By Nancy Miggins, DC & David Marcarian, MA
The current healthcare ecosystem mandates efficiency and objectivism. The requirements to document, bill third party payors and actually get paid are becoming increasingly more rigorous and laborious. It is no longer enough to properly document and code what you do in your examination and treatment of a patient, it is essential that you can prove medical necessity and substantiate your clinical decisions with objective data.
Chiropractors believe they are immune and can fly under the radar of insurance audits and fraud investigations. Unfortunately, you can’t avoid the radar. Insurance companies have been establishing utilization profiles for years and they know your every move.
Emphasis and focus should be placed on strict compliance, meeting normative standards and employing proper testing and technology to generate objective, clinically relevant data. Even well-intentioned outliers get audited.
Today’s successful Chiropractors are empowered with real data, not dogma, and are embracing evidence-based practice. Evidence-based practice incorporates objective data; data that is factual, unbiased, and unchanged by personal feelings or interpretations, to help determine the best course of treatment.
Unlike previous paradigms which relied heavily upon patients’ blind faith in their doctor, evidence-based practice seamlessly blends the doctor’s clinical expertise with research proven diagnostic technology. Evidence provides peace of mind for the patient and the third party payer.
Objective data bolsters your clinical opinion and provides a means to monitor patient progress and effectiveness of treatment. Adjustments to the patient’s program of care can be made efficiently, resulting in improved outcomes and more cost-effective treatment.
Technology is the answer to cover your assets. One size does not fit all, however, so it is important to use the right tool for the job.
Static sEMG provides information about muscle firing while in the neutral posture. Taking only a minute or two to perform, this is the ideal quick screening tool. It shows the effect of subluxation on the muscles of the spine, along with postural influence, short leg, and head forward position. At minimum, Static sEMG is a form of electronic palpation yet unlike palpation, has great inter-examiner reliability. It displays an easy to interpret graphic to enhance patient awareness and education.
New University research has validated Standing Static sEMG studies as clinically valuable.1 Even more important, the Veterans Administration established the Static sEMG as capable of accurately tracking patient progress (2).
Dynamic sEMG uses EKG electrodes attached to the skin, measuring muscle response continuously as the patient moves. This technology boasts over 7500 research papers published to date. It’s ability to determine presence or absence of soft tissue injury was established in a major Superior Court decision in the State of Florida (3). The AMA has recently provided a specific CPT code for billing.
Dynamic sEMG has recently evolved into a more effective and efficient technology known as DynaROM sEMG, in part due to a meta-analytic review from The University of Michigan. Researchers found the clinical value of Range of Motion was significantly enhanced by incorporating Dynamic sEMG. By measuring and graphing ROM and Dynamic sEMG simultaneously, one can see if muscle guarding and bracing accompanies limited range of motion. If it does not, the patient is most likely magnifying symptoms.
Dynamic sEMG coupled with simultaneous computerized ROM is the only truly objective testing available to Chiropractors for determining the presence or absence of soft tissue injury (1,4).
Brandon Casey, partner at Casey Law Offices, states “Attorneys like evidence, and by that I mean actual evidence-based treatment, not opinion.” He goes on to say “sEMG studies are the best proof of soft tissue injuries. In this day and age of skepticism, they are essential in a litigation case.”
With the latest in evidence-based technology, the process of providing insurers and attorneys with objective, physiologic data is simple and quick, requiring only a small time investment by the practitioner or trained assistant. Objective data leads to an objective Doctor, creating clinical competence. The doctor who embraces and integrates such technology will sleep better, knowing the burden of proof lies in the insurer’s hands in an audit, as data wins over opinion 99% of the time.
1. A Meta-Analytic Review of Surface Electromyography Among Persons With Low Back Pain and Normal, Healthy Controls. Geisser, Ranavaya, Haig, Roth, Zucker, Ambroz and Caruso published in the Journal of Pain, November 2005 p 711-726.
2. VAS Score Correlates with Static Surface EMG Signal Intensity in Chronic Spine Pain. Ambroz, Alex MD,VA Medical Center, Martinsburg, WV Ambroz, Clara MD, MPH, Disability Evaluation Services, Martinsburg,WV Zucker, Robert MD, MPH,VA Medical Center, Martinsburg, WV Benjamin, Eugene MD,VA Medical Center, Martinsburg, WV Caruso, Marianne RN,VA Medical Center, Martinsburg, WV. PAIN MEDICINE Volume 6, Number 2, 2005 p 28-29.
3. Richard W. Merritt vs. Florida Dept. of Health et al (Case No. 04-1149RX)
4. Gerhardt, John. “Utilizing sEMG in the medical-legal arena to prove presence or absence of soft tissue injury”, White paper: 2011.
Written by David Marcarian, MA and Nancy Miggins, DC
As the original Chiropractic “Technogeek”, I feel obligated to make the lives of Chiropractors easier and more productive through the use of technology. One age-old issue screaming out for a technological solution has piqued my interest. It is well known that patients retain only 5-20% of what the doctor communicates; even less at a screening. Without being able to reinforce the message we convey, and do so quickly and effectively we lose our patients’ attention. Traditional solutions have relied upon everything from general pamphlets and videos espousing the value of Chiropractic, to expensive celebrity endorsements. We have struggled for decades attempting to “sell the invisible” and still only appeal to 8% of the population.
The emergence of Static sEMG in the early 90’s attempted to provide a user-friendly technology that produced patient-friendly graphics, but was limited by technological and reliability issues. This technology not only forged the way for evidence-based practice, providing objective data that Chiropractors need and patients want, but also provided an effective tool for internal marketing and spinal screenings, a mainstay for generating new patients. Yet the problem still persists.
What does a NASA researcher do? Seek out data, and observe. So that is what I did. Instead of interviewing doctors, I spent four months interviewing patients.
In the process of interviewing patients, an issue with significantly greater impact on the profession was exposed: Those in pain easily garnered the support of friends and family members in choosing Chiropractic as the treatment of choice. Those not in pain seeking Chiropractic care for general health and wellness, clearly expressed one common challenge: Each and every one admitted they found it extremely difficult to justify their Chiropractic visits to family and friends.
More important than this was the emotional response I received from patients who had taken home their Static sEMG test as it validated their complaints to cynical family members. One patient actually cried saying “My husband didn’t believe me until I showed him my print out”. You go to the doctor when you’re sick. You see the Chiropractor in pain. Why would you possibly go if not in pain?
We’ve been attempting to implement the dental model of “preventive care” for years with little success. But to a Technogeek, this is just another fun problem to solve.
In reviewing the literature on patient communication, I found some clear trends (1, 2, 3, 4).
In the days prior to objective data, we would pleasantly say “thank you”, and go off to get several opinions potentially putting off fixing the problem for months or even years! Sound familiar?
We in the Chiropractic Profession share the mechanics dilemma, and may learn a lesson from their approach. We live in a data driven society. Show them why with “instant” indisputable, objective data and we overcome not only their objections and reinforce the need for care, but overcome family members objections. In a data driven world, objective data rules, and those with it have the power to convince. Whether it be mass airflow sensors or wellness care. The key is finding a way to transmit this data in an electronic, instantaneous form which is visual in nature for maximum effectiveness.
I realized that it would be most intelligent to meet the patient where they lived… on their smartphone! Nielsen reports that more than 50% of mobile consumers are using smartphones. According to Nielsen’s monthly analysis of cell phone bills for 65,000+ lines, smartphone owners – especially those with iPhones and Android devices — are consuming more data than ever before on a per-user basis. This is an enormous captive audience waiting to be engaged.
It was crucial that this process maximized the use of technology to remove the need for human interaction and labor. Unnecessary labor is proof of a poorly designed system. This tool had to be fast, allow for instant communication, and provide indisputable, objective data which could be easily presented to skeptical family members and friends. Due to the fact everyone has smartphones, it has to be easily viewable on the tiny screen. Allowing the texting of the image via SMS would improve its effectiveness.
With major technological improvements that have tripled the speed of muscle tension measurements, the tool of choice for this objective data would be Static sEMG. Although Thermography was considered, it is too finicky due to sensitivity to environmental heat and cold, making screenings difficult. Additionally, patients can’t feel temperature differences between left and right sides of their spines, making the results less “believable”. Modern, Wireless Static sEMG can be performed in virtually any environment. More importantly, everyone knows the ache of muscle tension, making instant credibility the doctor’s reward when the graphed results reflect what the patient feels. New University research has validated Standing Static sEMG studies as clinically valuable (6). Even more important, a major study by the Veterans Administration established the Static sEMG as capable of accurately tracking patient progress (7, 8).
Impersonal is ineffective. If the patient’s personal Static sEMG results, graphical in nature could be instantly transferred to the patient’s smartphone, that crucial communication between doctor and patient would be reinforced within seconds. Unlike a generic pamphlet on the value of Chiropractic, the patient needing to prove the necessity for care can instantly forward from their smartphone the test results to skeptical family members. Another requirement is for the graphical image to act as an “E-Business Card”, presenting both specific information on the doctor’s office, and an easily customized special offer. The impact on those who’ve received the forwarded, visually appealing graphic would provide powerful advertising for the clinic.
So I built this thing, filed patents and tested it. And guess what else happened. In Beta Testing all of the above conditions were met, and more. The big surprise was how many patients posted this graphic image on Facebook, and did so while still in the doctor’s office! Imagine the impact of your office information marketed by your patients at no cost to you? With the average person having 120 Facebook friends (5, 9), the value in terms of marketing alone is quite significant.
The tool proved invaluable at screenings where not only did the patient walk away with an instant personalized message, but also knew exactly how to reach you to take advantage of the special offer embedded in the graphic. Even better, the doctor stored the prospective patient’s email address for instant follow-up and future email marketing.
The term “Viral Growth” is an understatement when it comes to the impact of these visual images flying around the internet. The biggest surprise of all is that each and every patient tested said, and without exception (after saying “Cool”, that is): “Now I can show my _______ why I need my Chiropractor.” It is unknown if this can get us beyond that 8% of the population we’re seeking. Considering the massive proliferation of Smartphones, it at least takes advantage of a new form of high-tech, low cost marketing with potentially powerful consequences.
Technology can be your best friend or worst enemy. By finding the best product and support for your needs, you will have a great partner in building your practice. Follow the simple guidelines above, and you will enjoy all, the advantages of technology without the stress.
1. Thom DH. Training physicians to increase patient trust. J Eval Clin Pract. 2000 Aug;6(3):245-53.
2. Betancourt JR. Cultural competence—marginal or mainstream movement? N Engl J Med. 2004;351(10):953-5.
3. Osborne H. In Other Words…Actions Can Speak as Clearly as Words. Boston Globe’s On Call Magazine. Jan/Feb 2006. www.healthliteracy.com/article.asp?PageID=3763 (accessed Mar 3, 2006).
4. Osborne H. In Other Words…Teaching with Pictures. Boston Globe’s On Call Magazine. Nov 1999. www.healthliteracy.com/ article.asp?PageID=3822 (accessed Mar 3, 2006).
5. Dunbar, R.I.M. (June 1992). “Neocortex size as a constraint on group size in primates”. Journal of Human Evolution 22 (6): 469–493. doi:10.1016/0047-2484(92)90081-J
6. A Meta-Analytic Review of Surface Electromyography Among Persons With Low Back Pain and Normal, Healthy Controls. Geisser, Ranavaya, Haig, Roth, Zucker, Ambroz and Caruso published in the Journal of Pain, November 2005 p 711-726.
7. VAS Score Correlates with Static Surface EMG Signal Intensity in Chronic Spine Pain. Ambroz, Alex MD,VA Medical Center, Martinsburg, WV Ambroz, Clara MD, MPH, Disability Evaluation Services, Martinsburg,WV Zucker, Robert MD, MPH,VA Medical Center, Martinsburg, WV Benjamin, Eugene MD,VA Medical Center, Martinsburg, WV
8. Caruso, Marianne RN,VA Medical Center, Martinsburg, WV. PAIN MEDICINE Volume 6, Number 2, 2005 p 28-29.
9. Marlow, Cameron: “Maintained relationships on Facebook” 2009, March 9, www.facebook.com
Many Chiropractors find their way into the profession because they have had a positive, life-changing experience with Chiropractic. It is a profession where miracles, great and small, happen on a daily basis. Few Chiropractors, however, take the time to identify, plan and build their niche practice and instead accept what comes their way.
Most Chiropractors have dabbled with accident recovery, but only a small fraction of the Chiropractic profession has chosen to become experts in the personal injury arena. Personal Injury practices flourish regardless of the economy. In 2011 alone, an estimated 2.22 million people were injured in motor vehicle traffic crashes.1 This astounding number does not include those people who do not report injuries at the time of filing an accident report. Those who reported a traffic accident experienced an 84% increase in the likelihood of new onset chronic widespread pain (2).
Furthermore, according to the Bureau of Labor Statistics (BLS), more than one million workers suffer back injuries each year, and back injuries account for one of every five workplace injuries or illnesses. In addition BLS states that one-fourth of all compensation indemnity claims involve back injuries, costing industry billions of dollars on top of the pain and suffering borne by employees.
Personal Injury provides Chiropractic with an abundance of injured patients in need of treatment and guidance. The complexity and diversity of injuries sustained as a result of a motor vehicle or work-related accident can be intimidating to the victim. While these types of accidents are a common occurrence, few people understand the importance of seeking qualified expertise in both the medical and legal aspects of the case. Getting proper care from a qualified professional in a timely manner and, as important, following through with that care to full recovery is essential.
With the latest in evidence-based technology, the process of providing insurers and attorneys with objective, physiologic data is simple and quick, requiring only a small time investment by the practitioner or trained assistant. Dynamic sEMG coupled with simultaneous computerized ROM is the only truly objective testing available to Chiropractors for determining the presence or absence of soft tissue injury.3,4 Objective data leads to an objective Doctor, creating clinical competence.
There are no shortcuts to success in the personal injury industry. The skills developed by mastering this evidence-based, patient-centered field create a solid foundation for a sustainable, financially lucrative practice.
It takes more than clinical competence to thrive in the personal injury industry. As a Chiropractor, you can’t just rely on injured patients to find you. You need to validate and align yourself with attorneys who also specialize in personal injury and who can partner with you to achieve the best results for your patients.
In the past this endeavor has been daunting, however, when armed with indisputable objective data that will solidify an injury claim, attorneys will seek to work with you. Previously, attorneys had reservations about working with DCs, as most cases come down to credibility of a DC’s vs. MD’s opinion. Objective data levels the playing field, as data trumps opinion 99% of the time. Brandon Casey, partner at Casey Law Offices, states “Attorneys like evidence, and by that I mean actual evidence-based treatment, not opinion.” He goes on to say “sEMG studies are the best proof of soft tissue injuries. In this day and age of skepticism, they are essential in a litigation case.”
The rules of personal injury case management may be simple, but they are not necessarily easy. There is a definite process to follow to maximize your reimbursement potential. These simple guidelines will help streamline the legal process, leading to prompt and consistent payment for your Dynamic sEMG testing.
Adhere To Testing Protocol: It is essential to learn proper testing technique, as good data is crucial to your success. Proper technique insures accurate data. Without this your credibly may be in jeopardy, and your clinical conclusions open for dispute.
Practice makes perfect and mastering proper test protocol requires actually performing tests. Testing theory will not provide you with the skills required to flourish in this industry.
Clinical Interpretation: Unfortunately, accurate data is not enough to win cases and get paid. You must make clinical sense of the data, presenting it in a clear, concise manner. Receiving a bill without the required report is a red flag for insurers. Not only does it lead to claim denial, but possible disciplinary action.
It is imperative that you get proper training regarding accurate and thorough interpretation of the test findings. Relaying these findings, combined with the test graphics and your clinical recommendations is mandatory if you wish to gain professional respect and receive consistent payment for your services.
Prepare For Deposition: There is nothing worse than having solid data, and not being able to defend your work. Both patient and attorney are relying upon you as the Expert Witness. Take this responsibility and obligation seriously, and garner the respect you deserve as a doctor. Ultimately your income will abound.
Doing your research and educating yourself on the pertinent sEMG studies is a key component to deposition mastery. Take the time to learn from each attorney encounter to bolster your confidence and become the Expert Witness that you are.
Follow Up: It is imperative that proper follow-up and follow through is made with insurance carriers and attorneys. Most payment delays or denials occur from incomplete information or lack of documentation. Initially it might require diligence and tenacity, however as you persevere the process becomes streamlined.
Be proactive and utilize the power of FEDEX and Certified Mail. Insurers will claim they did not receive bills and reports, a common first attempt at denial. Insurers “learn” quickly who perseveres and who does not. Those who persevere get paid.
Retesting: Initial testing should be performed 4-6 weeks after a motor vehicle accident or workplace injury. The test and interpretation with written report must be included in insurance and attorney billing. Do not take this lightly. An important part of being paid for this service depends on the presentation and interpretation of the data.
Dr. Gregg Friedman, Chiropractor and personal injury expert, recommends performing Dynamic Surface EMG with simultaneous computerized ROM testing every 30 days of care to document progress and establish necessity for continued treatment. The additional test and written report, including a comparison of results should be included in the billing.
The key here is to practice, practice, practice. The more you do , the more confidence you will develop. And, as is true with any competent case management, refer out if necessary. A second opinion from a medical doctor or specialist helps to build your case, and your reputation. Working with a network of diversified practitioners solidifies results and strengthens the claim.
Attorneys want to see consistency in your testing and interpretations, case management, and ability to discriminate between those truly injured and symptom magnifiers. Objective data is the key element in being able to defend your diagnosis and justify your treatment recommendations.
Being a victim of an auto accident or workplace injury is both inconvenient and intimidating. Navigating the medical and legal aspects can be daunting. Dr. Allen Fraley, Chiropractor and personal injury expert, strongly urges other Chiropractors that are interested in becoming personal injury experts to acquire the proper technology, seek education to master the unique aspects of a personal injury practice, and gain confidence and expertise in the interpretation of sEMG. This mastery and confidence will be conveyed with patients, attorneys and judges. When combined with indisputable, objective sEMG data, you can’t lose.
1. National Highway Traffic Safety Administration. “2011 motor vehicle crashes: Overview” NHTSA’s National Center for Statistics and Analysis, 9313-120612-v3, December 2012
2. Jones GT, et al. “Road traffic accidents, but not other physically traumatic events, predict the onset of chronic widespread pain: Results from the EpiFunD Study” Arthritis Care and Research 2011.
3. Geisser M E, Ranavaya M, Haig A J, Roth R S, Zucker R, Ambroz C, Caruso M. A meta-analytic review of surface electromyography among persons with low back pain and normal, healthy controls. Journal of Pain 2005; 6(11): 711-726.
4. Gerhardt, John. “Utilizing sEMG in the medical-legal arena to prove presence or absence of soft tissue injury”, White paper: 2011.
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