Submitted by: ACA Insurance and Managed Care Committee
The American Chiropractic Association is the preeminent professional organization representing doctors of chiropractic in the United States. We have an obligation to our membership and to the profession as a whole to comment on topics that support or harm the profession and the public it serves. The topic of Multi-Discipline Practices (MDP) is receiving increased attention in the media, as a quality option for treating patients.
The goal of this policy is to provide general education as opposed to specific legal or practice advice. It is incumbent upon each doctor of chiropractic to determine relevant state or federal laws, local board regulations and/or association recommendations that may be preemptive.
Background: The ACA fields an increasing volume of calls from doctors of chiropractic as to the advisability of entering into a MDP, and who also seek more detailed information on its acceptance, structure and operating philosophies. At the same time, ACA receives complaints from payers that certain arrangements appear to emphasize financial gain for providers rather than clinical appropriateness and the best interests of patients. With respect to providing education to both the chiropractic and insurance professions, ACA established a Fraud Sub-Committee under the Insurance and Managed Care Committee to research and provide commentary on this topic and others.
These recommendations are not all-inclusive, but are intended to encourage thoughtful consideration and examination.
ACA RECOMMENDATIONS
Scope of Practice: The ACA encourages state associations and licensing/examining boards to adopt rules, regulations and laws that define the scope of practice for doctors of chiropractic and specifically comment on new and emerging practice arrangements including but not limited to Multi-Discipline Practices. Attention to the provision of ethical care and accepted treatment standards is important, as is identifying potentially illegal or unethical practice(s) that may constitute a danger to the health, safety and welfare of the public or that violate state statute. The Arizona Board of Chiropractic Examiners under section ARS 32-924(15) and a Chiropractic Practice Alert issued by the New York State Education Department Office of Professions http://www.op.nysed.gov/chiroalertmulti.htm may provide a model for discussion and action in other states.
It is also recommended doctors of chiropractic maintain a current license in good standing in the state in which they practice, and comply with the full letter and intent of that state’s chiropractic scope of practice statute. All care provided by a doctor of chiropractic must fall under the applicable scope of practice regardless of who recommends or orders it.
Seek Expert Opinion and Counsel:
To assist associations, boards and individual providers, ACA may be contacted for information on the National Association of Chiropractic Attorneys (NACA) as one source of possible legal counsel.
There are many potentially complex legal issues that one should keep in mind before getting involved in a Multi-Discipline Practice. You may consider seeking legal advice on specific issues, including the following:
- All licensed healthcare providers are held to administrative, civil and criminal law considerations. In addition, state and federal law impacts compliance, formation, ownership structure and operational issues and may present certain complexities requiring the advice of an attorney specializing in professional limited liability (PLLC), Partnership (PLLP) and/or other arrangements.
- A federal health care criminal statute, along with related state health fraud statutes, criminalize any “scheme or artifice” intended to obtain reimbursement from any healthcare plan or entity under false pretenses. Federal mail fraud concerns are included in this level of analysis, among other potential violations. (18 u.s.c. 1341, 1343)
- Another issue deals with legal concerns regarding federal and state anti-kickback laws. These are enforced for the most part by civil versus criminal sanctions. This requires a comprehensive review and careful consideration of “safe harbor” provisions of the Civil Monetary Penalty Act (42 u.s.c. 1320a-7a).
- Legal prohibitions against self-referral for some healthcare services, or “Stark Laws” (42 u.s.c. 1395 nn) are enforced through civil sanctions and relate to the provision of certain designated health care services. Mini-Stark laws may also exist at the state level and should be considered in any MDP analysis.
- The Internal Revenue Service (IRS) may also have specific compliance standards in the reporting of MDP revenue, investment gains and/or other financial situations.
Another source of advice may be the local or regional FBI (add website), or your state Attorney General’s office as to types of activities in the health care industry that may prompt investigation or indictment. Currently we are not aware of any national MDP directives or policies employed by the FBI, but we understand that initiatives exist in certain states.
The Department of Health and Human Services Office of Inspector General ‘Compliance Program for Individual and Small Group Physician Practices’ (65 Fed. Reg. 59434, Oct. 5, 2000) found at http://oig.hhs.gov/authorities/docs/physician.pdfis also another source to consult, and your malpractice carrier may also have additional recommendations based on risk management protocols and actual claim experience.
