Understand the legal framework to stay in compliance
The landscape of healthcare delivery is evolving rapidly, and chiropractic is at the forefront of this transformation.
Integrated practices bring together DCs, medical doctors, physical therapists, physician assistants and nurse practitioners to provide a comprehensive, patient-centered approach to healthcare. However, creating and operating a legally compliant and clinically effective integrated practice requires a deep understanding of the regulations governing collaborative care.
An increasing number of healthcare professionals recognize the benefits of collaboration. An integrated approach allows patients to receive a broader range of services within a single practice, improving outcomes and efficiency. However, transitioning from a chiropractic practice to an integrated model requires careful planning, including recruiting the right medical personnel and structuring the practice in compliance with state and federal laws. One of the first considerations is corporate structure, as some states prohibit DCs from owning medical practices. Understanding these legal frameworks is critical to ensuring a practice operates within the law.
Avoid legal pitfalls in integration
A properly structured integrated practice is not a loophole to circumvent scope-of-practice restrictions, nor is it an opportunity to increase reimbursement by misrepresenting chiropractic services as medical procedures. It is also not a way to fraudulently obtain insurance coverage for non-covered chiropractic care. Instead, when structured correctly, an integrated practice enhances patient care by integrating medical, chiropractic and rehabilitative services in a legally sound manner. The primary goals should always be to improve clinical outcomes, increase patient satisfaction and optimize operational efficiency.
Many regulations govern integrated practices, and compliance is non-negotiable. The Corporate Practice of Medicine (CPOM) doctrine, currently followed in 33 states, prohibits non-physicians from owning medical practices or employing physicians to provide clinical services. This doctrine ensures clinical decisions are made by licensed healthcare providers rather than influenced by business interests. Violating these laws can result in severe penalties, including fines, loss of licensure and criminal charges.
The role of the medical director
In those states that require medical ownership and a collaborating physician, an integrated practice requires a clearly defined role for its medical director. The medical director must actively participate in patient care and oversee clinical services. State board inspectors and federal agencies have increasingly scrutinized medical directors who fail to document their services or who lack an active role in the practice. If a medical director is paid but does not provide actual services, the government may consider those payments illegal kickbacks for referrals.
Violations of the federal Anti-Kickback Statute can lead to criminal charges, fines and exclusion from Medicare and other federal healthcare programs. To remain compliant, practices must ensure that medical directors actively participate in patient care, maintain thorough documentation of services provided and have a clearly defined role.
Billing and coding compliance
Billing and coding compliance is another critical aspect of running a legally sound integrated practice. Chiropractic services must always be billed under the DC’s provider number and cannot be billed under a medical doctor’s provider number. Physical therapy services must be performed by a licensed physical therapist or a physical therapy assistant under appropriate supervision. Recent changes in supervision rules now allow physical therapists to oversee physical therapy assistants remotely via telecommunication.
Practices must also avoid blended billing, where all services are billed under an MD or PA to maximize reimbursement. Each service must be billed under the provider who actually performed it. Patients cannot move between multiple tax ID numbers within the same practice to maximize reimbursement, as the Stark Law prohibits this type of financial arrangement. All licensed healthcare providers must be W2 employees of a single tax identification number. Independent contractor or 1099 employment agreements may be in violation of the Stark Law.
Eliminate risky practices
Integrated practices must also be mindful of the rules surrounding standing orders. Some practices attempt to pre-schedule medical services before a physician has examined the patient, a practice that is illegal. Before any medical service is billed, a physician must evaluate the patient, establish a diagnosis and order appropriate care.
Timing the onboarding of new providers is another crucial factor, as proper credentialing must be completed before insurance can be billed for their services. The credentialing process can take several months, making careful planning essential to avoid costly delays and compliance issues.
Another major compliance issue arises when integrated practices bill for the same service under two different providers’ numbers. If a DC and a physical therapist both bill for manual therapy for the same patient visit, this constitutes duplicate billing and is a red flag for auditors. Each provider should have a distinct role in the patient’s care, and their services should be clearly documented and differentiated.
A practice must also establish a compliance program that includes a designated compliance officer, regular training for all staff, a structured fee schedule aligned with regional standards and annual internal audits to identify and correct coding and billing errors.
Common pitfalls in integrated practices
Many practitioners believe they can figure out the complexities of running an integrated practice on their own, but failing to seek proper legal and compliance guidance can lead to severe consequences. Some of the most common mistakes include hiring a ghost medical director who does not actually participate in patient care, failing to credential new providers before billing insurance and lacking a collaborative treatment protocol. Without a well-defined care protocol, an integrated practice can quickly become chaotic, with patients receiving disjointed, uncoordinated care. Additionally, inadequate documentation can lead to payers and regulators assuming services were never provided, resulting in recoupments, audits and penalties.
The benefits of a well-structured integrated practice
When structured correctly, an integrated practice offers significant benefits. Expanding the team to include a physical therapist, physician assistant or nurse practitioner allows the practice to offer services that would otherwise require an external referral. A physical therapy department can become a practice within a practice, providing a steady source of new patients and income. While some medical doctors hesitate to refer patients to a DC, they are often more comfortable referring to a physical therapist or medical provider within the same integrated setting.
Adding a physician assistant or nurse practitioner under the direction of a collaborating physician allows for an expanded range of services, including pain management, regenerative medicine and aesthetic procedures. This diversification creates multiple revenue streams, both patient-pay and insurance-covered, which strengthens the financial health of the practice.
Final thoughts: Build a sustainable integrated practice
A successful integrated practice is not just about bringing different providers together under one roof—it is about integrating services in a way that improves patient outcomes while maintaining strict compliance with healthcare laws. The best way to ensure an integrated practice is structured correctly is to consult with a healthcare attorney who understands the regulations specific to each state. Practices must implement clear treatment protocols to facilitate collaboration and develop a comprehensive compliance program. Proper documentation of all services is essential to support billing and legal compliance.
While the rewards of collaborative care are substantial, they can only be realized through meticulous planning, adherence to legal requirements and a commitment to ethical and effective patient care.
Editor’s note: The author’s use of “integrated practice” includes physical therapist. Chiropractic Economics defines integrated practices as including DCs, MDs, DOs, NPs, NDs and PAs, and multidisciplinary practices as including PTs, MTs, nutritionists, acupuncturists, etc.
Mark Sanna, DC, ACRB Level II, FICC, is the CEO of Breakthrough Coaching, a practice management company for chiropractic and multidisciplinary practices. He is a Board member of the Foundation for Chiropractic Progress, a member of the Chiropractic Summit and a member of the Chiropractic Future Strategic Plan Leadership Committee. Sanna is the author of “Cracking the Code: Marketing Chiropractic—How Chiropractors Align Spines and Minds,” available on amazon.com. To learn more, call 800-723-8423 or visit mybreakthrough.com.
