By bringing a physical therapist (PT) or similar specialist on board, you can provide more thorough and collective care at your chiropractic practice.
“While the PT can spend time delivering therapy and rehabilitation, the chiropractor can focus on diagnosing, adjusting, and maintaining wellness,” says Stephanie Higashi, DC, CEO, and founder of Health Atlast, a multidisciplinary healthcare franchise.
Ultimately, adding a PT increases the number of services your practice can provide. “It also enables patients to receive comprehensive care, particularly those who’ve just had surgery or those who are looking to prevent undergoing surgery to increase their function,” she says.
First step — follow the law
If you’re considering adding a PT or other type of healthcare provider, begin by researching your state’s laws and regulations that govern the possible arrangements, such as hiring the individual as an employee or as an independent contractor, says Scott Fonda, DC, DABCO, of Sports Medicine Solutions.
Contact a healthcare attorney who knows what your state’s law allows, because every state is different, says Joel Dekanich, DC, RN, MS, DACBSP, and founder and director of the Vail Integrative Medical Group. There are both federal and state laws that a chiropractic practice must follow when employing a practitioner from another discipline.
“In some states you can employ a PT, and in others you can’t,” Dekanich continues. “There are pluses and minuses to both types of arrangements. Employing a healthcare provider as an employee versus an independent contractor is a cleaner arrangement, as all providers will function as one entity under one tax identification number.”
Attorneys can also help you navigate Stark law and anti-kickback statutes.
Physical therapy and chiropractic associations can serve as resources as well, Higashi adds.
By hiring someone as an employee (if your state permits it), you won’t violate Stark law if the chiropractor and employed PT both see a patient. “Any PT services provided must be billed under the practice’s tax identification number, with the PT’s national provider identifier (NPI) as the provider,” Fonda says. “The chiropractor’s services are billed under the practice’s tax identification number with the chiropractor’s NPI as the provider. You can pay the PT as either a full-time salaried employee or on an hourly basis.”
If the PT is an independent contractor, however, then the arrangement is quite different. Each provider has his or her own corporate structure (e.g., a limited liability corporation, C corporation, or S corporation) and tax identification number. Any referrals between providers cannot be incentivized. “In this scenario, the PT simply leases space in the chiropractic clinic for a standardized rate that cannot be linked to revenue,” Fonda says. “For example, the chiropractor could charge a flat fee for renting clinic space, but the rent charged cannot be based on a percentage of collections. Make sure to consult your attorney to draft an independent contractor agreement.”
After you’ve determined in what capacity you want to bring on a PT, it’s time to begin your search for one. Dekanich places advertisements on the American Academy of Physical Therapy website, as this strategy works well for him. He’s found many recent physical therapy graduates look for jobs there. If you’re seeking to add a personal trainer, advertise at a local gym or on Craigslist.
For Fonda, effective ways to find PTs include getting referrals from colleagues or patients, contacting a local university with a PT or doctor of PT program, and attending multidisciplinary conferences or post-graduate seminars with both chiropractic and PT attendees.
Spencer Baron, DC, DACBSP, president of NeuroSport Elite, has found PTs through referrals from other respected PTs, especially those who have worked in collegiate and professional sports.
By bringing on a new healthcare provider, you should expect some changes—for the better. “Hands down, the first change a practice should expect is better patient outcomes,” Dekanich says. “There is ample evidence in peer-reviewed literature that when chiropractic techniques, manual soft- tissue techniques, and manual therapy techniques are combined with physical therapy and exercise, patients get better results. The PT focuses on rehabilitation and discharges the patient when they reach maximum medical improvement and the chiropractor can focus on wellness and supportive care. The marriage works well.”
Aside from an increased revenue stream, the PT can provide added rehabilitation benefits that would typically tie up the chiropractor’s time. “Because my practice is oriented toward treating sports injuries, the model has been exercised at the collegiate and pro level with excellent results,” Baron says.
Accommodating a PT
Whether or not you need more space for a PT largely depends on the PT’s practice style and patient demographics.
“On the lower end of the spectrum, a solo PT working one-on-one with a patient in a low-tech rehabilitation setting could operate with a treatment table and some low-tech rehab equipment, such as stretch-bands, exercise tubing, and a gym ball,” Fonda says. “At the upper end of the spectrum, you could construct an entire rehabilitation facility to service a range of patient types.” Alan K. Sokoloff, DC, DACBSP, director of the Yalich Clinic Performance and Rehabilitation Center, has found that PTs and chiropractors share a lot of the same rehab equipment. “If the PT does specific techniques, different machines or products may be necessary,” he says. For example, at his practice, the chiropractic staff doesn’t use phonophoresis or iontophoresis modalities, but the PT team uses both regularly. In his practice, the PT department shares space with the chiropractors and chiropractic rehabilitation assistants.
Dekanich says his 1,500-square-foot clinic can accommodate several treatment rooms, a massage room, and an open physical therapy room. The PT requires simple equipment, because most rehabilitation is done with low- tech gear such as stretching-bands and free weights, as well as some resistance training.
Low-tech rehabilitation, in addition to having a minimal start-up cost, is a great way to help patients comply with performing their PT regimen, as it does not require high-tech equipment, Higashi says. A space ranging from 100 to 500 square feet suffices for most PTs.
Of course, you can add high-end physical therapy equipment such as weight machines, foam mats, exercise bikes, elliptical machines, treadmills, and computerized physical therapy equipment as your PT department develops and expands.
Sales of rehab equipment to patients assigned home exercise might serve as a potential source of revenue. “While it probably won’t be a large contributing factor to revenue, it is important to have more commonly used supplies available, because having immediate access to these items (e.g., resistance bands, foam rolls, or exercise balls) can improve patients’ adherence to prescribed home exercise programs,” Fonda says.
Expanding your patient demographic
By having a PT join your practice, you may be able to see patients who normally wouldn’t come to your door. “Because we are an extremity specialist group and sports medicine specialists, our demographic didn’t change that much (when adding a PT),” Dekanich says. “But for practices that maintain a PT to see post-surgery patients, such as those who’ve had shoulder or knee surgery, a different segment of patients will seek out your practice, as the standard of care is to refer these patients to a PT, not a chiropractor. But not all physical therapy patients will end up seeing a chiropractor; PTs can have their own patient bases.”
According to Higashi, any demographic changes will depend on the PT’s skill set. For example, a PT who specializes in sports medicine will tend to bring in younger patients with sports injuries. PTs who specialize in geriatrics will bring in more elderly patients. PTs who focus on women’s health could bring in more female patients.
Bringing a PT on board added to Baron’s patient base, and he thinks patients and physicians more readily make referrals when a PT is present because they readily understand their scope of practice. “An athlete usually does what it takes to get out of pain and train for peak performance levels, and then continues care based on the constant physical demands they place on their bodies, like a high-performance race car,” he says.
In addition to referring patients in your practice to other specialists, you may be able to gain referrals outside of your practice from orthopedic surgeons, primary care physicians, and other healthcare providers. “If these providers hear about your practice’s great results, they will be more likely to refer patients,” Higashi says. “But being in-network with insurance carriers also plays a big part in referrals. If your PT has a great reputation but is not in a patient’s network, due to the high cost of insurance many patients will choose an in-network provider.”
What could possibly go wrong?
Although adding a PT can be advantageous in many ways, there could be some potential downsides, such as personality conflicts among healthcare providers. “The relationship between the chiropractor and PT should not be adversarial, territorial, or competitive,” Fonda says. “The two providers should acknowledge that they have overlapping skill sets and use that as a common ground. Their individual and unique talents and skills, when combined to improve a patient’s quality of life, is a recipe for improving inter- professional relations and creating a personally rewarding and financially successful practice.”
Along these lines, Dekanich says it’s all about a good fit. “Hire the right person first,” he says. “Make sure your treatment philosophies are similar and that you are both on the same page before you hire someone.” He stresses that you and the PT need to be team-oriented, putting the patients’ interests first. The arrangement won’t work if either provider prefers to practice alone.
“All healthcare providers need to check their ego at the door,” Dekanich continues: “Chiropractors have certain skill sets that they have been trained in and are better at than PTs—and vice versa. In our clinic, we don’t allow PTs to do manipulation, that’s a chiropractor’s job. On the other hand, chiropractors don’t spend much time on rehabilitation, because PTs possess that expertise. Providers need to figure out who does what best, and make it a collaborative approach. But make sure you don’t duplicate services.”
Higashi says disagreements in philosophies and approaches to treatment and care can occur, resulting in mixed or confusing messages to patients. In addition, fee splitting, anti- kickback regulations, and incorrect reimbursements could become compliance issues potentially leading to penalties and fines.
Making it work
Regardless of the capacity in which you maintain a PT, your practice needs a team-oriented approach rather than having the PT feel as if he or she works for the chiropractor. Typically, PTs join an orthopedic group or large hospital group after graduation.
Working for a chiropractor is some-what nontraditional. “So, making it more about a team effort and having a multidisciplinary model will be more successful than having the PT feel as if they work for the chiropractor,” Dekanich says.
Allow the PT to devise his or her own treatment protocols for rehab, core stability work, and spinal stability. “Let them use their autonomy and skills sets,” Dekanich says. “We collaborate daily and our treatment plans are very dynamic; there is constant dialogue and we are always reviewing treatment protocols.”
In addition, ensure the PT you find is one who complements your practice. “That may be someone who sees a similar patient demographic to yours, who can add value to your manual skills by expanding the rehabilitation component, or perhaps it is a PT who specializes in a patient population very different from yours—which adds a totally new service that your clinic now provides in your community,” Fonda says. Doing so will increase your exposure, widen your market, and expand your referral sources.
Higashi says you should remember the purpose of what you are doing— trying to help more people and finding unique and effective ways to treat them—not necessarily just increasing your income. “This will prevent you from making decisions for the wrong reasons,” she concludes.
Karen Appold, an editorial consultant in Lehigh Valley, Pennsylvania, is dedicated to regular chiropractic care. She has been the president of Write Now Services, which offers writing, editing, and proofreading since 2003. Her experience includes chiropractic marketing. She can be contacted at 610-812-3040, firstname.lastname@example.org, or through writenowservices.com.