Understand the landscape before deciding to integrate a physical therapist into your practice.
If you’re like the majority of chiropractors working as a solo practitioner, the thought of branching out into a multidisciplinary operation has likely crossed your mind.
Perhaps you’ve toyed with the idea of integrating with a massage therapist, acupuncturist, or medical doctor in the hopes of expanding your services and appealing to a larger patient base.
Depending on your interest in muscle rehabilitation and function, you may have considered partnering with a physical therapist, given the over-lapping familiarity with certain codes and philosophy between the two professions.
Although PTs aren’t focused on misalignments of the spine, their skills can enhance your restoration and recovery offerings. PT services are apt to be covered by insurance when referred by a primary care physician, which can result in new patients for you.1-2
The potential benefits of collaboration may pique your interest and inspire you to create a multifaceted rehabilitation practice. But before delving into lofty reveries of flourishing cash flow and seamless integration, evaluate whether adding a PT would be a feasible direction for your practice, based on a number of logistical and legal factors.
Exercise your mind
The first step you should take in appraising your viability in this market is a mental one. To lay the groundwork for your decision, ask yourself some important questions about the nature of your current modus operandi and whether your routine is flexible enough to permit a significant change.
Do you have a willingness to work with others? Stephanie C. Higashi, DC, CEO and president of Health Atlast, says that if you can’t answer yes to this inquiry, then you might as well stop where you are. “If chiropractors do not work well with others or with professionals who have differing opinions from their own, I would not recommend it,” she says, adding that such a disposition can lead you to “clash and not succeed.”
Why are you thinking of integrating your practice? If you’re doing it solely for the money, that may not be the best reason. “The purpose of integrating practices is to help more people and offer more services,” Higashi says. “Patients can go to one clinic and receive all the treatment they need. Offices are able to bill for services that wouldn’t otherwise be covered.”
That’s not to say you shouldn’t think about the extra money. But if it’s your only reason for doing this, you may regret it.
Your first move
Prior to making any plans, be sure that you have enough patients already coming to your practice. Mark Sanna, DC, president and CEO of Breakthrough Coaching, says that chiropractors with 80 to 100 patient visits per week benefit most from the multidisciplinary practice model.
Daniel H. Dahan, DC, senior consultant with Consultants of America, estimates that number to be a little higher at 125 patient visits per week, with a minimum of 15 to 20 new patients per month.
Dahan recommends making sure you have enough funds to cover the expenses to set up this kind of enterprise. He estimates between $5,000 and $10,000 will be needed.
All three experts agree that you must work with an attorney. But not just any lawyer. “You should hire a licensed healthcare attorney who has done this type of integration before,” Higashi says. “The last thing you want to do is get this bright idea, set it up incorrectly, and then find out that it is not legal in your state or that your state has outlawed your hiring PTs—which has been contemplated several times in California.”
Hiring someone who hasn’t established a multidisciplinary practice before may also cost you a lot more money: “We have known several DCs who will just hire an attorney who is general and doesn’t know healthcare, or they will hire a healthcare attorney who doesn’t specialize in this type of integration, which results in the DC paying high rates for the attorney to research the information,” she says. “Therefore, the advice is to hire an attorney who has done this and knows what he or she is doing.”
Structurally sound
Another reason to work with a specialized lawyer is to sift through the variety of legal and corporate multi-disciplinary practice structures in your region and obtain counseling for your best interests. “The legal climate for medical practices of all kinds, including integrated or multidisciplinary practices, is in a state of constant change and varies by state,” Sanna says. “Multi-disciplinary practice varies in legal structure, from single corporate entities to multiple corporate structures linked through a complex series of legal and financial agreements. This is governed by each state’s corporate practice of medicine (CPM) doctrine. Corporate structures also vary in percentage of medical ownership required.”
For this reason, Sanna encourages the owners of multidisciplinary practices to review these structures with local legal counsel familiar with healthcare law to minimize the risk of a challenge. “The overriding legal issue relating to multidisciplinary practices is that, when required by the CPM doctrine, the medical physician plays a bona fide role as the owner and supervisor of medical services,” he says.
Likewise, it’s crucial to find out what current legislation in your state says about physicians and DCs hiring physical therapists, Higashi says. In addition to making sure that you can establish this type of practice, find out whether your state has any laws or proposed bills to eliminate this practice model. “The last thing DCs want to do is spend all the money and cost to set up an integrated model, recruit and hire a PT, and later find out that, with a stroke of a pen, the model could be outlawed,” she says.
Recruit to suit you
If you are in a state where you cannot legally hire a PT, you may be able to have one come to your office and work in conjunction as an associate to the practice. Consult with your specialized legal counsel to make sure that this arrangement is properly organized, Dahan says.
Not sure how to contact a PT? The experts suggest connecting with PTs employed within your community as well as PT schools, employment agencies, websites that promote available PT positions, and graduating students by posting on bulletin boards at the schools. You can also take an ad in local classifieds, medical journals in your area, or regional medical trade magazines. If need be, you can pay a headhunter or recruiter to find the right person for you.
If your state allows integration with a PT, think about what is important to you before conducting interviews. It’s essential to hire someone you will work well with and whose philosophies mesh with yours.
The PT you choose should be familiar with chiropractic and how it differs from his or her work. “We have seen some PTs who would watch the chiropractor adjust patients and shriek because they didn’t like how it sounded when bones ‘cracked,’” Higashi says. “Make sure the PT likes chiropractic or is willing to learn about it.”
Some PTs specialize—so check to ensure that a candidate will fit into your practice. Someone who focuses on urinary incontinence or hand rehabilitation may not be the best match.
Color between the legal lines
In addition to obtaining counseling about available practice structures and getting familiar with your state’s legislation, you also need to understand the billing complications that arise with an integrated operation. “Some insurance policies allow multidisciplinary practice members of separate licenses to access separate insurance benefits,” Sanna says. “Other policies lump all benefits under one category. He emphasizes that chiropractic services—services and procedures performed by the chiropractor—are to be billed under the DCs provider number. In addition, when patients go to see a PT, they must have a current prescription for PT before any services are performed.
“No duplication of services should occur under the various multidisciplinary practice provider numbers,” Sanna says. “For example, manual therapy, 97140, may not be billed under the chiropractor’s provider number and also under the physical therapist’s provider number.”
Higashi suggests that the more details the better. “It’s important to know that there are strict timed codes in billing and coding—they need to be aware of the codes and units they are billing as well as the required times,” she says. “I have seen and heard of DCs wanting to rush the PT. However, if they are billing timed codes, they must be performed for the allotted time to be reimbursed.”
Words of warning
If you can’t hire a PT, and choose to rent space to one, Higashi has this caution: “Note that many DCs have structured the payment by and between themselves and the PT in such a way that it violates Stark law, fee splitting, and self-referral laws,” she says. Higashi has heard of chiropractors charging inflated rent in establishing a financial partnership with a PT to work around state laws that forbid integration. But this practice is generally illegal as you can’t set rates beyond what’s considered fair market value.
“I have also heard of DCs paying PTs a percentage of what they perform as an independent contractor—again, fee splitting and self-referral laws could be violated in this situation,” she says. “Do it legally.”
Dahan concurs that these regulations are not matters to be taken lightly. “In the past, many practices have gotten in trouble for billing for services from one practitioner to the other and misusing the appropriate coding or licenses,” he says. “Those practitioners have had to shut down or refund a tremendous amount of money to the carriers.”
Tied up with a bow
Higashi advocates that you and the PT share front-office staff—provided your state allows it. Make sure your staff understands what changes will take place and that the distribution of work between team members is fair. If you’re splitting costs based on work performed or the number of staff members involved, she suggests reviewing those numbers each quarter in case growth or decline in work occurs.
As for sharing space and possibly equipment, Dahan encourages a mutual understanding that your two professions are not competing but rather complementing each other.
Before the switch occurs, let your patients know what is happening and how they can benefit from it. “Explain to patients how DCs and PTs are different and how they are similar, as well as how and why it would benefit the patient for them to work together,” Higashi says. “And the explanation needs to be more than ‘just so we can get paid more.’ ”
Inform local physicians of your practice transformation as well, Dahan says. They might make referrals to your PT if they know you have one. “If you do it well and legally, you will love it and make people better,” Higashi says.
Michele Wojciechowski is an award-winning journalist, humorist, and author of the book Next Time I Move, They’ll Carry Me Out in a Box. For more information and to contact her, visit wojosworld.com.
References
1 Freburger JK, Holmes GM, Carey TS. Physician referrals to physical therapy for the treatment of musculoskeletal conditions. Arch Phys Med Rehabil. 2003;84(12):1839-49.
2 American Physical Therapy Association. “Role of a Physical Therapist.” APTA.org. http://www.apta.org/PTCareers/RoleofaPT/. Updated February 2015. Accessed March 2015.
