EPISODE 408: The Hot Targets of Chiropractic Compliance with Scott Munsterman, DC

Hey, chiropractors. We're ready for another Modern Chiropractic Marketing Show with Dr. Kevin Christie, where we discuss the latest in marketing strategies, contact marketing, direct response marketing, and business development with some of the leading experts in the industry. 

Dr. Kevin Christie: [00:00:00] Welcome to another episode, excited to have you back and today I've got an interview for you with Dr. Scott Munsterman of ChiroArmor and he is all things compliance and a little disclosure, I've been working with his group for my private practice since the summer of 2024, we've taken on the project of clinical compliance and it's been really good, we've done everything from Building out best practice manuals to, uh, you know, getting clear on compliance, uh, issues and year end trainings and, uh, notes and, and all the things.

I mean, it's really, when you're running a healthcare practice, uh, there is a lot of regulation, as you know, and there's a lot of things that you have to be keeping up with. And it's part of your responsibility to, to do that and start to learn that process. And so I, we did finally, uh, you know, we were piecemealing it before.[00:01:00]

But definitely eye opening to actually go through training and it was kind of like not knowing what I didn't know at some points or sometimes knowing what I knew, but wanted to be in denial about it. And so, uh, it was great. It's been great to go through that and we dive into a lot of the key aspects of, uh, what, um, Dr.

Scott looks for when working with clinics to give you an idea of some of the things you need to be thinking about in your practice and, um, starting to be as, You know, be compliant, whether it's with your state, uh, or obviously the, the U S federal government. And then, uh, you know, if you're, uh, if you're in a different country, which a lot of you are, I know we get quite an audience in Canada and Europe and Australia, which is cool.

I love you guys. Uh, you know, look at compliance, how it would relate, uh, obviously to your country or province and, and make sure that you are. Working towards compliance. All right, without further ado, here is my interview with Dr. [00:02:00] Scott Munsterman.

 All right. Welcome to the show. I got Dr. Scott Munsterman on here and we're going to talk all things compliance and really get you up to speed to at least a certain perspective on what you need to be considering for your chiropractic practice. But before we dive into it, tell us a little bit about yourself, doc.

Scott Munsterman: Oh, happy to. Thanks for having me, Dr. Kevin. I appreciate it. It's an honor. Um, well, uh, Coming up. Let's see here. I graduated from Northwestern in December of 1984. And so coming up on 40 years here, um, I'd have to do the math. Maybe it's 41. I don't know. Yeah, you're getting,

Dr. Kevin Christie: getting there 41 by the time this comes out.

Scott Munsterman: Yeah, exactly. Well, and, and just had just really. loved the career, you know, loved chiropractic, loved what it does for people. Um, and just really kind of found myself through a lot of different phases and chapters of my life, you know, professional life. And just all of that, [00:03:00] uh, was in practice for over 25 years, uh, had a large group practice of six DCs and a PT.

Um, and, uh, we, uh, practiced in a surgery center, uh, that was co owned with pain management anesthesiologist. So learned a lot about Integrative care, you know, how to work with patients, with other providers through the meantime. Um, over the course of time, um, I served 13 years as an elected official, uh, first on the city council within my community.

Uh, then a couple of terms as mayor, uh, then a few terms as a state legislator and chaired a number of committees and, and, uh, was, uh, active in the, in the party and. And leadership within the state and, and over the last probably 15 years now, uh, I've been primarily consulting role, uh, working with, uh, uh, clients, all, uh, chiropractic practices, integrated multidisciplinary practices all across the United States and helping them with their compliance [00:04:00] programs and, and, uh, uh, being a, a, uh, uh, sounding board and, and helping them in their practice management discussions, business.

you know, discussions, all of that. We work also with an electronic health record that, that is worldwide, that, um, is, uh, in hospital and medical clinics. And, and we found that to be very helpful for especially those multidisciplinary practices. And so really have found myself towards the, towards. This end of my career, I'm not saying it's the end no means, but, uh, using a lot of the experiences that I've had, both in clinical practice and, you know, and, and seeing patients and working in, you know, group practice settings and, you know, and all that.

Um, and then. And public policy, and then, you know, more along the lines of, of just the, the experience and expertise that I've been grateful to gain over the last 10 to 15 years in helping other practices. So this is how you [00:05:00] found me today, uh, Dr. Kevin is kind of at this phase at this point in time in my life and, and as always just have felt.

You know, I'm blessed to feel very purposeful, you know, with what I, with what I do. So I don't know if that's the answer you're looking for, but that's the one you got.

Dr. Kevin Christie: That's, that's the answer. And, uh, I'm, I'm proud to say I'm one of your happy, uh, clients here and been working with you, uh, since I think early summer, and this is, uh, of 2024, this comes out.

And early 2025, but yeah, it's been quite a learning experience for me as well. And someone that's, you know, been practicing since oh five and had my own practice, uh, you know, I was a practice owner since oh seven in a partnership and then my own practice in 2010. And, you know, so my practice was 14 years old when, when I took this head on, on the compliance side of things, uh, to, to make sure that.

Uh, we're doing things right. You know, ultimately, uh, you know, healthcare is, is definitely tricky. It's, it's, um, [00:06:00] it's not easy being compliant. It's not difficult, but it's, but there's a lot to it and that's something that I've learned. So I want to thank you for that.

Scott Munsterman: Well, um, two, two things to that. I mean, I've been around long enough, uh, that I knew what it was like before HIPAA.

And, and, and back then, you know, way back, and of course this is before the 1990s, it was all about, you know, confidentiality. I mean, there was just an ethical. No, you did, you know, and, and, you know, likewise with other types of regulatory environments and, and even going way back to those 1990s, I mean, that's where the office of inspector general, um, First had their look at healthcare and compliance.

And it was the university of Pennsylvania that, um, had to learn a 25 million, uh, lesson, uh, when they were doing billings that weren't accurate. to Medicare and the OIG picked up [00:07:00] on it. Well, and then the OIG looked at that and like, holy cow, we have this whole industry here that is like, you know, the Wild West, you know, back then.

And so all of a sudden, then we began to see some of these changes, regulatory systems get put into play, you know, and they kind of, it wasn't so much that it was all in a concerted, concerted, You know, effort, you know, kind of thing, but it was more like, you know, OSHA saw this and of course, then the high tech act came out and, you know, HIPAA and, you know, all of that.

And then the OIG rolls out, here's what we think a compliance program needs to be in healthcare facilities. They published that way back in 2000 and that's really has not changed and is for all healthcare facilities. And so that's, you start looking back, you know, and what's transpired that healthcare environment to your point.

Is highly regulated. I mean, both on a federal level, but then also on a state level, and then we have our state boards, but it's nothing to be fearful of, [00:08:00] you know, it's kind of like the conversations we have with our clients right away. And we typically see them start to relax after about the third visit with us.

Dr. Kevin Christie: Yeah, yeah, exactly.

Scott Munsterman: Gosh, you know, we, we got it covered, you know, we, this, there are a lot of things, but you know what, you build a system around that and you know, when you need to do the things you need to do and, and you're guided, then you don't have to worry about it, you know, because you're just doing the right things.

You have to worry about wondering if you're doing the right thing. Um, and then the second point, um, too, is that there, we, many times docs don't know what they don't know. You know, and so then they become overwhelmed and, you know, they can react to that, you know, too, in different ways. But so, yeah, it's, it is the environment that we're in.

You know, I just think back 40 years ago, you know, when I started practice and open my own practice and all of that. I mean, what the environment was like then is just. It's night and day difference to what it is today. Some, some good [00:09:00] and some that are like, um, are more challenging. I'll just put it that way.

Dr. Kevin Christie: My secret hope is that Elon and the Doge, uh, also, uh, tackles healthcare compliance.

Scott Munsterman: There you go.

Dr. Kevin Christie: And gets rid of some of the inefficiencies, but, uh, no, on a, on a more serious note, you know, it's like, uh, you mentioned docs that might've been practicing since the late eighties, early nineties. You know, it definitely was, has probably been a frustrating process to keep up with all of the additions of, of compliance.

And again, like you mentioned, federal state plus your, your chiropractic board, uh, you know, if you've gone through it for 40 years, I mean, it is night and day, there's no doubt about it. And then on the other end of the spectrum, you know, you get. The young DC coming out that, um, let's just say they open up their own practice.

Uh, you got a lot to figure out just to even make that business, um, actually survive and then trying to understand and go through all the [00:10:00] compliance is something that is, uh, challenging. And then you get the docs that are in, you know, kind of, uh, I would say maybe my, uh, spot of like 20 years of practice where you're kind of both things like you're you know things have changed even in 20 years and you're trying to keep up with that and every administration or something new and You know like one of the things I We might as well make mention That I didn't know about until I was working with you was the fact that this past July and now in January the minimum wage On salaried non doctor employees.

So if you got an office manager that's on, uh, on hourly pay and they are full time, uh, sorry, if they are salaried in full time, there's a minimum on that. Can you, can you explain to that new one that happened in July and then it escalates in January?

Scott Munsterman: Yeah. So the, so the salary, um, and this was, there was quite a few different things that occurred this year.

Uh, that came out and it'll be interesting to see if [00:11:00] anything gets rolled back.

Dr. Kevin Christie: Yeah, I think of some will

Scott Munsterman: a different administration, but it set a minimum wage, if you will, for people that are on a salary. Um, now within the last couple of months, one of the things that, that has been brought forward and some refinement of that.

Is that if you do have somebody on a salary that is below what that minimum wage is going to be, um, then making sure that you do document what their hours are, you know, during the week, um, and that if they go over those hours, that overtime would be paid. And so there are some updates to that, but it'll be interesting to see coming into January and, and if there's going to be any refinements of that, um, whole discussion that.

That it, you know, it'll, you know, a small business has to adjust to a lot of these things. I think there are times where things sound really good on the surface, um, but [00:12:00] how the impact is to a small business can be, I won't say devastating, but it can definitely challenge that business into, into how to continue to do what they're doing.

Um, but yeah, there are regulations like that, that. That will come forward and then it's all about, okay, how does this impact me and what do I need to do and how do I need to learn more? And then as time goes on, there's challenges to that, you know, and then those change as well. I mean, we had that happen with the Corporate Transparency Act this year, you know, and we're beginning of the year.

It's like, you know, we got to have everybody registered. And we even waited, our company waited until June because we thought, okay, this is going to get challenged. And, and then it seemed to like die away and we thought, you know what, we're going to have to start telling our clients they're going to need to do this because the fines were really heavy in January, beginning January 1.

Well, what was it a week or a week and a half ago, Supreme Court [00:13:00] put an injunction on it, you know, but it was like last minute, you know. And so it is a little maddening where you're like monitoring these things and you're reacting to it. And, and yet, you know, you've got to kind of move with the times and that's kind of the world we're living in right now and how to keep up on that as a doc who's trying to treat patients.

I don't know. I couldn't do it. I mean, I would need somebody to help me. Yeah. Yeah,

Dr. Kevin Christie: for sure. And that's the thing is like when you do think about it, you mentioned it can be devastating to a small business and it can, and cause you know, if you're a small chiropractic practice and you're, and you're in network with insurances, not only are you dealing with all the games, the insurance companies are playing with reimbursement and trying to keep up with the.

Billing compliance and insurance reimbursement situation. But then, yes, you do need to navigate the waters of regular compliance. And if you really do think about it, a lot of the things that we have to abide by. With compliance, it actually does hinder your ability to operate your, [00:14:00] um, to grow your business that other businesses can do.

Right? Like a dry cleaner business can offer 25 percent discounts and can offer buy one, get one freeze. And like, I mean, you think about all of the businesses out there that use tried and true strategies to grow. A low margin business, which we're in, uh, they have a lot of things they can do. And then we can't do many of those things, right?

Like you can't even treat your sister in law, probably your ex, something like that. Like what's the cutoff on who you could treat for free? Is it a cousin or something? What, what is that?

Scott Munsterman: Well, um. Couple of things. So I think what you're referring to would be like your professional courtesy.

Dr. Kevin Christie: Yeah,

Scott Munsterman: of what you're going to provide.

Um, and, and really, as a practice, you can, you can set that policy, but it's, it has to be group, you know, like, for instance, um, if, if, if you have a dentist friend and you're treating that [00:15:00] dentist friend for free, Um, and you're going in and you're paying him for his service, but he's referring to patients.

Well, that would go against the Stark law, you know, because there's inducement there and there's, there's like a reward system going on. But if you wanted to treat all the dentists in your region for free, you could do that. you know, because it's not in regards to referrals, you know, that you're doing it, blanket all

Dr. Kevin Christie: dentists.

Scott Munsterman: So, but in a professional courtesy situation, you brought up family, you can extend your family as much as you want, but where the caveat is, is that, okay, if there's. a medicare federal beneficiary Yeah Then you can't give free care to them But if it's your immediate relative, I know i'm going to lose everybody on this now, but if you're relative you have to Give free care to them, you know, um, and so there's just these different rules around, you know, the point that you're trying to [00:16:00] make is that it can be complicated, you know, you're standing between navigating the stark law and the anti kickback law.

And then you got Medicare guidelines. And, and that's why having a policy like, um, professional courtesy as a part of your policy so that you don't accidentally give free care to somebody or charge somebody, you know, that you shouldn't be, you know, kind of thing. Um, anyway. There is good news. No, no,

Dr. Kevin Christie: there, there is good news.

And, and we, we will get to that. But, um, what I want to do is transition into some what you call is your hot targets. You know, you're working with a clinic and you, and you getting started with them. Uh, talk to us a little bit about some of the hot targets you look at right out of the gates.

Scott Munsterman: Oh, and, and we developed this list over.

Years and I even added more to it this year because, uh, one of the things that, that, that we do when we bring on a new client, we have to be as the consultant or as the one helping the [00:17:00] client, we have to really be careful that we don't assume that they come, you know, with a certain level of compliance, you know, and so, you know, beginning with, you know, how are we doing our billing today, you know, and I, and I always make sure that That our clients feel like, okay, if they're doing something wrong, I mean, this is our, you know, come to Jesus moment on everything here.

We want to know everything that you're doing today. And then if there is something that's not right, we're going to work on that to fix it. And so our hot target list really are those. Number of things that that are so integral that we need to make sure we're doing right and they were like rise to the surface.

So NPI's, you know, and how are we billing for our services? What type of services do we provide? And then from the offshoot of that in your state, you know, are you capable or able to do that within your scope of practice? Um, [00:18:00] you know, many times we assume that if we saw it or we bring it in or whatever, that.

You know, we can just go ahead and use it because somebody in another state is using it. Well, that's not necessarily the case because many state laws are built around. If it's taught at a unit chiropractic college, then it's approved or depending on your state, you know, language. So understanding the, the law, your state law and the jurisprudence around that becomes really important.

And so when we ask about services, you know, we're like our radar is up. In saying that, okay, that's a common practice that's taught in universities, or maybe it isn't. And so we call that out. Again, services, what, then if we have certain services, how are we coding those services? What codes are we using?

Are they properly being used? That wraps into our look at CPT code utilization in general, so that we know what's billed, how many times it's being billed. You know, how are evaluation and management codes utilized? [00:19:00] Are they being utilized correctly? Does our client understand, you know, that there's two different ways that you can code an exam?

Dr. Kevin Christie: Yeah. Can you talk about that? Cause I know that was something you taught me. I thought it was interesting.

Scott Munsterman: Yeah. So in 2021, there was, there were changes made to the E and M. Um, coding, um, definitions, the AMA and Medicare actually put a lot of work into that and rolled that out. Um, and the, basically the, the thing that changed is it puts, uh, providers, uh, clinicians in control of how they want to go about coding their evaluation management based on two essential criteria.

Okay. The first one is through medical decision making, and there's actually three categories. Uh, number one is based on the problem complexity, you know, your diagnosis complexity. So let's say for instance, Scott slipped in his garage, fell on his butt and he strained his back and he's got, you know, pain going into his leg.

So we, we know [00:20:00] just by that clinical picture that, yeah, well, he probably has a radiculopathy or he's definitely hurt his back, strained it, you know, it could be some complexity involved. That would be an acute, uncomplicated or acute complicated situation. Which would be that diagnosis code is complex, you know, so number one would be the problem complexity and the number of those diagnosis is number two would be or the second category would be in this medical decision making model or thinking.

is what, how much data did I have to, as a clinician, go through? Did I order any tests? Did I read any tests? Did I interpret any tests that were done outside of my clinic? Um, do I have a written report on those tests? You know, did I get any, did I have to pick up the phone to call Scott's primary care or, or whoever to talk about his case or a specialist?

That would be the complexity of the data that the clinician has to wrestle with, think about. And this is all done in the same day of the encounter. Okay. The same day as the exam, [00:21:00] the third category is what is called the table of risk. And that would be how risky is my procedure that I do? Well, right away off the, you know, we are a very low risk, uh, uh, type of skill or a service that we provide manipulation, very low risk, very safe and what we do.

So right away, that complexity level is. So then it really depends on the complexity of the diagnosis and the complexity of what we did. If we took x rays, we have a written report for the day, you know, then those two things will drive, if that coding should be a 99202, 203, or 204, depending on complexity, so that's one way to go about it.

And if you, um, if, if that's how you're going about it, then your documentation needs to be on that initial visit. Pretty well laid out. With those things in it so that if it's audited, they can see that, you know, oh, this is a [00:22:00] complexity level that's moderate, you know, which 99203 then is. Fine. The second way to go about it, which is the way that I typically recommend, uh, more so in most cases is time.

And so evaluation management time at that date of the encounter, we're talking about the day that you examine the patient. You can add both the face to face time that you spend with the patient for history, for exam. For report of findings. If it's done on that day. Um, any counseling you're doing with the patient.

If you had to pick up the phone and call somebody about the patient, um, you know, on that same day, as well as non face to face time. So let's say prior to the patient visit. You went through their file and it took you two minutes or five minutes. Well, that gets added to that E& M time. Maybe the patient left and [00:23:00] still on the same day, um, you're documenting in your EHR, you know, for that initial visit.

That could take 8 to 15 minutes, depending on how complex and all that. All of that is time that can be documented for that visit that would then equate into that evaluation management code, whether it's a 202, 203, 204, and there are time increments ranges for those codes, as we know. So that's, those are the two ways to document your E& M and typically.

to help. And you can decide it could be one way for one patient, one way for the other. You know, it's not all or nothing there. It's either or. Um, but it's good for the, for the clinician to figure out, you know, what is, what is really going to be the best option? And then you make sure that you document that time, that total time spent with patient a day for evaluation of management services.

Was 33 minutes, you know, um, and I'll, and I'll throw out these tidbits as well. Um, [00:24:00] it should never be the same number every single time for every single patient. Okay. When, when there's audits that go on, one of the first things that is seen is that how can it be 45 minutes for every single patient that we audited?

You know, so we have to really be careful about making sure our documentation is very authentic and is on the mark. If it was 33 minutes, it's 33 minutes, you know, then go to your chart. Oh, that's a 99203. Bam. It's done. Um, so anyway, but that, that, no, I,

Dr. Kevin Christie: I liked it because that question gets popped up in Facebook groups all the time or questions about it and, and things of that nature.

And I remember when you told me about it, it was a lot more, um, different options, like you said. And then. There's the time one I thought was great, because I think a lot of people think it's just literally when they examine the patient, but they don't realize the report of findings, the notes you're doing, if you're going over ice and [00:25:00] heat instruction, you know, that type of stuff, ergonomics or whatever it all is including there.

So thank you for clearing that up. I want to I want to segue a little bit to Um, I know that like some of the hot targets are essentially like the MPI, the billing, the essentials around the EM codes and everything. What about, uh, I just want to get this off the table too, because a lot, there's so many questions about this.

The ABN form. I know this is for Medicare. What is that? When, who needs to fill it out? What are some of the details around that?

Scott Munsterman: And that is definitely a hot target, Dr. Keller. Um, there, it many times is misunderstood. And then use maybe not right or appropriately, um, the very first thing we do. And when we work with clients, we have them produce their intake form to us.

That's what I asked for. And then I can kind of go through, see what they're, what they're going and remind me, I have a story about informed consent too. I want to share that.

Dr. Kevin Christie: We'll go, we'll go from ABN to informed consent.

Scott Munsterman: Perfect. So anyway, with ABN form, number one, [00:26:00] we want to make sure that it's not expired.

You know, and so in the lower left hand corner of the AVN form, you'll be able to say, be able to see the date, you know, expiration date. It should say 2026. Okay. And that's, that would be the most active one. The AVN form technically and primarily is used for covered services. that are not payable because they may be deemed not medically necessary.

So, right from the get go, that's exactly what the ABN form is for. And so, for chiropractic, the only thing that's covered is CMT 989404142 are covered services if they are medically necessary, found to need that patient is found to have a medically necessary condition that is going to respond to treatment and improve their functional ability.

Okay, and when we and I'll stop there because we could get in the weeds of, you know, what is [00:27:00] the initial visit requirements, you know, and all that stuff. Um, and then when that patient has completed that active treatment has reached the end of their episode of care and they've reached their goals, they're released from active treatment.

And if they, and if it is recommended for them to be on maintenance therapy, then they would at that time sign an ABN form because that covered service then would be not payable. And according to Medicare, they're not going to pay for that maintenance therapy, even though they recognize it. You know, and then it becomes the patient's responsibility.

And so that ABN form is that cutoff point, you know, saying that, okay, this care is not going to be medically necessary. It's for maintenance therapy for you. Um, and these covered services will no longer be paid by Medicare and you'll be responsible. So the ABN form acknowledges to the patient their responsibility financially.

And it releases liability from you that, Hey, you told [00:28:00] the patient, they signed the form and there it is now, um, those services will be in that part D section where you'll say it's, you know, chiropractic manipulative therapy, you know, at X amount is not covered, you know, because maintenance therapy.

Further down in that form, you'll see three options, option one, option two, option three. It's very important to understand that that patient is the one that determines what option they want. Okay, so option one, if they select that, that means that you are going to still file a claim to Medicare, even though you know It's not going to be payable, all right, because you're going to put a modifier, GA modifier on it to say that this is maintenance therapy.

And Medicare is going to deny it, okay, not pay on it, then you'll get that back, that EOB back that says that, but then many times a [00:29:00] patient will take that and go to their supplemental plan or whatever, who may or may not pay on it. But that's what option one is, is that the patient chooses that, you're still sending that to Medicare, patient is paying you because.

You know, it's not it's not going to be payable. The second option Basically says don't bother sending it to medicare. You know, i'm responsible Don't waste your time. I mean exactly like that. That's pretty much what it is option three Um basically says that they don't want the care It's kind of a moot point in my opinion, but it's there.

So anyway, but it's very important that the patient is the one selecting those options. It's their right to choose that. And then of course, signature at the bottom, making sure that, you know, that that is that signatures their date, you know, and it's executed appropriately.

Dr. Kevin Christie: Good. So it's, you know, not for if you've got laser therapy and you charge 60 for laser for that patient, you don't, they don't need it.

And the [00:30:00] Medicare patient doesn't need an ABN form for the laser therapy because it's a non covered service. Correct.

Scott Munsterman: So what's what that's technically correct. Okay. But when you're working with that Medicare patient, um, Medicare has told us that it's okay to go ahead and put those non covered services.

On the ABN form, if we want to communicate to the patient what their full responsibility is, you don't have to, you can, but we do recommend that you have a form that does help educate them, you know, if it's aside from the ABN, um, because then they know what their full responsibility is. You know, under, you know, that's,

Dr. Kevin Christie: yeah, that's what we've done because we do act, we're certified in active release technique and we, we do charge for that.

And so we've just used the ABN form to educate them on that charge. And so they're aware.

Scott Munsterman: So, but I wanted to be very clear on the, you know, technically what that ABN form is for, you know, with the covered non payable [00:31:00] covered services. You know, it's okay. And it's really good to make sure we inform the patient, you know, obviously of what their full responsibility, you know, is financially.

Dr. Kevin Christie: All right. Let's, uh, rock our world with the informed consent. What do you

Scott Munsterman: got? So, um, I get, I probably about half dozen times a year, I am out speaking. And, and what I've found is that, um, whenever we get on the topic of informed consent, In the audience that of my colleagues that I'm speaking to, it's, it's really misunderstood in, in several different ways.

Okay. Um, and it's led me into understanding more and, and even speaking more on patient safety and all that. But that's for another day topic for another day. Another time, maybe. The key thing that we find with informed consent is number one, the form. Does it have everything that it needs to have? Does it cover the risk?

Does it cover the benefit? Does it [00:32:00] cover that alternatives have been talked to the patient about? Does it cover what happens? You know, I mean, that the patient would be at risk if they don't go through with treatment. You know, is it signed by the patient and is it signed by the doctor? You know, and so these are really key elements that, that we talk about in informed consent and that the informed consent, depending on the procedure that you're doing.

is really important to build that informed consent around that procedure. So for instance, um, manipulation, you know, it is a specific procedure that carries risk. It carries benefits, you know, what are alternatives, you know, all of that. Many of the other, um, new, especially newer modalities that are out, you know, whether it's laser or You know, the shock wave, soft wave, you know, all that, um, different types of modalities.

They carry with them with on their own specific types of things [00:33:00] that we need to think about and both from a contraindication perspective and a benefit perspective and all that. And so number one would be the form and understanding what services that you're providing. Really, the next thought is like, okay, what's my informed consent for these services?

So that's really important and making sure that it has the pieces that it needs to have. The second thing, which is just as important, is the process. Yeah, too many times our colleagues and, and, and it's not just our colleagues. It's, it is other healthcare professionals, um, believe that informed consent, if you do it once, then you're done and you're not.

And what's really important is to understand that if there is ever a material change in the patient's condition. And I'll give you a couple of examples in just a minute if there's ever a material change in the patient's condition, whether it's maybe a new region, a new [00:34:00] diagnosis, maybe an injury that could have, you know, compounded something or aggravated, you know, a previous condition.

Or maybe there's a change in the type of treatment that you're doing now, a different technique that's different than what they had before, that they were informed of before. Anytime there's a material change, then an informed consent needs to be provided. Okay? And then finally, if you have a patient that is on wellness, Therapy or, or it's like maybe PRM they're in, you know, a couple, three times a year, you know, kind of ongoing or is on maintenance therapy.

Uh, informed consent should be provided on an annual basis for those patients so that they don't, don't ever forget about. You know, and, and the, you create that opportunity for them, um, to be able to ask questions about what they're providing. In addition to that informed consent conversation, what we're finding is really important to do at that time, um, especially with your new patients, because [00:35:00] they're maybe completely new to chiropractic or they are certainly completely new to you and what you're doing, your technique and how you're, you're operating your methodology.

Is to let them know at informed consent. This is how we do the adjustment or this is how we do this. This is what your experience is going to be. I'm going to put my hands on you. I'm going to do this or I'm going to do that or we're going to use this instrument. But that's the time to really talk about that, what their experience is going to be so that they aren't shocked when something, you know, when you begin treating them and they're like, Oh my gosh, I, you know, they had something else going on in their mind, either from previous experience or something they saw or whatever.

So that's a really important part of the informed consent process as you go through that so that you have that shared decision making element that goes along with it, because it's really at that point that you can find out from the patient what their preference is, you know, I mean, you may [00:36:00] have a wide variety of techniques.

And you may learn right away that Sally is scared to death of, you know, of a certain type of procedure or diversified move or whatever, but it's okay to use that instrument or use, you know, a light pressure or whatever. So, getting that all ironed out and informed consent is really important. So my story is this.

Brought on a new client this year. Did the normal intake work, you know, give me all your paperwork, your intake and, and, and it was a husband, wife team and, and got it. And I went through it and analyze it and I made notes and all that. And I noticed that there wasn't an informed consent form in the production that, that they sent me.

And so I had a face to face meeting, you know, them quite well, uh, with me and I'm sitting across and I'm going through the forms and I got through the forms and I said, you know, I, the only thing I didn't see. Uh, was informed consent and, and the doctor was like, Oh yeah, it's right there. And, and I, and I said, okay, well maybe I missed it because hey, I'm human.

[00:37:00] So I'm going back through the forms. There's probably one of 20 pages and he's like, it's right there, you know? And, and, and I said, well, I said, that's your HIPAA authorization form.

Dr. Kevin Christie: Yeah.

Scott Munsterman: And he just turned white as a sheet. And he's like, Oh my gosh. I haven't been giving informed consent to my patients all the time.

He thought that was his informed consent form because he didn't, you know, it was there, it was a form, they signed it, you know, and. And there's stories, I can tell you all kinds of stories about, you know, how things can get missed. And so, very important, the form, match to your services, make sure the form has those key elements in it, and then the process.

And the process, that new patient, any material change in the patient after that, it could be three months later, you know, and the patient's in and they have something different, um, or that [00:38:00] ongoing, you know, maintenance therapy. Um, the last story I'll tell you is that, uh, right now I'm involved in a program, um, and, and I'm, I won't get into it, but.

where I've been doing, uh, a lot of reviews of case studies in malpractice cases. And, um, and the analysis that I just shared this week with that carrier is that, uh, whenever there is a gap of care, uh, with a patient, so let's say Scott comes in, we treat him, six weeks later, he's good to go. Six months later, he comes back.

And it may be for something similar or something different or whatever. What we've learned through our initial review of these case studies is that gap in care many times eludes providers. Um, and maybe even because we've seen Scott before, it was a slow back before, you know, it's the same thing, you know, whatever.

Um, half the time the [00:39:00] doctor evaluated the patient, the other half of the time the doctor didn't following a gap in care. There were no informed consents provided, you know, and, and the doctor missed a material change. Um, and there are some key indicators that should be red flags, which we can cover at some point.

But the point being is that that informed consent is a very important part of patient safety. And there's things that have to occur prior to us knowing we need to give it. And one of those things is recognizing material change in our patient's conditions. And so I just, as a red flag, when that patient comes back, following a gap in care, it could be two months, it could be three months, you could have released them a month ago, and now they're back again.

That should be something that clicks in your mind that says, okay. You know, let's take a look. Let me, let me, let's do another deeper look at this, you know, because is there something going on that the [00:40:00] patient is going to be experiencing adversity, adverse event that could be underway. And yet we're not able to detect that yet and that we should be aware of that.

So, so anyway, I just wanted to share that because. It's a part of that informed consent process that makes us know that we need to do an informed consent is when we love it.

Dr. Kevin Christie: No, that's good. And I know there's a lot to informed consent and that kind of really gives us a good understanding of a lot of the forms and all that.

I want to segue just a couple quick topics on different aspects of compliance. But obviously hip is a whole beast in itself. I just want to have you briefly discuss. The, the business associate agreement, uh, who needs to sign that and what that is. And then we'll kind of go to the third kind of, in my mind, and I know there's more to it, but just overall, like compliance training and the value importance of that in a, in a business.

But let's start with the, the BAA and we'll go from there.

Scott Munsterman: Yeah, great. So business associate agreements, um, [00:41:00] anytime that. that we have determined that we have outside entities. These are people that are not our employees, but people who do work for us. For instance, like a biller, outside biller that you're outsourcing to, your EHR company.

Anybody, uh, consultants like myself that are helping you with the program, may do audit reviews or that type of thing. It's important to have a business associate agreement. And that business associate agreement essentially says that, Hey, Scott, you're going to do this work for me, and I'm going to give you the minimum PHI that you need to get your job done that I need you to get done for me.

But you, you, the business associate, are agreeing to Uh, keep that. PHI secure and you're under the same rules that I am. You the covered entity. Um, under HIPAA. Because they are so basically that [00:42:00] agreement is very important. That says that, look, I'm going to give you this PHI. You know, Mr. Consultant or, or, you know, uh, billing person or whatever, um, and you're agreeing to keep that confidential and that you're going to use the same, uh, protections to, uh, prevent any disclosure or inadvertent access to that PHI, um, and they're held under HIPAA law, just like you are the covered entity.

And so that agreement is very important. And, and if you haven't had an updated agreement since probably, I want to say probably 2015 or 2014, you should have that updated and then, you know, re re have that sent and signed by, you know, those folks that you are doing business with. And so for instance, even like your.

You know, if you're storing your like with your EHR could be cloud based, or maybe you're having it backed up on the cloud and you have a server base. You know, these are all considerations that you need to to [00:43:00] keep in mind. So yeah, thanks for bringing that up because that's another one of those mechanical things that can go overlooked.

Dr. Kevin Christie: Yeah, absolutely. And there's a ton to HIPAA. We could obviously do a whole other episode on HIPAA alone, but I just wanted to make mention of that, but our audience needs to realize there is a lot of compliance around HIPAA that we know about. And so we've so far talked about a lot of compliance around billing, coding your documentation, uh, your forms.

Then there's the whole compliance around HIPAA you got to consider. And then one of the things we're doing right now in our clinic, as we record this, it's in December of 2024, it won't come out until early 2025, but we're doing our annual training, each of our team members, uh, through your program and, and going through that, uh, now.

Is compliance trainings and screenings and things of that nature, is that something that we, we have to do as a clinic or is it a nice to do, uh, as a clinic? What, what give us the, the scoop on all the [00:44:00] different, um, monthlies and quarterlies and yearly annual training around this stuff?

Scott Munsterman: Yeah, you bet. So there are annual, uh, training requirements federally.

So there, it's annual training required as, uh, training is required for HIPAA, for OSHA, for fraud, waste, and abuse. And then most recently this year, as you know, uh, we had the non discrimination health care law that came out, um, uh, which included under sexual discrimination, sexual orientation, and gender identity.

And so we created a training, you know, program for that. But those are the four. annual required training, federally required training that need to be done. Now, from the OSHA side of it, bloodborne pathogen is typically where I'd like to see the focus of of the health care. And so we build out our annual training more towards blood borne pathogen and airborne pathogen, um, as we've had the experience with [00:45:00] COVID over the years, um, and then building any safety or any other pieces around that, uh, with HIPAA, typically anything new that's come about within the last year gets included in our annual training programs to bring, you know, our clients up to speed and their staff, um, as well as some, some of the basic elements and then fraud, waste and abuse.

You know, typically that's pretty standard and, and that's required as, as, uh, practices that are enrolled in Medicare and, and other commercial, you know, payer programs. Um, you know, our other training that we do for our clients typically, um, is through what we call micro learning modules. And we've been doing this for, That's over a decade now with our clients.

Um, in a couple of years ago, the Department of Justice actually made a comment in one of their publications that micro learning is probably one of the better ways to learn and teach, you know, compliance and, and they're just primarily that two to five minute, um, quickie on here's how you do this, or here's how you do [00:46:00] that.

And we release those a couple every month to our clients on very key things that are just basics and they just help remind, um, remind staff and providers how to do certain things. So that's another element of kind of helping build knowledge base. And then the third piece is the role based. You know, so if you have a specific role, you know, billing or whatever, that you can, you know, give that individual more knowledge.

Um, in the chiropractic industry, as we know, many times we hire people that have not necessarily been in health care, but they have a great skill set. They're great people, personality. They're a great fit for our practices, but they don't know the first thing about health care, really. And so we have to begin with them.

And so we've developed programs that help bring those people up to speed on what it's like being in a health care facility. You know that, hey, we have this thing called HIPAA. You know, we can't talk about certain things. We have professional boundaries. We've got, you know, a number of things that just need to be learned.

And, and [00:47:00] so those are, are on the training side, not necessarily required, but, you know, important to, you know, stay compliant in certain areas of your policy. But the annual required training, HIPAA, OSHA, fraud, waste and abuse and non discrimination health care. Those four are federally required.

Dr. Kevin Christie: Love it.

This has been great information. You know, I just want to, you know, challenge our audience. I know it's not always, um, the most fun and exciting thing to, to work through and provide leadership to your, to your team and your business. But once you have decided to. Uh, be a business owner of a health care clinic.

You, there are certain things you've signed up for just like having to do your notes and pay your taxes. Uh, you've got to lead your team on compliance and you know, don't, I think some people feel guilty about. Like the fact that they know it's like they're not necessarily keeping up with compliance or not doing anything about it is never too late.

You know, [00:48:00] it's, it's, you know, you put in the effort, you'll, you'll get there. It's not gonna happen overnight as I've seen, but we've made quite a stride, you know, strides in the last 678 months. So it's been really good. Um, how can our audience find out more information in the name of your business and how they can reach out to you if they're interested in getting this compliance training going?

And that's the thing, just, uh, To kind of leave you with this before we do that is, um, you know, part of the leadership is delegating. Part of delegating is finding experts that, uh, necessarily they can, you can actually attach them to your business. Like I have with you, um, to, to essentially become our compliance team and, and officer.

And, uh, it's been, it's been, you know, peace of mind to, to get that done. So how can they find out more?

Scott Munsterman: Well, um, you can just reach out to us, go to our website, chiroarmor. com and you can You know, shoot us an email and say, Hey, I'm interested in a demo. We even have like calendar links that make it easy for you.

You can click on that. You can find a date that [00:49:00] works for you. And it automatically creates a zoom meeting. Um, and typically what happens is that one of our, uh, folks on our team, uh, We'll reach out to you right away and, you know, introduce himself or herself and, and then, you know, work up to the point where there's a demo and many times I'm involved with that, not all the time, but many times I am.

And, and then just giving, you know, the, uh, doc a good idea of what. Program that, you know, they, or he or she feels best. Um, and our clients range from those that have been in practice a long time, like myself to those that are just starting the practices, you know, and so it's just really a wide range and, and gosh, we just, we really enjoy what we do.

Dr. Kevin Christie: Yeah, no, you definitely do and passionate about it. And one of the other things that was nice to work through was a whole employee handbook with all the specifics we wanted to do. And we had a unique scenario of our first employee, um, taking maternity leave. So we even worked through some of that and [00:50:00] getting that in there.

And then obviously a full compliance training manual and the whole nine yards. So, uh, feeling good about that. And again, thanks for your time today, doc.

Scott Munsterman: Yeah, thank you.