Confessions from a chiropractic review expert

You can avoid various chiropractic review violations and patient complaints by adopting a clear communication strategy that underscores the importance of trust between doctor and patient.

I have been a chiropractic review expert for almost 20 years. In that time, I have reviewed a lot of cases brought as complaints from patients, attorneys, family members, other doctors, employees and claims adjusters.

I would estimate two thirds of the chiropractic review complaints I have reviewed during my career were invalid, meaning the DC did nothing wrong. Several of these complaints arose due to billing issues, miscommunication or the patient making assumptions about the treatment. Examples of these include:

A patient paid for a prepaid plan and at the end of treatment, felt they were not completely better or “cured” and filed a claim against the DC. In this particular case, the DC never promised a cure and the patient had signed several disclosure forms that explained no specific outcome was guaranteed. Remember, you cannot promise cures, and you cannot make claims of professional superiority unless you have objective scientific evidence.

In a personal injury case, either a patient or their attorney filed a complaint about the cost of treatment after all treatment had been performed. The DC, who is not required to reduce the bill in these circumstances, was not willing to reduce the bill or did not reduce the bill enough to satisfy the complaint.

A patient paid for a prepaid plan with a credit card, then had a change of heart and wanted her money back. She refused to give the DC her card again so he could credit her account. In the end, she stopped payment on the card and did not lose any money, but still filed a complaint against the DC.

A patient unhappy with treatment or feeling they were injured by the treatment went to another doctor who, without any documented proof, unprofessionally made statements that the initial DC had hurt the patient. In one case, an older patient who had been treated by a DC had several health problems, including a previous stroke, and three days after an adjustment had a second stroke. According to the patient, she went to a neurologist who told her the DC caused her stroke, although the neurologist’s records made no reference to this claim.

Many complaints were issued simply because the DC did not explain to the patient what they were doing. In one instance, a complaint came from the patient, who had been a patient for years, because the doctor was doing Logan basic for the first time on the patient and didn’t explain where he was going to touch the patient. Another complaint occurred because the patient felt uncomfortable when the doctor did an anterior rib adjustment but didn’t explain where on her body he was going to put his hands; that doctor ended up with another complaint issued against him because he touched the patient’s buttocks while doing a sacral adjustment.

So, always explain to patients what you’re going to do before you do it. Make sure they understand where you’re going to place your hands and why you are doing what you’re doing. For instance, I practice Activator Technique. When I am going to perform a pubic bone adjustment on the patient, I show them on a skeleton model where I’m going to adjust, have them find the bone on their own body, and then, using discretion, I perform the adjustment.

Billing issues

If you are a Medicare provider, you can only bill the patient for those services Medicare does not cover. You cannot collect cash for an adjustment and then bill Medicare for that same adjustment.

You cannot forge the patient’s signature or copy the patient’s signature and paste it to several other dates. You cannot charge for services without documenting what you did. Do not just copy and paste your notes to save time. For example: One doctor’s notes had the same misspellings 19 times in a row. He saw the patient 28 times, and his subjective complaint notes never really changed.

Other complaint cases

Inappropriate conduct allegations

Unprofessional conduct, sexual abuse, sexual misconduct: No need to go into detail—just don’t do it. Don’t touch a patient inappropriately. Don’t make suggestive comments to a patient or respond to a patient’s suggestive comments. Don’t try to have a relationship with a patient other than the doctor-patient relationship. Don’t become friends with the patient on Facebook or Instagram. Do not text the patient, with the exception of scheduling an appointment or following up on a missed appointment.

If you really want to protect yourself from this type of complaint, never be alone with a patient. This does not mean you have to have a staff member in the room with you, but never see a patient in your office alone. If you need to see a patient after hours for whatever reason, have someone with you. Bring your spouse, friend, son or daughter.

My treatment rooms have no doors, and the walls do not extend all the way to the ceiling. Patients are informed of this situation in my informed consent and on my HIPAA form. If a patient needs total privacy for any reason, I have three rooms they can use.

Documentation violations

There are also chiropractic review cases in which the doctor may not be guilty of a patient’s accusations, but is guilty when it comes to improper documentation. Violations in documentation include:

Not having the patient’s full name, date of birth and Social Security number, if available
Not having the patient’s height, weight and gender
Not having a history or chief complaint
Not providing a diagnosis
No signatures of the doctor providing treatment
No signatures of the patient agreeing to costs or treatment
Missing dates of treatment that were billed
And the number one violation I see: no signed informed consent form.

Self-defense strategies

The patient can file a complaint for many reasons. Many of those reasons are unjustified, but you still have to go through the process of defending yourself, which is not fun. So here are some things you can do to protect yourself as much as possible:

Sign or initial each date of treatment.
Put all of your forms on letterhead.
Keep all emails and texts to and from patients.
Stop with the “check-mark” notes.
Do not copy and paste your notes.
Don’t just bill the highest E/M code without the proper documentation and service to justify the charge.
Do not bill a 98941 code if you only have two areas of complaint with only two areas diagnosed.
Be professional at all times with your patients. Always maintain the doctor-patient relationship. If a patient is making uncomfortable advances, be sure to have a staff member around when you treat them.
Keep good, legible, complete notes.
If a patient complains about billing, keep a documented history of the complaints and your correspondence.
Make sure you have an informed consent form in writing, signed by the patient.
Be professional with your employees. Do not date your employees.
One doctor was very proactive and smart: He had an employee who was becoming a problem. He planned to fire this employee. He had a human resources professional, a woman, present when he fired the employee. This one act saved him because the employee filed a complaint alleging sexual harassment. Her actions during the termination process, which were documented by the female HR professional, saved his reputation and possibly his license.
If you want to terminate a patient relationship, write a termination letter to the patient giving that patient three other doctors’ names and contact information so they may choose one of those doctors to continue care.
Communicate with your patients. If they are unhappy for whatever reason, discuss it with them. Sometimes a little misunderstanding can be ironed out, but if you do nothing that patient may file a complaint, and justified or not, you will have to defend yourself against it.
If you are getting weird vibes from a patient, don’t ignore those feelings. Be on guard for the patient who refuses to sign any paperwork, the patient who complains that the last two or three DCs were abusive or sexually inappropriate, or the patient who, innocently or not, asks you to do something inappropriate or even illegal. For example, asking to be put on disability for a month when you clearly know the patient can perform their job or asking you to treat a friend but bill their insurance. Watch out, too, for the attorney who wants a kickback for referring a patient to you. These are all red flags. In my office in these cases, we do what we call GPO3 (“Get Patient Out of Office”).

Final thoughts

Always be professional. Document. Keep personal distance. Bill properly. Communicate. If something doesn’t seem right, get more testing. If you need to, refer a patient out or release the patient with a choice of three other doctors. Your reputation, your livelihood, your license and your family depend on it. If it does not seem right, just don’t do it.

Chiropractic review expert Edward Olff, DC, has been a practicing doctor of chiropractic for 31 years and is the owner of Blackstone Chiropractic. After completing his studies at the State University of New York at Stony Brook and Suffolk County Community College, he attended the National College of Chiropractic, now the National University of Health Sciences, in Lombard, Illinois. Olff is a longtime member of the California Chiropractic Association. He specializes in treatment of motor vehicle crash injuries. For more information, email epodc@att.net.