So I've had someone reach out to do some coverage for things like injections, regenerative medicine, etc in the Chiro world. I am I think the only PM&R provider in my community, which comes with pros and cons, and there is a lot of need for MSK related stuff. MSK stuff mostly goes to Orthos in the area who end up giving everyone TKAs and THAs. What are your thoughts about working with local chiros to set up an MSK type clinic for knee/hip, etc joint type injections? Anyone have experience doing this? Thanks!
MSK/chiro stuff
- Thread starter Iamnew2
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Availability. Affability. Ability. In that order.
Get referrals in ASAP (same day or next day is hard to beat), be nice, be at least moderately competent and not a scumbag.
If you can be their first referral source instead of ortho sounds like people will get more appropriate care and you will get busier. Easier to do if you're ok reciprocating and sending a few referrals their way as well. A lot comes down to just making personal connections and making yourself "the MSK guy/gal".
Get referrals in ASAP (same day or next day is hard to beat), be nice, be at least moderately competent and not a scumbag.
If you can be their first referral source instead of ortho sounds like people will get more appropriate care and you will get busier. Easier to do if you're ok reciprocating and sending a few referrals their way as well. A lot comes down to just making personal connections and making yourself "the MSK guy/gal".
I appreciate the comments. The need is there and there are a ton of patients that want to be seen, but I guess my question was would it be questionable to do it from a standpoint of in affiliation with a chiro clinic? I will still keep my med director gig and my inpatient practice, but I don't want to go through the hassle of setting up a clinic on my own. I like the flexibility of not having to pay overhead it's awesome. So from a business perspective the set up would be to do maybe one day a week and see patients and cut the chiro a certain percentage.
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What exactly is the chiro's involvement?
Well chiros are seeing a lot of the MSK stuff but don't have anyone currently to refer patients for any injections - so for example they see them for the typical back pain/adjustments, and then patients bring up knee/hip pain, etc. so they have no one to refer them to. So the idea would be I would be the physician they refer to, I would set up say a day a week clinic, see patients, do injections as appropriate, and they would get a percentage of that.
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Sounds fishy. I don't think you can give them a cut of the injections due to kickback laws. You can certainly pay them to rent space in their clinic though. But nothing can come across as a possible bribe/kickback for referrals.
I don't think it would be worth the time personally. My time is better spent on the rehab unit where there's more need. I'd rather not be stressed with a clinic, but that's me. Will the Chiro's clinic staff handle all the insurance auth, and your clinic billings? A chiro office may not know how to do that stuff if they only do cash pay.
I assume you're doing your own own exam/full consult to make sure the injections are indicated?
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Depends how it is set up. Chiros send referrals my way on occasion, but I have no affiliation with them. Just make sure you follow all the appropriate laws and don't get into a business model where the chrio is ordering the procedure and you are just performing the injection. Then I would think that you might loose your license. I'm not sure or not if your malpractice gets more expensive doing regenerative medicine (stem cells might be risky depending how you are doing it).
I saw your other post where you were seeing 30 inpatients per day + medical director duties. I would worry about stretching myself too thin. I do mostly inpatient as well, but my skills for U/S injections have reduced as I just can't be good at everything. Regenerative medicine is basically a full time job and there is quite a bit of research to follow to keep up with the times.
I saw your other post where you were seeing 30 inpatients per day + medical director duties. I would worry about stretching myself too thin. I do mostly inpatient as well, but my skills for U/S injections have reduced as I just can't be good at everything. Regenerative medicine is basically a full time job and there is quite a bit of research to follow to keep up with the times.
Yes I'd be doing all the exams and the injections, correct. All the clinical stuff would be done by me.
Thank you for the thoughts, yes I want to ensure that the set up is appropriate.
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Did locum while a fellow years ago. Dirty arrangement and bad actors everywhere. Not worth the risks you do not know about.
Fair enough! I appreciate your thoughts on these guys.
In a different topic, do you guys sign off on reports from therapists after patients are discharged from your IRF? So if you send a patient out for outpatient therapy and the therapists do a report do you sign off on those reports?
Do your therapists do any type of home evaluations? Therapists at my institution do. Haven't seen this before.
One more - our census dropped a little bit to around 24 patients or so so corporate is freaking out. So director of marketing out of the blue and without my knowledge "reviews" some of the notes that the liaison team sends me and informs the team about how a patient is appropriate for rehab, what the diagnosis and etiology should be and how their "comorbidities" play into their appropriateness for rehab. I had previously denied the patient as they were wanting to admit a patient with a UTI as a debility. I said no.
I also got rather frustrated that the director of marketing would have the gall to think that somehow their opinion matters in the least? I told the ceo look this person is a marketing director not a physician, it's completely inappropriate! Thoughts? Has anyone ever come across this?
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In terms of the signing, no I mean if I send a patient to an outside facility for therapy, that outside facility unrelated to your hospital does PT/OT and then they send you the notes in paper format. You no longer see the patient or anything. How do you get RVUs for that?
I do agree with the home eval thing, I think it is a valuable service, I had never seen it before so was curious what others did.
Yes i am fully aware of comorbidities playing a significant role into qualifying. Admitting someone just with a UTI I find absurd. Do you admit patients with UTIs to inpatient rehab? Isn't this what Encompass Health got fined 48 million dollars for - for questionable diagnoses like "urosepsis" and disuse myopathy, etc? So your medical directors don't provide diagnosis/RIC the execs do at your institution? I don't mind review of notes, I find issue with a random marketing person at the institution saying hey team we are admitting this patient with this diagnosis, etc. I have never heard of that nonsense.
I do agree with the home eval thing, I think it is a valuable service, I had never seen it before so was curious what others did.
Yes i am fully aware of comorbidities playing a significant role into qualifying. Admitting someone just with a UTI I find absurd. Do you admit patients with UTIs to inpatient rehab? Isn't this what Encompass Health got fined 48 million dollars for - for questionable diagnoses like "urosepsis" and disuse myopathy, etc? So your medical directors don't provide diagnosis/RIC the execs do at your institution? I don't mind review of notes, I find issue with a random marketing person at the institution saying hey team we are admitting this patient with this diagnosis, etc. I have never heard of that nonsense.
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We admit patients with UTI's all the time. Usually for debility. If they're not at their functional baseline, have medical necessity, and otherwise meet rehab criteria, and we have beds, why not admit them?
As my attending in residency used to say, we're in the business of helping people. He'd remind us of this when we'd look for reasons not to admit a pt (not medically complicated enough, or too complicated, poor dispo, questionable tolerance, etc.). When you've got the beds, why not give the person a chance?
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I'm not aware of how you'd be able to get RVU's for signing a therapist's note. They're likely just sending it to you as an FYI. If you're still following the pt as outpt, then you can bill for your follow up visit where you review the therapy note. But otherwise anytime therapy notes get sent to us our unit secretary shreds it if no signature is needed. If signature is needed usually secretary sends the therapist a note saying to fax it to the PCP since we don't follow pt's after dc. Every now and then I end up signing one of the notes or HH notes because pt's can't get into their PCP soon enough. No biggie--I sign, and it's free of charge. It's only a few seconds of work, so it doesn't bother me. I've never received a note that required any kind of action.
We rarely do home evals. I agree it's a valuable service, but we're a smaller unit in a more spread out area (our cachement area spans multiple smaller towns/cities up to a couple hours away), so it takes our therapists out for a while.
I would imagine Encompass Health got fined because their documentation was poor. But it really doesn't take much to knock an 80 or 90y old previously independent patient down, and so a little rehab after a UTI that caused debility sounds reasonable to me, as long as documentation is in order. How many patients are still encephalitic a week after a UTI? Some of us a quite frail.
There is a reason there are corporate overloads in the rehab setting--they know how to "game the system" so to speak. We (physicians) generally don't. But they have legal and all these other people to support them (and by default, us), so unless I actually think they're pushing fraud (our CL's never have), I admit the patient. If I'm not certain a pt will pass audit I run it by our program director, who knows her stuff well.
Remember, the rehab company and hospital have way more to lose than we do. Insurance rarely tries to recoup physician fees--they're going after facility fees when they challenge an admission. And the patient wins--worst case scenario is they need more time at a SNF, but we're well under our SNF dc goal so there's plenty of room to take a chance on people. I always err on the side of helping the patient--it's much easier to help an IPR patient who can't tolerate IPR than the one who was never admitted.
I get sent outpatient therapy notes all the time - since obviously we don’t follow the patient anymore I don’t sign them but they send me countless repeated requests to sign them. I called one company and said we don’t sign them and they we’re surprised. Normally I also let them know that it would have to be signed by their pcp or medical director. Particularly because some of our patients have ongoing therapy for months I don’t see how they expect us to sign weekly therapy notes of a patient we no longer follow?
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Tell your unit clerk (or whoever collects the faxes) to just toss them in the shredder, and ignore the repeat faxes. That's about all you can do if you've already told the therapists you don't follow the patients/continue to sign after dc.
Either that, or just sign them all.
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You are correct. I looked at my spreadsheet and it was for HHC certification. Sorry I wrote that incorrectly.
As far as therapy notes are concerned, you ordered it and that is why they send the initial certification or recertification to the ordering physician. Only takes me a few seconds to sign. Do whatever you want, but they will keep sending them to the ordering doctor. I believe these are for insurance purposes. So if someone doesn’t sign it then they won’t do anymore therapy at some point. I transition 99% of my patients to more therapy after discharge and feel like it is my job to see that the initial evaluations are done and therapy is started. I have, however, never heard of weekly therapy notes that they request to sign. I am also willing to do HHC plans for patients that don’t have PCPs yet.
I admitted a patient today for acute cystitis actually. No one can sign preadmission screens besides a rehab physician. So a marketing person cannot admit a patient to a rehab unit. But I do take advise and feedback from administrators and I don’t see what is wrong with that. No, admin does not choose the impairment codes and I am a medical director.
Realize that the 60/40 rule, in my opinion, is partially good but partially BS. I’ve seen a lot of low level patients come through rehab and do well for something like UTI, but if they went to SNF they may have not lasted long. I practice with the knowledge that SNF rehab isn’t what is was a few years ago and I even get patients with a CVA that go to SNFs and never got any rehab there. So I try to keep that in mind when I think about declining a patient.
Any myopathy diagnosis is a bad diagnosis for a patient to have. Places got in trouble for classifying everyone that spent 1 day in the hospital with myopathy. Which isn’t really even possible. Follow the diagnostic criteria and you can make the clinical diagnosis, which is most commonly critical illness myopathy.
As far as therapy notes are concerned, you ordered it and that is why they send the initial certification or recertification to the ordering physician. Only takes me a few seconds to sign. Do whatever you want, but they will keep sending them to the ordering doctor. I believe these are for insurance purposes. So if someone doesn’t sign it then they won’t do anymore therapy at some point. I transition 99% of my patients to more therapy after discharge and feel like it is my job to see that the initial evaluations are done and therapy is started. I have, however, never heard of weekly therapy notes that they request to sign. I am also willing to do HHC plans for patients that don’t have PCPs yet.
I admitted a patient today for acute cystitis actually. No one can sign preadmission screens besides a rehab physician. So a marketing person cannot admit a patient to a rehab unit. But I do take advise and feedback from administrators and I don’t see what is wrong with that. No, admin does not choose the impairment codes and I am a medical director.
Realize that the 60/40 rule, in my opinion, is partially good but partially BS. I’ve seen a lot of low level patients come through rehab and do well for something like UTI, but if they went to SNF they may have not lasted long. I practice with the knowledge that SNF rehab isn’t what is was a few years ago and I even get patients with a CVA that go to SNFs and never got any rehab there. So I try to keep that in mind when I think about declining a patient.
Any myopathy diagnosis is a bad diagnosis for a patient to have. Places got in trouble for classifying everyone that spent 1 day in the hospital with myopathy. Which isn’t really even possible. Follow the diagnostic criteria and you can make the clinical diagnosis, which is most commonly critical illness myopathy.
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I was just thinking, there are laws on patient abandonment. I would ask some legal counsel to make sure you wouldn’t get in a situation where the patients therapy was interrupted by not signing a care plan and they sued for substantial loss of function. Or get in an agreement where you don’t order therapy yourself on d/c or make a documented handoff to another physician that they will take over.
I tend to over think these things, so maybe someone on here knows that this isn’t possible. But some ppl are litigious or have good lawyers.
I tend to over think these things, so maybe someone on here knows that this isn’t possible. But some ppl are litigious or have good lawyers.
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Probably good advice.
Thankfully I rarely get sent PT/OT notes, and I’ll typically sign them since it’s quicker, and write “send future notes to PCP”.
I continue to certify HH often if the pt can get into their PCP. My job is to help the patient recover their function, and they can’t do that if therapy stops.
So perhaps my above advice to ignore the notes should itself be ignored until you run it by legal. I’m not sure why signing weekly notes is needed, but if it is required to continue therapy then ignoring the notes will create problems for the patient.
You could pre-empt a lot by writing on your therapy script to fax any notes/recertifications for help pts PCP
Thanks for your thoughts guys, always appreciated.
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