<![CDATA[ChiroLogika - The Advocate]]>Thu, 17 Aug 2023 23:05:02 -0400Weebly<![CDATA[$300K SettlemenT for Improper PHI Disposal]]>Thu, 25 Aug 2022 14:58:44 GMThttps://www.chirologika.com/the-advocate/300k-settlement-for-improper-phi-disposalA press release from HHS (US Department of Health and Human Services) summarizes the final settlement between the OCR (Office for Civil Rights) and a private New England dermatology practice for numerous HIPAA (Health Insurance Portability and Accountability Act) violations. At issue was the improper disposal of empty specimen containers, which were disposed of in a parking lot garbage bin. ​
HHS Press Release
​Regardless of practice type, every office needs a HIPAA Compliance Manual specifically tailored to its data collection practices and workflow. Standard operating procedures (SOPs) for the proper handling of PHI should be a part of the Manual, along with employee HIPAA training records.

​Links for more information:
Frequently Asked Questions About the Disposal of Protected Health Information (hhs.gov)
HIPAA for Professionals | HHS.gov
U.S. Department of Health & Human Services - Office for Civil Rights (hhs.gov)
]]><![CDATA[No Surprises in Your Chiropractic Practice]]>Tue, 22 Feb 2022 22:19:37 GMThttps://www.chirologika.com/the-advocate/no-surprises-in-your-chiropractic-practice
No Surprises in Chiropractic
At the beginning of 2022, a new law, known as the No Surprises Act, went into effect. While most of us are probably up to speed on the new requirements, some chiropractors are still out there who aren’t compliant. If you’re one of them or if you’re unsure about the basics of the new rules, this blog post is for you.

The No Surprises Act is a part of the greater Consolidated Appropriations Act of 2021, which was passed into law in December 2020.[1] The purpose of the legislation is to protect healthcare consumers by addressing the pervasive issue of medical debt and improving transparency in medical billing practices. Much of the law targets healthcare facilities that provide emergency services or utilize a combination of network and non-network providers like hospitals, out-patient facilities, and transport services. But the scope of the law does not end there. Several elements apply to all providers and private practices who treat and bill any self-pay patients or provide non-covered or out-of-network services to insured patients, and chiropractic practices are no exception.

Two essential requirements must be met right away:

Notice of Patients’ Rights   
A one-page disclosure describing patients’ rights under the new law should be posted prominently in your physical office wherever discussions about finances take place. It should also be published and easily accessible on your website. CMS has a sample notice available for reference or download online. It can be accessed here: (No Surprises: Understand your rights against surprise medical bills (cms.gov))

Good Faith Estimates
Self-pay patients are entitled to receive a “good faith estimate” of the cost of care. This estimate is fairly simple. It’s a disclosure of the services and the associated charges you expect your patient to receive. It should be as accurate as possible, but since it’s an estimate and not a payment contract, deviations are allowed if and when the patient’s case demands it.  

Many chiropractic offices (especially all-cash practices) already include thorough financial disclosures in their standard new patient procedures, but the new requirements include more than just the estimate itself. They cover timing and documentation, too. By law, good faith estimates must be provided “in advance of scheduled services, or upon request.”[2] This means that an estimate should be presented at the time of scheduling and pre-appointment registration (i.e., over the phone or online). It should then be reviewed again when the patient shows up for their appointment and before any billable services start. Also, since the requirement applies to new and established patients, an estimate must be provided whenever a change to the treatment plan alters a patient’s financial responsibility or whenever a patient asks for one.

Documents, Documents, Documents

As usual, how you document these interactions matters. Your good faith estimate paperwork should include an acknowledgment that the patient signs. It should state that the estimate was provided and reviewed. It should also note that the patient had the opportunity to ask questions about it (as long as you legitimately give them the chance to ask). The signed copy then becomes part of the patient’s file, and a second copy goes to the patient for their records.

When creating your estimate forms, be sure to include procedure codes and consider any outside services that will be performed “in conjunction with the primary item or service, including items or services that may be provided by other providers or services.”[3] For example, if your standard work-up requires outside labs, x-rays, or other diagnostic testing, those charges should be included.

Disputes and Penalties

The No Surprises Act provides patients with a clear process for disputes. Bills exceeding the associated estimate by $400 or more can be formally disputed when filed within 120 days of the bill date. (More information about the dispute process and a link for dispute submissions is available online at https://www.cms.gov/nosurprises/consumers.)

As we’ve seen with other laws like HIPAA, penalties for non-compliance can be hefty and random inspections of providers or facilities are possible. Monetary penalties of up to $10,000[4] per violation can be levied in addition to mandated patient refunds.

If you aren’t already offering estimates to your self-pay patients, don’t wait. Sample forms are available online that can be downloaded and put to use right away: Notice & Consent Form Example (cms.gov), CMS-10791 | CMS. They might not fit your preferred style, but they will get the job done until you can create or find one you like better. If you already offer estimates, be sure to review your current procedures and align them with new requirements.
Implementation of the No Surprises Act is in its infancy, and more guidance on the matter is expected in the future. In the meantime, it’s worth it to review the guidance already available directly from CMS. The following links are a great place to start:
​
HHS PPDR Providers Guidance (cms.gov).  
Good Faith Estimates FAQ 12.21.2021 FINAL (cms.gov)
CMS website

Sources:
[1] PUBL260A.PS (congress.gov) Title I of Division BB of the Consolidated Appropriations Act, 2021

[2] “High level overview of No Surprises Act provider requirements”, Accessed 15feb2022 online at https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf

[3] “High level overview of No Surprises Act provider requirements”, Accessed 15feb2022 online at https://www.cms.gov/files/document/high-level-overview-provider-requirements.pdf

[4] “Surprise! It's the No Surprises Act” National Law Review, Volume XI, Number 292. October 19, 2021. Accessed online at https://www.natlawreview.com/article/surprise-it-s-no-surprises-act
]]><![CDATA[No Debate Over Masks for Chiropractors]]>Mon, 20 Jul 2020 15:06:34 GMThttps://www.chirologika.com/the-advocate/no-debate-over-masks-for-chiropractorsEditorial 

As our country struggles to manage the reality of COVID-19, governmental and organizational leaders find themselves in positions that they likely never anticipated when they initially sought their posts. Their decisions in this environment reach far beyond the typical boundaries of their constituencies, members, and direct stakeholders. They now find themselves making decisions about a global pandemic, which poses a material threat to the public at large. With that in mind, it is easy to be sympathetic to the plight of chiropractic professional boards and organizations as they juggle the diverse and passionate views of the chiropractors they oversee.

Here in North Carolina, the Chiropractic Board released a position statement requiring Doctors of Chiropractic to follow CDC guidance as well as all applicable state and local requirements. Their position statement is both prudent and reasonable. It officially aligns chiropractic in the state with the same guidance and regulations imposed upon other businesses. To put it simply, it directs chiropractors to wear masks in their offices and to follow recommended best practices to prevent widespread transmission of SARS-CoV-2.

On June 23, 2020, the Board sent the position statement along with a brief message from the president of the Board, which included the following quote: “Remember that the Board consists of 8 members, 6 of which are practicing doctors of chiropractic. At a meeting on June 19th, the Board considered input from multiple sources on the issue of masks in the chiropractic office. The Board considered the obvious challenges such as discomfort and image issues related to doctors and staff wearing masks in the chiropractic office.”

It is comforting that our State Board landed on the side of science and public health. While a robust discussion of fact and opinion is appropriate before any action taken by the Board, it is, however, disconcerting that they felt compelled to highlight their debate over “discomfort and image” in their message to their licentiates.

As a follow-up to the Board’s email, North Carolina’s newest chiropractic professional association sent out an open poll to its email marketing list. The survey contained several questions regarding opinions about the Board’s position, including nonsensical questions about mask-related CO2 toxicity and pleurisy, as well as other philosophy-driven questions that lacked any apparent awareness of the rapidly rising infection counts and death rates in our state and across the county.

The debate over masks in chiropractic offices is not isolated at the state level. On July 13, 2020, the International Chiropractic Association (ICA) released a YouTube video, promoting the opinions of Kelly Victory, MD and describing her words as “the truth about COVID-19.” Victory’s video presents her claims as facts. She perpetuates a host of extreme statements about SARS-CoV-2 and COVID-19, including an unsubstantiated assertion that social distancing and masks are not scientifically justified. Since scientific understanding of this virus remains incomplete at this time, statements made with absolute certainty that minimize SARS-CoV-2’s potential for widespread harm are dangerous until we know more. (Victory’s original video has been removed from YouTube as of July 16, 2020, but it is archived here.)

COVID-19 has become an extreme public health event largely because of political and philosophical hubris. It is undeniable that SARS-CoV-2 is highly communicable, it disperses through aerosolized droplets, and it can be emitted by symptomatic, pre-symptomatic, and asymptomatic people. In a perfect world, this new virus would behave like a common cold virus. It would proliferate, our immune systems would respond, some of us would become visibly ill, some of us would not, and the world would move on with limited disability and loss of life. That is not what is happening in this case. SARS-CoV-2 is not following the path of a common cold virus, nor is our world a utopia of perfect immune systems. Our world and this virus are complicated, and this global crisis requires an extreme and unified response from us all—healthcare workers and non-healthcare workers alike.

In chiropractic, many doctors lean heavily on philosophy for marketing and patient education. While Chiropractic Philosophy is not necessarily incorrect, we must have the humility to admit that there is not a plethora of reproducible, peer-reviewed evidence to support those claims. Many of us have witnessed dramatic changes in the general health of our patients after commencing chiropractic care, but without adequate research, much of this information remains anecdotal. When viewed through the lens of general public health during this pandemic, it is clear that a philosophy-only approach is inadequate to save the most lives. We cannot know which of our patients will achieve a sufficient degree of innate immunity to weather COVID-19 successfully. We cannot know if their families, friends, and coworkers will be suitably equipped if our patients pass the virus along to them. Furthermore, we do not yet know with certainty that SARS-CoV-2 infections will clear without sequelae or long-term disability.

Conversely, there is adequate evidence to support the use of masks to mitigate the spread of viral particles between humans. Face masks are easily manageable tools that can help change the course of this epic national event for everyone. (A list of informational resources for patients is available at the bottom of this article.)

“Optimal health” is a moving target for many chiropractic professionals and their patients. Often, it is a goal rather than a reliable reality. It is unconscionable to promote a philosophy that suggests a life lost to COVID-19 is merely collateral damage on the path toward “herd immunity,” which is frequently misunderstood and is unlikely to be achieved in the immediate future.  We must never lose sight of the lives that have been lost, just as we must never wantonly risk the lives of those that remain. It is a chiropractor’s duty to help and protect all people—whether they utilize chiropractic care or not.

In the context of COVID-19, donning a mask is neither an act of capitulation nor an excessive burden. It is imperative that chiropractors continue to provide treatment during this crisis, but we must do so in a manner that integrates unfolding scientific evidence and public health policies. As chiropractors, we should be leading the charge for widespread use of facemasks, distancing, and handwashing in addition to the promotion of healthy diets and lifestyles. At a minimum, we must put the safety and wellbeing of our patients and our communities first, which requires us to put aside our internal polarizations and dogmatic mudslinging until this crisis has passed.

Author: Kirstin A. Counts, DC
​July 20, 2020

For resources concerning cloth masks for the general public, please visit the following links:
How to Properly Wear a Face Mask: Infographic
How to Wear Cloth Face Coverings
COVID-19 advice for the public: When and how to use masks
 
References Links]]><![CDATA[COVID-19 Chiropractic Documentation]]>Wed, 10 Jun 2020 14:48:26 GMThttps://www.chirologika.com/the-advocate/covid-19-chiropractic-documentationCOVID-19 Chiropractic Documentation—Creating a TPP

In the era of COVID-19, chiropractic practices are facing many challenges. The rapid changes to practice guidelines, restrictions, and recommendations can be overwhelming and present a new area of personal and professional vulnerability. 

This article presents a basic outline for the creation of a Transmission Prevention Plan (TPP) as a formal epidemic response plan for your office. If an event like COVID-19 can happen once, it can happen again. Whether it’s a local outbreak or a global pandemic, it’s important to be prepared and document your efforts to mitigate risk on multiple fronts.

The outline offered here is, by no means, complete or perfect. It is merely a starting point. Your plan must be customized to fit the specific needs of your office, as well as your state and local regulations. If Federal regulations pertaining to this issue expand to include chiropractic facilities, it will also need to be modified to meet those requirements.

The general TPP outline is as follows:

Transmission Prevention Plan (TPP)
Practice Name:
Practice Address:
Document Creation Date: 
  (1) Definition and purpose. 
  (2) Written procedures and standards. 
        a. Cleaning procedures
              i. Products. 
             ii. Frequency. 
            iii. Disposal. 
            iv. Instructions.
                    1. General Procedures.
                    2. Restrooms.
                    3. Other patient areas/rooms.
                    4. Other employee-only areas/rooms.
                    5. Equipment.
                    6. Fixtures/Furniture.
                    7. Other. 
         b. Hand Hygiene.
         c. Personal Protective Equipment (PPE). 
         d. Procedural changes.
               i. Patient intake procedures. 
              ii. Employee/patient interactions. 
             iii. Gowns. 
             iv. Laundry.
              v. Adjustment techniques. 
             vi. Examination procedures.
            vii. Laboratory testing.
           viii. Imaging Procedures.
             ix. Therapies and Modalities. 
         e. Temporary Signage.
          f. Employees.
         g. Staff/Employee Health Monitoring.
         h. Staff/Employee Training. 
  (3) Records.
         a. Training records.
         b. Cleaning records.
         c. Daily staff health monitoring records.
       d. Plan Implementation and Change Log (PICL). [This is a log style record of the significant events pertaining to the plan: when and why the plan was put into action, when modifications were made, any deviations that occurred, and when the plan was discontinued. Think of it as progress notes for your office while the TPP is in effect. Additions should be dated and signed.]
     e. Incident Reports (IRs) and the Corrective and Preventive Action (CAPAs). [Describe how and when these reports will be used and how they will be maintained. Use an IR to describe any critical events that occur. Use a CAPA to describe what has been done to prevent the issue from happening again.] 
  (4) Designated TPP Manager. [Name the person responsible for creating and maintaining the TPP, associated documents, and activities.]
  (5) Annual Review. [Describe how, when, and by whom the plan should be reviewed.]
 (6) Document Maintenance. [Describe where, how long, and in what format these documents should be maintained.]
  (7) Signatures/Dates. [Named reviewers should sign and date the document as indicated.]

As with any other office plan, a TPP will grow and change over time in response to experience and circumstance. When updates or changes occur, a statement of the changes must be created, signed, dated, and permanently attached or stored with the original document. If the plan must be significantly changed or rewritten, a new version of the entire plan document should be created. The new version will supersede its predecessor. It must be clearly identified as a replacement for the original with appropriate dates and signatures, and all versions of the plan must be maintained together. 

Should your TPP be a physical or electronic document?

At this stage, it doesn’t matter. The most important thing is to develop your TPP and put it into practice. A paper manual is a simple way to get started. In the long run, an electronic TPP and electronic versions of the associated records and updates may be easiest to maintain with appropriate electronic signatures and audit trails. 

Why should I bother when a TPP isn’t required?

Chiropractic is not typically a passive form of practice. While we can successfully utilize use tools like telehealth appointments to communicate with our patients, our interactions most typically happen on a personal level—face to face, hand to spine, and so on. It is incumbent upon every member of our profession to take measures to prevent the transmission of potentially harmful communicable diseases through robust hygiene and sanitation practices. Adequate documentation of these practices is critical to demonstrate those efforts, and the TPP can be referenced in your patient notes to document your cleaning procedures.

If it isn’t written down, it didn’t happen. 

In many cases, documentation is more complex than simply writing down a few sentences. Proper documentation usually needs to be legibly noted, signed, dated, maintained, and retrievable. Otherwise, our ability to defend our actions is limited. 

Most often, patients seek chiropractic care because their bodies are injured, sick, or in pain. This means that their systems (including their immune systems) are not functioning at their peaks. It’s our mandate as healthcare providers to do everything in our power to protect them and help them heal. Proper sanitation and hygiene practices are important components this mandate. As a profession, we must be prepared and consistent with our actions. We do not want our offices to be unjustly viewed as vectors of transmission. The creation and implementation of a TPP will provide your practice with a well-considered, documented path forward through this uncertain and stressful period. 

Remember, documentation is not just about getting insurance to pay for patient visits. It’s about protecting you, your practice, your employees, your patients, and our profession as a whole. Over the next few weeks, more information on TPP documentation and tools related to this subject will be posted on the main ChiroLogika website. As we move forward together through COVID-19 and beyond, let’s all be healthy, safe, and united for the future of Chiropractic and for the patients who need us.

Author: Kirstin A. Counts, DC
June 10, 2020
​
Reference Note:
The information suggested here is loosely based on information found in the Code of Federal Regulations, or CFR. The complete CFR with updates can be accessed here: 
https://www.ecfr.gov/cgi-bin/ECFR?page=browse&mc=true&SID=3676b23e49b9605f3ef5ed5f80b0395a

​Additional Resources:
https://www.osha.gov/SLTC/covid-19/
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/businesses-employers.html
https://www.cdc.gov/coronavirus/2019-ncov/hcp/us-healthcare-facilities.html]]>