Added value

Mueller16-2013Certified CA training is changing the face of reimbursement while strengthening and protecting practices.

By Laurie Mueller, DC

In May 2013, the Federation of Chiropractic Licensing Boards (FCLB) announced their new Certified Chiropractic Clinical Assistant (CCCA) guidelines, establishing an application process and a national examination that extends standards of chiropractic excellence to CAs.

Because other professions have long- standing training credentials for medical assistants, physical therapy assistants, dental assistants, and so on, this step was crucial for chiropractic’s credibility. It also aims to reduce patient risk and vicarious liability in chiropractic offices.

Several states have had formal regulations in place for years: Oregon, Florida, and Tennessee to name three. However, with a national program now up and running, the profession may encounter regulatory changes in many more states, and third-party payers may also look to require CA training if any billable modalities involve the CA working with a patient. This could certainly affect future reimbursement.

NCMIC has reported that about 5 percent of claims stem from burns to the patient. This is likely the result of modality use — and most probably the result of untrained staff. Such cases would fall under the vicarious liability category for offices.

According to the ACA website, “‘Incident to’ is a phrase that describes the delivery of certain services through an individual other than the actual healthcare practitioner, e.g., electrical stimulation performed by a chiropractic assistant ‘incident to’ a doctor of chiropractic. As of July 25, 2005, for therapy to be reimbursed in Medicare, the therapy must be delivered by either a physician or someone that qualifies as a ‘therapist.’”

Can FCLB’s national program fit the bill for such Medicare regulations? The answer is yet to be seen, but it certainly creates more credibility for the chiropractic profession and offers a route to prove competency. Meanwhile, other third-party payers who are being billed for services performed by office employees who don’t have documented training could start requiring CA training for reimbursement, citing the national certification as a standard. Many are already following suit with Medicare.

The FCLB quoted UnitedHealthCare as saying “services rendered by non-licensed individuals are not eligible for reimbursement.” BlueCross/BlueShield of Kansas City similarly stated: “Supervised treatment in the absence of skilled intervention is not billable time.” If services are not provided by individuals with documented training, insurance companies retain the right to reverse payments — including the electronic recovery of funds.

The FCLB solution to this ongoing issue was to create standardized training guidelines and testing for a formal national certification for chiropractic clinical assistants.

The FCLB proposes the following core curriculum components:

Foundational knowledge: The successful CA should have general entry-level knowledge necessary for working in a practice. Examples of areas requiring basic knowledge include

  • Human anatomy — being able to identify large muscle groups and common bones
  • Human physiology — knowing the basic function of the major organs such as the heart and lungs, and that ovaries are classified as reproductive organs
  • Clinical terminology — e.g., knowing flexion versus extension, superior versus inferior, and anterior versus posterior
  • Treatments and conditions — recognizing common diagnostic and treatment terminology, e.g., sprain, strain, tendinosis, low-back pain

Patient safety and procedures: The successful CA should have at least an entry-level ability to complete tasks related to patient treatment, and recognize and appropriately respond to situations that may compromise patient safety. Examples of such items include

  • Recognizing and preventing office hazards; e.g., proper use of passive-modality equipment
  • Therapeutic modalities and procedures; e.g., safe therapy set up and use, and how to apply ice and heat
  • X-ray safety; e.g., asking female patients about pregnancy
  • Responding to health and office emergencies; e.g., knowing CPR, types of safety equipment and general adverse reactions to common treatments.
  • Recognize indications and contraindications for common modalities; e.g., knowing indications such as tight muscles and swelling, and contraindications such as pregnancy and cancer
  • Vital statistics (height, weight, blood pressure) — e.g., knowing basic terminology and general procedures for obtaining vitals

Documentation: The successful CA will have at least an entry-level ability to complete tasks related to the creation, handling, and storage of patient data, including the billing of patient services. These tasks may include

  • Use of appropriate intake and informed consent forms
  • HIPAA compliance; e.g., understanding that there must be no discussion of patients outside of the office
  • Red flags of fraud; e.g., understanding that taking money or billing for therapies not performed is unethical and illegal
  • Use of procedure and billing codes; e.g., knowing those commonly used on CMS 1500 and to identify common chiropractic procedures
  • Recordkeeping; e.g., knowing the basic SOAP note format and common medical and chiropractic abbreviations

Ethics and boundaries: The successful CA will exhibit ethical decision-making ability and recognize appropriate interpersonal boundaries. This section of the test contains basic scenarios pertaining to the following

  • Understanding of sexual boundaries and harassment
  • Maintaining basic patient-staff relations
  • Maintaining basic doctor-staff relations
  • Proper handling of finances and billing
  • Managing confrontational patients

The current guidelines and exam are heavily weighted toward passive-care modalities, and do not currently include active care (exercise); however that may change in coming years.

Whether mandated or not, in light of patient protection, safety, and office liability, CA training can increase the competency of CAs, increase patient confidence and safety, and decrease office risk and liability.

It can take months or years for an untrained CA to learn everything on the job. With guidelines and programs in place, doctors can now train current and new CAs and ensure minimum competency for their offices, and likely help satisfy the new insurance mandates.

LaurieMuellerLaurie Mueller, DC, was the post-graduate director for Palmer Colleges from 2000 to 2010. She served as the Acc post graduate subcommittee chair for six years, peer reviewed for the Research Agenda Conference, and wrote the role determination study that aided in the development of the FCLB’s guidelines for CAs. She currently works as a private eLearning consultant with a focus on healthcare topics. She can be contacted through