patient and is at your regular fees.
Subrogation
Subrogation = You get a refund, that is controlled by the state. Subrogation is a clause in your major medical insurance policy. The clause says that if you ever get a liability settlement (NOT MED PAY), we will subrogate your claim. Any money Blue Cross/Blue Shield has paid, they want it back from a settlement with Progressive. They will use a lein. About 90% of the time, they don’t subrogate.
The significance is that policies do not have a subrogation clause, yet they will attempt to subrogate. If you are the patient and doctor, “show me in the policy the right to subrogate.” They try to send you a letter later, to force a subrogation, but it is usually not in the original policy. They can only subrogate a liability claim.
Excess Coverage Statutes
Half of the fault states (like Missouri) have passed excess coverage statutes. On paper, excess coverage statutes says that between Roy’s insurance (Geico and Blue Cross/Blue Shield), no more than a certain dollar amount can be paid. The excess coverage says that if the bill is $700, one company fights to be primary and the other pays the excess.
In certain states, the auto insurance fights to be primary and of your bill (700) they will pay (500) and the other company owes you the balance (200). You send the bill to the other company and they now want to reduce the bill to what it was cut to or what is reasonable and necessary. The danger is that excess coverage statutes and who pays what portion of your bill should be based on usual and customary and reasonable and necessary, not an arbitrary number of what your fees are in network. You will find most practitioners that have a large volume of personal injury, that drop out of all networks. You cannot collect any fees above your in network fees.
The attorney can argue, that your interpretation of the in network participating provider contract is bogus.
Know that if you are in network in any one of these there may be language that any money from Med Pay or the person that hit you (his liability), that there is a max that you can collect. 99% of practitioners ignore the ruling. An attorney for the patient (Roy) can suggest, that when you join networks, look at that contract to how much you can charge, personal injury, worker’s comp, etc.
Which is primary, which is secondary? What are the charges? What fees are used (in network or out of network)? -- These are the big questions.
FAULT VS. NO FAULT STATE
No Fault = Look at the car insurance card….If you have Med Pay, you are in a fault state. If you are in a no-fault state, it will say PIP (personal injury protection). PIP is Med Pay in a no fault state. ½ the states are no fault (Illinois, Colorado, etc.)
Same Scenario
No fault, means no fault. Mike ran into Roy, but it doesn’t matter. According to the state statute, you try to get rid of frivolous personal injury lawsuits. The only way to know if you are hurt, is to look at your bill. If your bill is high, it is more of an injury than a small bill. The no fault statute means that if you are hurt, the only coverage you have is your own car.
Roy (victim) comes in your office, you bill his auto insurance (Geico). In a no fault state, he gets 1 coverage only (PIP). You can’t bill major medical, stacking or anything else. The law requires you to have it. Here is the catch, each no fault state HAS A THRESHOLD AMOUNT OF PIP. THE THRESHOLD IS THE STATE STATUROY AMOUNT OF MONEY FOR CARE THAT THE PATIENT MUST RECEIVE (the amount is published). If he receives care up to the state statute amount, he can now sue Mike’s auto liability (Progressive).
If you are an insurance company, you want a high threshold (10-15,000). The intent is to not clog the court system. Instead, some attorneys in a no fault state, coach the patients to get to the high level of care. Attorney’s live by 1/3 (1/3 of settlement). The attorney considers getting to know a couple of people that he can refer patients to including medical doctors, osteopaths, and other specialists. They want their patient to have an expensive evaluation/physical exam, imaging, rehabilitation/physical therapy, and some chiropractors. He may use a couple of chiropractors at the end to top off the bill. No fault states, have seen patients get an excessive amount of care, to meet the threshold. IN an attempt, to unclog the court system we have created a greater legal financial mess to try to circumvent the system and extrapolate more money.
PIP only & liability turns into fault, when the threshold is met (for any health care that has to deal with the treatment of Roy’s injury).
The passenger (Ian) will fall under PIP for Roy or Ian’s PIP. PIP coverage also follows the car (car they were in).
WORKER’S COMPENSATION
Every state in the US has different worker’s compensation statutes. There are attorneys that do nothing but worker’s compensation only. Worker’s compensation coverage is nothing more than an insurance policy that employers purchase to cover employees injured on the job. Each state has their own laws. In Missouri, you are required to purchase insurance coverage. The state law tells you how many employees are required for what amount of coverage. In Missouri, more than 6 employees is required for worker’s comp.
When patients are hurt at work, and want to see you, 3 scenarios arise:
1. The patient has the right to choose the treating physician…Notify your employer (within 24-72 hours), fill out the paperwork, and go see a provider. YOU CANNOT BILL THE PATIENT DIRECTLY!
2. Employer Chooses Treating Physician = This is typically the “company doctor.” The doctor bills the worker’s comp carrier. You need employer authorization form. Missouri is an employer authorization state. Typically, a company doctor is an insurance doctor.
3. Insurance Company Chooses the Treating Physician = This is a bad scenario. The insurance company will pick “insurance company friendly” doctors.
If you do worker’s comp, find a state where the patient can pick the physician. Patients can abuse the worker’s comp system.
*** MIDTERM: Hand in assignment…Get 2 pieces of poster board…Make a sketch of what your office will look like ***
Project #1: On the 1st poster board imagine that this is your first office. You wan a 40x30 plan. You want your first office to have low overhead, room to grow, and a good feel for the patient. Draw in the rooms and label in the rooms with tables. You can draw in things like a Thomspon Room, X-ray room, reception area, etc. Draw the rooms to scale. Grading will be 100% subjective. Draw in you floor plan and on the poster board list all the equipment and furnishings, guessing the costs of the furnishings in each room. The total value of the equipment or furnishings should be given. A dollar amount should be given for build-out (“lease hold improvements”). Use the following fee for build-out ($20-25,000). Give the total for this office, how much will it cost you to open up an office.
Project #2: 15 foot wide and 60 feet wide…Draw a floor plan to accommodate this design. List your rooms, list what you will have in your rooms, and note your costs for this office. The 900 square feet will take 20-25,000 for the build out. ***
*** Grading: Everyone starts with a C on this project. These are 100% bonus points. If you get a C on this project, you will get 5 bonus points on the final exam. A B will get 7.5 points. An A will get 10 points. Your grade will be recorded on the midterm. Turn the project in! Use a ruler for the project and a pen. Neatness and accuracy are important. ***
The due date is July 8th, 2009 during 2nd hour.
WORKERS COMPENSTAION
Unapproved claims are not work compensation claims. Major medical often won’t pay, so these are cash patients.
You send the bill, they decide how much you get paid, and you must write everything else off. You cannot bill the patient for the remaining sum of money. Many chiropractors don’t do worker’s comp, because money is written off. In lawsuits, it can take 3-4 years to settle the lawsuit. You may not get paid for the balance you are owed.
Fault is placed on the employer and not the employee. The big issue is money.
Most of this is on the job training. You may have to fight with insurance companies for the money.
Category 1 = Personal Injury/Worker’s Comp
Cat 2 = Insurance
Cat 3 = Cash
INSURANCE – (CATEGORY #2)
This is a growing practice problem and paradigm. The criteria was “usual and customary, reasonable and necessary.” Managed health care, wanted to be more competitive. They wanted ERISA. They wanted to contract with doctors to be providers in a “club” and charge patients a smaller premium. They wanted a better deal with doctors, drugs and savings. The federal government wanted to increase competition and agreed to changes, instituting in the managed care era. In networks means a couple of things (in the directory, you make less money, but you may make it up on volume). They have brought the medical practice to its knees and chiropractic with it.
The managed care model is falling apart. You have to set up your practice to set up assignment. Assignment means that you will bill your insurance company, you pay me a copay (in network), and they will determine what you will be reimbursed, with the doctor writing off the amount that is left.
6/26/09
Managed Health Care
Today we are seeing co-pays going up, deductibles going up, and premiums going up. The groups that are doing well are the insurance companies.
Some parts of the US have insurance reimbursement that is better than other places in the US. Most people will join a plan, for the guarantee of new patients.
2 Parts:
1. In Network (Participating):
Advantage: #1 You get your name in the directory.
#2. Patient pays you a co-pay and the insurance sends you a check. You don’t have to ask the patient to pay you the entirety of the bill. The check can come weekly (typically there is 1-2 months before you get the check).
Disadvantage: #1. Patients looking for an in network provider won’t choose you. It is a better financial deal to see someone in network. It may not benefit the patient from a clinical standpoint as some in network providers don’t do a good job of care.
#2. Your fees are reduced (diagnostics 50-80%, treatment 20-80%) or written off.
The draw for insurance companies (what they say) is that you will make it up in volume. You need to accept insurances when you come out of school, but be selective. Find out the good ones and bad ones in your area. If you don’t take insurance coming out of school, the chances for success go down. If you take too many insurances, the chances for success go down.
2. Out of Network (Non Par)
7/6/09
CAPACITY CONCEPT
You want the office to have as little overhead with as much potential for profit.
#1. Geared to Growth: When you set up an office is it conducive to growth? Start small, keep your overhead down and grow from there. Keep your square footage down (under 1,000 square feet). Most people will be at 4000-6000 per month for rent.
#2. Lower Overhead: Be wary of how much room you have vs. how much room is operable, profit generating space. Be careful of getting big ticket items like decompression, cold lasers, etc.
#3. Only Need 1 Adjusting Room: Keep the room empty, with nothing in it but the adjusting table. Open adjusting rooms require different protocols than closed rooms.
#4. Consider a specific therapy bay: IF you do therapies, consider doing that in a separate room or in a therapy bay. The bay helps patient flow. When possible, do unattended therapies because it frees up your time. If the therapy is something you absolutely need, then buy it and use it. There is a tendency today, not to have passive therapies reimbursed.
#4. Try to avoid gowning your patients: If you can take care of patients without a gown, do so. On the first visit or a re-exam gown them. For normal patient visits, do not gown. Gowning patients bottlenecks patient flow. Consider a dressing room if you do gown your patient. If you do have a dressing room, this is dead space. You don’t get paid for dead space.
#5. Paperwork System: Everyone will have a computer in their office. In our practice lifetime, all records will be electronic. Right now the government is offering a $44,000 discount to go to an all electronic office. Software packages allow you to bill, store patient records. Medicare will mandate electronic billing and records. You cannot opt out of Medicare according to federal law.
#6. Electronic Billing: It is cheaper than postage to electronically bill. Paper mailing costs 44 cents for the postage, 1 cent for the envelope, and someone to process the paperwork. If the paper claim is rejected, it takes weeks to months to correct. If the electronic claim is rejected it takes hours to days and then you can resubmit. Even with software systems, their still will be paper present. Insurance companies may be having trouble discerning the electronic SOAP notes. The notes are all the same via a computer format.
If you don’t have the volume to support electronic billing, don’t do it. You can still do paper billings. There is a certain point, where the volume will support it.
#7. SOAP Notes: Your SOAP notes (student’s notes) are better than the average medical SOAP notes. IN reality, most practitioners do minimal SOAP note entry. The SOAP note requirements for chiropractic exceeds that of other medical profession. Most people in practice check off the SOAP note columns and get it done. It is a ridiculous request to ask the same questions every visit.
#8. Small Amount of Staff: Hire the staff that you need to be successful. Do not hire more than you need.
Think about your goals and what you need to be successful.
INDEPENDENT CONTRACTORS & ASSOCIATESHIPS
The majority prefers to open their own private practice (you are the boss). That is the personality that is attracted to chiropractic; however, we find that we aren’t ready for that after graduation. You may not be personally ready, financially ready, or not have the skills.
Solo Private Practice
You pay the rent
You are the boss
Your name is on the door
Associateships
You are an employee according to the IRS. Your malpractice is treated as an employee (if your employer gets sued, so will you). These positions are rare in chiropractic. These are paid positions (salary). Your hours are dictated. Your responsibilities are dictated. The goal is to make the doctor a profit. You often need to generate a certain amount of collection and services. The employer is your boss. The employer takes your income taxes out (FICA, Social Security and Medicare). This can be 7.5% off your paycheck. The employer contributes another 7.5% (matched). So, 15% for the FICA tax (split from the company and the individual). If you are your own boss (solo practice – then you will pay all 15%). The employer holds the state income tax from your checks.
Independent Contractor
You work for yourself. The chiropractor you work with is your landlord. This is the best chance for win-win situation, other than opening your own office. You are self employed as an IC. You pay a portion of what you make to rent, overhead, etc. It is geared towards a percentage of your collections. You don’t have a flat, overhead rate/percentage to pay.
Benefits to the Established DC
1. Contribution towards overhead
2. Income when owner is gone: Even taking care of the IC’s patient’s provides income
3. Independent Contractor can cover vacations, sick days, etc.
4. Can sell to Chiropractor: The doctor can sell their practice to the IC. There is familiarity with the patients.
5. Can have multiple DC contractions = Increased Income
Benefits to the Independent Contractor
1. No initial start-up (usually 50,000)
2. Lower start-up cots overall (less each month – no massive overhead)
3. Profit is realized sooner
4. No control by owner – leave each day/work when you want
5. Affiliation with chiropractic office that is successful, good for supporting the DC
6. New DC can learn from established DC by just watching (good habits)
7. New DC patients will be impressed with an office that works and helps them
8. You can reduce your financial stress and emotional stress 1000% (not constantly worried about overhead): This is the #1 reason to be an IC.
9. You can concentrate on building practice
10. Your collections will be higher %: The office knows how to collect and you don’t.
Disadvantages of Independent Contractor
1. Competition of established DC in the area for NP’s
2. No management/control of practice/business (loss of control)
3. Play 2nd fiddle; natural
4. Staff loyalty is always for established DC (payor)
5. Can be asked to leave: Can be asked to leave tomorrow…
6. Could pick up bad habits, poor procedures, etc. if practicing with unsuccessful doctor
Overall, the benefits of practicing as an IC far outweigh the disadvantages
IC is Responsible for:
1. Personal marketing expenses
2. Travel, seminar, license renewal
3. Malpractice insurance premium
4. Health insurance premium
5. Personal Phone Charges
6. Minimal office fee to established office for reduction of charges on relatives, friends, etc.: A minimal fee is required to treat family
7. Additional equipment purchases: Ex. decompression, pro-adjuster…Work out a deal for equipment and patient collections from new equipment.
7/13/09
INDEPENDENT CONTRACTORS VS. ASSOCIATES
Independent Contractors
The cheapest way to hire additional help. It works well with both the business owner and contractor. You are not guaranteed an income at all. Your landlord will sublease your space and services. You have a base fee as a landlord (contribution towards overhead and rent). You have a base monthly rent. You then later pay a percentage rate. The more you collect, the more that you get. Example: If you collect 10,000 you’ll get 67% of that as gross income. Most IC’s can get to a position where it is not favorable for the owner to have them anymore. There is no withholdings, so you have to pay all your taxes (federal, FICA, Social Security, Medicare, and State taxes). Independent contractors FICA (all 15%) is paid by the IC. According to the IRS, you must meet certain criteria to be called an independent contractor. The IRS is really looking at the IC relationship, because it feels that it is not getting paid sufficient funds. If there is a problem with the nature of your position, the IRS will go after the business owner (after the deepest pockets). Be very clear in the language of the contract for the independent contractor. A key component to the IC relationship, is under what set of circumstances will this relationship end? What will happen from the employers end to terminate the relationship? What will happen from the employees end to terminate the relationship? This needs to be in writing.
Associateships
You are hired, given a salary, and told when to show up. Associateships are in less demand due to managed health care. Often associates want guaranteed money. The hardest thing for the business owner is to guarantee someone money. An associateship has an employment contract. You are at the mercy of the employer. You need to have a good relationship with the employer to make this work. There is also the issue of bringing in new patients. Your employer must withhold federal income tax. The government mandates that the employer must withhold taxes ((Federal, State and FICA). Money is taken from your paycheck and the employer’s paycheck to send to the federal government. 7.5% is taken from paycheck. 7.5% from the employer is taken to match the amount of the employee. The #1 reason why doctors don’t want associates is because they have to pay FICA taxes.
Partnerships
May need legal help to set this up. True partnerships aren’t too common in chiropractic.
Buying Real Estate
The good news is that you own the property, but the bad news is that you own the property. Anything that needs to be fixed is your responsibility.
Leasing and Renting
Triple Net Lease: There is 3 parts to the lease
1. Rent: How much money per square foot…Ex: 1200x$18 per square foot = $1800 per month (Square Foot x Cost of Square Foot = Total Cost of rent…Total Cost or Rent/12 = Monthly Rent)
2. Maintenance = How much per square foot for maintenance (general upkeep of the facility, trash removal, snow removal, gardening, landscaping, outside upkeep, lighting (outdoors), etc). They may charge additional fees per square foot (ex. $2 per square foot)
3. Taxes and Insurance: The property is appraised. Based on the appraisal you owe real estate taxes. Real estate taxes go to fire department, school district, police department, roads, streets and sanitation. $600/12 = $2-3 per square foot monthly. You must also account for liability, and other coverages. The additional coverages may be additional money.
Example:
$18 PER square foot rent
$2-3 Per square foot maintenance
2-3 Per square foot taxes and insurance
Ex $22 per square foot per month
Some key questions is what does the lease entail? Is it a triple net lease? Full service lease is 1 fee regardless of what happens.
You can put anything in the lease that is legal based on state regulations. The lease is written for the landlord. The lessee must be taken into consideration. It is wise to have an attorney or someone with real estate experience look at your lease. You want to be sure that in your lease that you don’t want an open end lease. It is critical for you have the first right of refusal or acceptance. Example you want to lease for 2011-2013. The contract lays out the terms of the lease. Before you sign the lease, you want to be able to negotiate. You want the right to negotiate another lease for the exact same rent. You DO NOT WANT TO GO INTO AN OPEN ENDED LEASE! If you cannot negotiate at the time of signing the lease, then you want in writing a number that it will not exceed.
As leverage, you may want to bluff that you will relocate at the end of 3 years if your term is not met. Threatening/bluffing relocating often forces the landlord into negotiating. YOU WANT TO KNOW A CEILING! A key for negotiations is that you want a ceiling.
7/20/09
BUYING/LEASING EQUIPMENT
Cheaper overall to buy, rather than to lease in the long run. In the short run, it is easier to you to lease than buy. Your net worth is your liabilities. Your liabilities are what you owe. The bank looks at you and your business plan as risk. The catch is that the bank has to lone money to you, and that you must be able to pay back the money to them. The banker does not know you well personally. They see your business plan, your risk, your liabilities, your credit and they have to make a decision on you. Your financial projections are key to the bank. Banks look at your projections and compare them to what the normal projections are for your area. Talk to several colleagues in your area about their businesses, their numbers, etc.
Today’s Economy
Coming out of school (new practitioner, new field, and new responsibilities) is would be best to lease. Keep your cash. Cash is king. Pay the extra amount of money to lease your equipment. You can always buy it later. You will spend more money, but keeping your cash in hand is important. Key the cash to market, to advertise, and to drive more new patients.
Recommendations
Small Office, Lease Equipment, High Volume, Few Employees, High Yield
Leasing
You will spend more money than buying because there is a middle man (leasing company). Most of the companies that lease equipment have an in house leasing office or a relationship with a bank that they will refer you to. When you lease equipment, you have to calculate the cost (see below)
*** ON FINAL: CALCULATING A LEASE PAYMENT ***
Cost of Piece of Equipment: 15,000 ----- Do you want to pay for it 3, 4 or 5 years
Lease Factor: A converted % rate expressed as a decimal (.037)…Round to 1st three numbers….020-.040 is a typical range.
Ex. = Take your lease amount & multiply it by your lease factor = 15,000 x .037 = $555 = MONTHLY LEASE PAYMENT
Ex. = 15,000 x .031 = $465
Over a 3 year lease (36 months) you will pay (36 x $465) = YOUR PAYMENT IS 19,000. So the cost of leasing is an extra 4,000 for the 3 years.
Ex. = 17,000 x .035 = Ex. 48 payments
Ex. = 35,000 x .030 = $1000 per month for your monthly payments for the ProAdjuster
You need to get into practice as quickly as possible. Start as small as you can and build from there. Keep your overhead down. Used equipment, simple equipment and cheap equipment will help keep your overhead down.
At the End of your Lease
3 options:
1). Return the Equipment: They will pick up the equipment. They will try to sell or lease you another table.
2). Buy the Table: You can buy the table for less than its original tag price. Often this is 10% of the original cost of the table. Work your best deal on the lease. Do not tell the leasing company that you will offer them $1 for the equipment at the end of the lease to buy the table. Buy it for 10% and/or a $1.
3). Purchase Plan: Continue leasing the table for 3 more years or 4 more years, for 1 lease payment per year. You pay the lease payment once yearly for the term of the lease (ex. 3 or 4 years).
Ex. TOTAL COST = 15,000 x .037 = $555 ….$555 x 36 payments. = COST OF TABLE….COST OF TABLE + STANDARD BUYOUT ($1500) = TRUE VALUE OF WHAT THE TABLE COSTS!
If you save $90 per month, could you have purchased something else (equipment) that will make you additional income and services? Add the lost income to the cost of the table.
IN real life, discounted fees in health care it costs you 20-30% more than what you budgeted for.
Depreciation Scale
Talk to the IRS about depreciation
Depreciation scale = If you borrow money for equipment, you can write off a percentage per year of the lease…
Examples:
1/7th of the cost for 7 years…15,000 x 1/7 for 7 years = Amount that you can depreciate.
1/10th for ten years
¼ for 4 years
The good news is that in year 3 and beyond, you can write off 2,000 per year as non-taxable income as if you make the payment for the 4th, 5th, and 6th year. You need to talk to the CPA about this, because IRS coding changes routinely. The CPA can set you up on a depreciation schedule. Stretch out your depreciation as long as you can with your accountant.
NEW PATIENT ACQUISITION
Where are your new patients coming from? They come from a recipe of doing multiple things, multiple times successfully. In real life, it is you becoming pro-active towards getting new patients. Practice is personality driven and procedurally based. Certain procedures are conducive to practice growth. In a given location, given personalities, given competencies different doctors will make certain situations work.
The biggest concern about cash practices is that you may not have certain patients come into your office because of it. If you are out in practice for years, you may be able to absorb it. A particular practice style or technique may create uniqueness and people may be more apt to come to your cash practice. You need to willing to make the cash practice work.
Gena Shaw Article – Cash Practice and New Patients
Patients may not be willing to pay cash, when they are used to handing over an insurance card. Going cash won’t suit all practices. Surveys indicate 60-70% of patients want to be able to use insurance. Can your practice survive on that 30-40%? The practices that survive on cash survive on the concept of chiropractic wellness. There is no such thing as cash only practice. You have to work with Medicare. The only way to opt out of Medicare is to never see a Medicare patient. Switching to cash does not exclude you from documentation and coding as worker’s comp, state government, Medicare, Medicaid may ask for your documents. A good approach is to:
1). Give your patients a warning
2). Explain what switching to cash means
3). Give the patients a super bill that the patient can submit
4). Expect a dip in income…Have some cash reserves
5). Explain to patients that you are losing money on patient care with certain insurance plans
6). Send a fee schedule to the patients with reduced fees, because of administrative costs will go down because you will no longer bill insurance companies
7/22/09
What can you do to get new patient flow into your office?
1. Your best source of new patients are from your present patients: They are in your zone/presence. They get a chance to interact and connect with you via verbal and non-verbal communication. There is a positive environment present. They hear people talk about how they feel better. You get to motivate them, intentionally or un-intentionally.
2. Your second best source of patients are your past patients: Past patients are defined when they are not there within a calendar year. The majority of your patients will be past patients. It takes training, discussion and understanding to get the idea of chiropractic as a lifestyle. Past patients are happy with you and satisfied about the results they got. Sometimes past patients will be current patients; additionally, they are happy people and refer patients to you.
3. All the other people you have not seen: This is the worst group for referrals. They are motivated by someone in network, unless they get referral. They view that all chiropractors are alike. Others are the worst group for referrals, but the biggest group to draw from. Once you start, focus on the first 2 groups and not the other group. For the same dollar, you will get a higher return on investment from the present patients and past patients.
To get a referral practice, it will take 3-5 years. You want a referral practice, but it takes at least 500 present and/or past patients to start building a referral practice. Some will do it quicker, some will do it later. Referral practice is where all your patients are referral, from another patient/person. The dilemma is that you are starting a new practice and need 500 new patients as quickly as possible. You need to know 500 people personally. Meeting them 1:1 personally (within 3 feet of them) is a huge asset to your practice. To get to know 500 people, it can take 5 years to see 500 new patients (100 per year or 8 new patients per month). Personality and engaging new people are important to your practice. The average personality is not conducive to doing this.
Getting Into the Zone
You may need to prep yourself to get into the zone. Put together a personal bibliography (a brag sheet that is a handout). This is a letter paragraph format about you. This is typically the size of a sheet of paper. Use your credentials, degrees, special training. When you have your brag sheet done, go to your local newspaper and pay to have the brag sheet printed. Ask them to run it as a news article. When it is run, take the copy and go to Kinko’s and print lots of these (1,000). Print them and take them with you as your handout, what’s left mail them out. The brag sheet can be used to meet people. The purpose of doing this is to introduce yourself to people. Commercial is 1st and residential 2nd.
Start at a 3-5 mile radius from your office and focus your marketing to that area. The goal is to go out and introduce yourself to 20 people daily. Make sure to pick the 20 people in your area that may successfully help to build your practice. You can start with 20 commercial people. Local small business owners are a good source, because they want to build relationships to sell you something.
When You Go Out to Market
#1. Dress Appropriately: How you dress tells someone how to treat you. Corporate American dress maybe best.
#2. Use a Script and Your Brag Sheet: Get into the zone.
#3. Present Yourself/Introduce Yourself: Use eye to eye contact and a 3 foot circle. When you are done with your intro, you want that person to talk. Talk about you and then have them talk about themselves.
#4. Get a New Black Book: The book contains the names of businesses and business owners.
#5. Handwritten Thank You Cards: Send them to the business owners after you see them.
#6. Put the business owners on your mailing list: Update the mailing list 2x yearly.
7/24/09
Personal Contact - Commercial
It is a good idea to get out and meet many people before you open your practice, to let your business grow. Don’t rely on the electronic media, there is something to be said about meeting people. People are more prone to like you and see you professionally if they meet you. Meet 500 people and create a mailing list of 500-600 people. Send these people something personal about your practice.
Go back to your office and write a hand written thank you to the business owners. Put the business owners on your mailing list. If you can make it to their office a couple of times per year, even better. As your practice grows, your sphere will get bigger. You will see patients from different areas. At first, focus on your core (within 5-10 miles of your practice).
When you get your 500, memorize their name and cross refer patients.
Residential Contact
People are concerned that you are a mugger. Put a name tag with your name when you go door to door, business name and title to verify that you are not a threat to them. When you are in a residential setting, this is the wrong time to do a free exam, the wrong time to do a consult, the wrong time to do anything but introduce yourself.
Ideas to Consider
1. Applaud someone for using chiropractic
2. Suggest that you can fill in or help the patient out if needed
7/27/09
Mailing List and Newsletters
It is recommended to use a mailing list and mail hard copies to people. The younger generation appreciates e-mails, text messages, while the older generation may actually appreciate hard copies. Add every new patient to your mailing. All the people that you know add to the mailing list. You want to keep the mailing list up to date.
Get creative with your mailing list and newsletter with what you say and who you send it to.
New Patient Orientation Class
This is a great way to build your practice. The class has the GREATEST POTENTIAL TO BRING IN NEW PATIENTS IMMEDIATELY. Take all of your new patients and put them through a mandatory new patient class. This is key to how you practice, the type of chiropractor you are, and why you do it. This class doesn’t cost a lot of money and has great potential. Ask the new patients to bring a friend, spouse, etc.
We routinely find that practices that fail aren’t doing things pro-actively. Practices that fail don’t market, don’t talk to people, whither and fail. Mandatory new patient orientation classes are important to your practice. This does not include talking to clubs and organization within your area.
#1. Make it Mandatory: Make it mandatory up front, just like an exam, consultation, etc. Your new patient orientation should be stated to the patient, that it is a two part process. The first part is the final report (where you mention the class), and the second is one week later where you give them the new patient orientation class. Turn over authority to the CA to make the appointment/schedule for the new patient orientation class. First thing to do when the patient leaves after the first visit is make the next appointment and the second thing is to receive any payments. Have them set up the second part of the final report (new patient orientation class). Make it mandatory, by putting it in writing. Have on the form, the patient’s name, appointment date and time, and the verbage “this is a mandatory appointment in order to receive care at this office. Failure to attend the class results in patient dismissal from the office.” This form and language means that it is important and is significant. The average patient will not say no to the doctor. 10% or less will test you on this, and 90% won’t. Typically, you want to do this within 10 visits. On the third visit, (treatment visit) ask the patient if the CA scheduled the new patient orientation class. Mention to them that it is important for them to understand how chiropractic works, how people improve and how you do things. The class helps patients understand that you are the expert.
#2. Make it something that people want to attend: It should be worth listening to. Don’t make it a lecture, make it more interactive.
#3. Typically you want a small group (a class): You can do the new patient class with as little as 1 person.
Signs in Your Office
Put up signs in your office about your orientation class. You need to personally remind patients in the days preceding the class about the orientation class. People will make the transition from pain care to actual chiropractic care (chiropractic lifestyle) from the new patient orientation and patient education. The class helps put context on why we do what we do.
Ideas for Your New Patient Class
1. 3x5 Posters on an easel - Flipchart: This can become your new patient orientation class slides/posters to use as a flip chart
2. Give a Handout of References: So the patient can have the information to take home and look it up or look at it if possible.
3. Power Point Presentation: The downside of a power point presentation is that it takes away from your charisma, and your image as an expert.
4. Have an Occasional Speaker: Can give the class a different feel. They can give a testimonial that will add credibility to your class.
5. Introduction: Put yourself & state to your patients that there is nothing to buy tonight and that you will be finished by a certain time. “I will talk to you about why chiropractic works, how I can help you and why you should be chiropractic patients for life. I will talk for 45 minutes only.”
6. End Your Presentation: End the presentation by asking people to bring in their family members and friends.
You want a format to fall back on, but want to do as you can live, with personality and in an interactive format. This format gives credibility to your class. In the class you want to convey, how chiropractic is important to their life. A small amount of patients will make a big part of your daily practice. About 5% of your practice, will make up 80% of your practice income.
You cannot entice a Medicare patient to receive treatment under federal law. Bring in the non-Medicare patients and their families to your new patient class.
7/29/09
Tidbits to get New Patients
1. Have someone on your staff actively pursue speaking engagements
2. Use your mailing list and address book to your benefit
3. Effective is 1:1 (talking to someone 1:1), but don’t neglect a small group where you can reach multiple people
4. The more controversial you make your talk, the more interesting your talk will be
a. Don’t be controversial, to be controversial…Be controversial with stats, references and facts from journals
5. The larger the group that you speak to, the quicker that you want to vacate the premise after your speech
MARKETING
It is worth it to spend money on marketing? How much money are you willing to spend? What is your return on your investment (ROI)?
Make a commitment to put an add in the paper 1-2x monthly for at least a year, before you see the benefit. We need to go to the population to get patients vs. the allopathic realm which doesn’t need to market what they do. We as chiropractors compete with ourselves and compete with allopathic medicine. 90% of patients have some form of allopathic care for their chief complaint. Today, the average new patient had seen another chiropractor before they have seen you. IN many cases, they were unsatisfied with their chiropractic care leading to them to your office.
8/03/09
ADVERTISING & MARKETING
As a professional, you should understand what you are marketing. You are selling either goods or services. Goods are tangible. There are 3 ways of professionally marketing services. Chiropractors sell services (adjustments, consultations, examinations, therapies, opinions, read X-rays). Occasionally chiros sell goods (nutritionals, orthotics, cervical pillows). There are different ways to sell goods and different ways to sell services.
3 PRIMARY WAYS TO EFFECTIVELY SELL SERVICES
1. IMAGE: Image gives our community perception. Try to create an image to make people feel like you are part of the community. Sponsoring teams, sponsoring food drives, sponsoring anything is a way to sell your image.
2. EDUCATIONAL: This is what most professionals do to sell services. Advertisements, printed media, health columns (ask the doctor columns) are ways to sell your services.
3. CALL TO ACTION: An advertisement that says “try me and try me now.” Put a date on it to get people to try your services. Reduction in fee, increased services, “free consultation” are calls to action. By placing a date on the service, you are communicating that you want the client to take immediate action, stimulating/motivating them to come in.
All 3 things work together to effectively market. Focus on 1, but use the other 2 ideas to support the 1. Doing all 3 at the same time may “dilute or change the message” of the add. If you are doing an ad that is education, stick with the educational route on the ad. Don’t have your ad say too much. Use the other 2 sources in other media or in other forms, but not on the same add to sell your services.
The lower the socioeconomic level of your community, the better free works! The socioeconomic status is determined by 3 major criteria.
1. Income of the Community: 5 Levels
a. Upper
b. Upper Middle
c. Middle:
d. Lower Middle: Ex. Trades people, Blue Collar…
e. Lower
2. Education: High school, dropouts, bachelor’s, post-grad education can tie into income. Education determines how people think, which determines who you vote for and what services you use.
3. Location???
Open up a chiropractic office in a community where you feel comfortable. Tailor your goods, services, marketing and advertising to those communities. Ask yourself, what group do you identify with and what group do you belong with. Typically, chiropractic today is valued as higher income and highly educated areas. Higher income – highly educated areas don’t respond to free services very well. Free services appeal to price sensitive areas. If you are in Chesterfield and offer free things, it won’t work. You need to understand the demographics of your community to know what will work.
Look at the state board laws, because they may not allow you to advertise in certain ways.
Advertising Ideas
Yellow Page Advertisement
Will it work or not? It depends on your cost, ROI, Socioeconomic status of your community, etc. In a small town, yellow pages may be a good idea. Yellow page ads in a metro area are often very expensive. Fees may be above $2,000. The key is whether you are making money off the ad or not. Most small towns have ads that are $75 or less for a half to full page ads. Keep stats of how people find you. The yellow page people keep stats, but their findings may be skewed based on how they track their information. Their idea is whether someone looks for you and successfully finds your number, but this is not productive for a chiropractor who wants people that don’t know you to find your ad.
They try to sell you the ad, good or service, by saying, “3 more visits per week will pay for the ad, good or service.” The problem is that you cannot guarantee the patient visit to begin with. Most chiropractors are referral based practice and not walk-in based practice.
Group Lectures
Talk to as many groups as you can, particularly in your first couple of years. The more people you meet, the more that you can treat. U. An example would be, “Chiropractic: An Alternative to Spinal Surgery.”
Advertising in the Newspaper
A health column in the local newspaper may be a good idea. It is a long term commitment. You can do an “Ask the Doctor” segment for the newspaper. Local newspapers are better than larger newspapers. You may get a return on your time 6 months or later from the time you start the column.
Fliers
May or may not be as successful.
Doctors (Medical – Allopathic)
Can refer patients to your office if you understand the way they think and operate. Nurses often make good allopathic and chiropractic patients. Nurses understand the good and bad with the allopathic model, since they are around it all day.
Sports Doctor
Another way to market yourself, but you have to show serious interest in this area.
Examination for Free Policy
This policy would be an examination for free of an immediate family member with a paying customer/family member. This is a gift from the doctor to the patient and their family member to eliminate the financial barrier where multiple people need care.
New Business
Most new businesses fail because they are under funded.
8/5/09
New Patients
The greater the amount of services that you offer, the greater chance that you have to see new patients. What interests do you have and how do you want to share your interests?
1. Look at your fees – Do you need to change your fee structure? Typically, chiros change their fee every 2-3 years. You are better off to change your fees yearly with small amounts than $5 every 2-3 years. Fees can keep patients in or out of your office. Low fees can be cheap from the patient perspective. Excessive fees can keep people out of the office. Most people can grow into your fee structure. When it comes time to changing your fees, do not make a massive announcement. Make the change immediate. Do not discuss it. Do not apologize for it. Have a staff meeting and say starting the following Monday, we will be making fee schedule changes. Tell your CA to make the changes in your computer and the changes will be effective. Tell your staff, that this fee change is not negotiable and the changes will be effective immediately. If someone has already made a check out, take the lower fee, let them know that the price has changed and that you will write the small amount off. State to the patient that “we try to keep our fees congruent with the type of service and results that we offer.”
2. Services: Evaluate the services you offer. Are they worth it? What is your ROI? Are you happy with your services? Are there services that you offer that you are not using? Are there services for you to unload?
3. Patient Categories (Insurance and Cash): Have a balance in your practice. Know how many cash patients, how many insurance patients you have. You need a balance. How much insurance do you want to have? Most experts say 25-50% should be insurance coverage. You do not have to be all or nothing. You can mix cash and insurance, but you choose. Personal injury (maybe 10-15%). Worker’s comp should be smaller stats. Worker’s comp depends on the state. It may be wise, to have worker’s comp be a cash based service and state to the patients that they may not get it back. Let them know, “Don’t make your decision to come here based on money, make it based on whether you want to get better. “
a. Medicare: You will see patients with Medicare coverage. You can either participate or not-participate. The last thing you want is a high volume of Medicare patients, because you are at the mercy of the federal government.
A small percentage of your patients will make up a majority of practice. Communicate to them the message that you provide a service that adds to the quality of their life.
Things to Consider
Going Cash: More practices are starting to go cash (mostly out of necessity)
8/7/09
*** Review of Material Covered this trimester from this date to the end of the trimester***
*** Dr. Tim Maggs – Bringing Chiropractic to Mainstream***
He says there should be standardized procedures that chiropractors should employ across the board as a profession.
1. Decide on a universal message (Structural Based).
2. Decide on a logical, universal in office procedure. Get away from symptom based, medical model. Structural evaluations are recommended.
3. Train all chiropractors to become better ambassadors to get the message out through public speaking and writing.
4. Pool our resources to create 1 group to market and advertise the message.
5. Continue research studies that are practical and applicable to the public.
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