Board’s ResponsibilityBoard’s Responsibility

Most healthcare professions overseen by Most healthcare professions overseen by a variety of organizationsa variety of organizations

Chiropractic (due to the independence and Chiropractic (due to the independence and lack of full integration) does not have as lack of full integration) does not have as much oversightmuch oversight

Boards have a fiduciary responsibility to Boards have a fiduciary responsibility to assure health, safety, welfare & assure health, safety, welfare & quality of quality of care care

The Need for BPThe Need for BP

85% of 85% of allall healthcare is estimated to be healthcare is estimated to be scientifically invalidscientifically invalid

If Dr. read one paper/day for 1yr-99 years If Dr. read one paper/day for 1yr-99 years behindbehind

There is increasing demand for evidence There is increasing demand for evidence in practicein practice

Advent of pay for performance-MedicareAdvent of pay for performance-Medicare

Current increased public Current increased public awareness of fraud & abuseawareness of fraud & abuse

PI overutilization- Payor complaints to PI overutilization- Payor complaints to BORBOR

Local DA prosecution of Docs for criminal Local DA prosecution of Docs for criminal chargescharges

Attorney firms specializing in ins. Fraud to Attorney firms specializing in ins. Fraud to gain big insurance contractsgain big insurance contracts

Medicare Fraud-coding, billing, document.Medicare Fraud-coding, billing, document.

Current increased public Current increased public awareness of fraud & abuseawareness of fraud & abuse

FBI Investigations into multidisciplinary FBI Investigations into multidisciplinary practicespractices

Patient complaints to BORPatient complaints to BOR

FraudFraud

Require deceptionRequire deception

Intentional misrepresentationIntentional misrepresentation

Financial gainFinancial gain

IME/ICE board examplesIME/ICE board examples

“ “ you have indicated that your IME you have indicated that your IME evaluation was based on your opinions, …evaluation was based on your opinions, …and this is based on your knowledge, and this is based on your knowledge, educational training and educational training and experience”……… which may fail to experience”……… which may fail to uphold the validity and reliability of your uphold the validity and reliability of your evaluation in a legal forum”evaluation in a legal forum”

Best Practices & RegulationBest Practices & Regulation

How does the Best Practices How does the Best Practices effect our Boards?effect our Boards?

How may the BP be applied by How may the BP be applied by the Boards?the Boards?

ImplementationImplementation

Training and certification course is being Training and certification course is being developeddeveloped

Doc available at Doc available at www.ccgpp.orgwww.ccgpp.org

Comments requested from all Comments requested from all stakeholdersstakeholders

Board consensus comments to Board consensus comments to dntaylordc@comcast.netdntaylordc@comcast.net or or dliewer@fclb.orgdliewer@fclb.org

How does this apply to the How does this apply to the Licensing Boards.Licensing Boards.

BOR has to determine:BOR has to determine:

1.1. Appropriateness of careAppropriateness of care

2.2. Abuse of careAbuse of care

3.3. Overutilization of care Overutilization of care

4.4. FraudFraud

AbuseAbuse

Incidents or practices of providers that are Incidents or practices of providers that are inconsistent with accepted sound clinical, inconsistent with accepted sound clinical, business or fiscal practicesbusiness or fiscal practices

Excessive or unnecessary careExcessive or unnecessary care

Improper or sloppy business practicesImproper or sloppy business practices

Poor clinical documentationPoor clinical documentation

Improper coding or billing mistakesImproper coding or billing mistakes

Unintentionally mispresentation of factsUnintentionally mispresentation of facts

FraudFraudOverutilization is fraud if it is proved to be Overutilization is fraud if it is proved to be intentionalintentionalHow can you prove intent?How can you prove intent?– Individual case proofIndividual case proof– Clinical evidence with support from external evidence Clinical evidence with support from external evidence

based literaturebased literature– Consistency across a number of casesConsistency across a number of cases

Documentation & appropriate clinical decision Documentation & appropriate clinical decision making based on the evidencemaking based on the evidenceBP will provide the reliable source for the BP will provide the reliable source for the evaluationevaluation..

How can BP help?How can BP help?

Boards need some type of basis to Boards need some type of basis to demonstrate demonstrate what is appropriatewhat is appropriate care to care to substantiate the decisions on case reviewssubstantiate the decisions on case reviews

Must have a “preponderance of evidence”Must have a “preponderance of evidence”

& it must be “clear and convincing”& it must be “clear and convincing”

BP is the answer as a resource!BP is the answer as a resource!

How can BP help?How can BP help?

IME/ICE and Record Review Dr IME/ICE and Record Review Dr complaintscomplaints– Improper opinionated denial of careImproper opinionated denial of care– Improper parameters of dosage and Improper parameters of dosage and

frequency set up by opinionfrequency set up by opinion– Improper denial of modalities or other Improper denial of modalities or other

treatments- based on “cherry picking” treatments- based on “cherry picking” literatureliterature

IME/ICE board examplesIME/ICE board examples

There is a lack “ of description of the There is a lack “ of description of the missing supportive clinical evidence”missing supportive clinical evidence”““the report did not contain any references the report did not contain any references to any recognized source…which you may to any recognized source…which you may have utilized in reaching your conclusion”have utilized in reaching your conclusion”““your assertion that only 3 txs were your assertion that only 3 txs were necessary…based on age…takes away necessary…based on age…takes away from the actual objective clinical elements from the actual objective clinical elements of the patient presentation”of the patient presentation”

IME/ICE board examplesIME/ICE board examples

““there is an obligation for an adequate there is an obligation for an adequate factual basis for any and all professional factual basis for any and all professional opinions expressed”opinions expressed”““to ensure opinions are based on accepted to ensure opinions are based on accepted data… it must be from currently accepted data… it must be from currently accepted clinical literature”clinical literature”““the report did not indicate what clinical the report did not indicate what clinical findings or facts led you to your findings or facts led you to your conclusions”conclusions”

IME/ICE board examplesIME/ICE board examples

“ “ it is the board’s stance that an objective it is the board’s stance that an objective IME review shall be based on a IME review shall be based on a comparative assessment of case comparative assessment of case findings…with the published research and findings…with the published research and common practice ”common practice ”

Evidence BasedEvidence Based

Adjudicatory reviews and subsequent Adjudicatory reviews and subsequent hearings will progress with a defined hearings will progress with a defined substance that licentiates will have to substance that licentiates will have to addressaddress

Diminished judgment calls-aids both Diminished judgment calls-aids both plaintiff and defendantplaintiff and defendant

Appeals will be upheld due to consistency Appeals will be upheld due to consistency of evidence that decisions are basedof evidence that decisions are based

Practical UsagePractical Usage

Aids providers in substantiating med. Nec.Aids providers in substantiating med. Nec.

Allows negotiations on artificial stop care Allows negotiations on artificial stop care limitslimits

Aids in enhancing quality of care by Aids in enhancing quality of care by utilization of benchmarking as a baseline.utilization of benchmarking as a baseline.

Practical UsagePractical Usage

Addresses underutilizationAddresses underutilizationPromotes more equitable and fair payor Promotes more equitable and fair payor judgmentsjudgmentsDoes not follow algorithms, includes pt Does not follow algorithms, includes pt individuality, and clinical experience and individuality, and clinical experience and judgment of Dr.judgment of Dr.Aids in clinical decision making on pt pop.Aids in clinical decision making on pt pop.Allows focus on process of care and Allows focus on process of care and dose/responsedose/response

Benchmark-Low BackBenchmark-Low Back

90%-90 days- symptom improvement90%-90 days- symptom improvement

40%-6 months40%-6 months

62%- 1year62%- 1year

Common Complicating/Risk Common Complicating/Risk Factors –Physical or personalFactors –Physical or personal

– AgeAge– GenderGender– Severity of SymptomsSeverity of Symptoms– Prior SurgeryPrior Surgery– Prior recent injury (<6mo)Prior recent injury (<6mo)– Poor Body MechanicsPoor Body Mechanics– Falling as mechanism of injuryFalling as mechanism of injury

Risk Factors-BiomechanicalRisk Factors-Biomechanical

– BiomechanicalBiomechanicalProlonged static postureProlonged static posture

Poor Spinal motor controlPoor Spinal motor control

Sustained trunk loadSustained trunk load

Frequent bending, twisting, lifting, pushing, pullingFrequent bending, twisting, lifting, pushing, pulling

Risk Factors-PsychosocialRisk Factors-Psychosocial

ChronicityChronicity

Attorney RetentionAttorney Retention

Employment SatisfactionEmployment Satisfaction

Expectations for recoveryExpectations for recovery

Participation in social welfare or disability programParticipation in social welfare or disability program

Risk Factors-physiolog. Red/yellow Risk Factors-physiolog. Red/yellow flags.flags.

DJD, articular inflammatory dz, boney dzDJD, articular inflammatory dz, boney dz

Spinal stenosis, or physiol. narrow canalSpinal stenosis, or physiol. narrow canal

Osteoporosis, bone weakening disordersOsteoporosis, bone weakening disorders

ScoliosisScoliosis

Neurological signs or symptomsNeurological signs or symptoms

Write this down!Write this down!

Best Practices is not a standard!Best Practices is not a standard!Best Practice is a resource that bridges Best Practice is a resource that bridges the gap between the researchers and the the gap between the researchers and the clinicians or between laboratory and clinicians or between laboratory and practicepracticeBest Practices takes into account the Best Practices takes into account the clinicians experience and judgment along clinicians experience and judgment along with the individual patients unique with the individual patients unique personal values, presentation and desires personal values, presentation and desires

ImplementationImplementation

Implementation Recommendation: Implementation Recommendation:

Internal board policy or ruleInternal board policy or rule

Not statute, or regulation.Not statute, or regulation.

ImplementationImplementation

Training and certification course is being Training and certification course is being developeddeveloped

Doc available at Doc available at www.ccgpp.orgwww.ccgpp.org

Comments requested from all Comments requested from all stakeholdersstakeholders

Board consensus comments to Board consensus comments to dntaylordc@comcast.netdntaylordc@comcast.net or or dliewer@fclb.orgdliewer@fclb.org