One of the more potentially volatile risk areas for health care practitioners today is the delegation of therapeutic procedures to unlicensed assistants, and billing for those procedures as though the practitioner personally provided the procedures. This practice activity is particularly prevalent and ever-growing in chiropractic!

Some practice consultants - with promises of increased income, coach chiropractors to integrate low-tech rehab and protocols into their practices. Chiropractors are advised that it is legally permissible for unlicensed assistants (e.g., chiropractic assistants) to perform the therapeutic procedures on patients that are billed (per "incident-to") as if personally performed by the chiropractor, who at the same time, is providing services to other patients who are billed for the chiropractor's services during the same time frames as the therapeutic procedures.

Does the regulatory board allow for delegation of therapeutic procedures to unlicensed staff?
Individual state health care regulatory boards establish their own state's administrative practice standards for licensees for the purpose of protecting the public from conduct that does not conform to their state's accepted standards of conduct. Such administrative regulations almost always include standards relating to the delegation of services to persons other than the licensed provider. In many states, chiropractic boards do not allow their licensees to delegate therapeutic procedures to unlicensed staff, and, as such it would be inappropriate in any and all circumstances for the licensees to engage in this conduct!

However, some boards opine that licensees (e.g., chiropractors) can delegate therapeutic procedures to qualified and properly trained unlicensed staff (e.g., chiropractic assistants) acting under a licensee's supervision consistent with the health and welfare of a patient so as to encourage the more effective use of the skills of licensees. It would appear prudent for chiropractors to gain clarification from respective regulatory agencies regarding the following:

What are the standards that must be met by chiropractors to ensure their unlicensed staff are "qualified and properly trained"?

What level of supervision (general, direct or personnel) is required of the chiropractor relative to unlicensed staff directing therapeutic procedures?

What is meant by "consistent with the health and welfare of a patient so as to encourage the more effective use of the skills of licensees"?

How should the therapeutic procedures (supervised) by unlicensed staff be documented in the patient's clinical record?

How should the therapeutic procedures be reported to payers - especially those following Medicare standards, to avoid potential allegations of misconduct?

Is reporting therapeutic procedure codes for supervised procedures consistent with CPT?

Therapeutic procedure codes (97110-97546) identify the application of clinical skills and/or services that attempt to improve function that requires the physician or therapist to have direct (one-on-one) contact with the patient. These procedure codes do not indicate "supervised" services and to report them to payers in such a manner could result in allegations of misconduct. Consequently, it is imperative for the practitioner (e.g., chiropractor) to obtain prior approval for this billing practice from ALL involved payers notwithstanding the fact that this type of practice activity has previously been found to be consistent with state regulatory standards on delegation. The purpose of seeking the payer's approval is not to enable the payer to make determinations on what practices are legal and what practices are not; rather, it is to protect the individual provider from a payer's unilateral referral of the provider billing practices to law enforcement authorities who may have a differing interpretation of the acceptable standards of delegation that the provider's state regulatory board.

Current Procedural Terminology (CPT) is a listing of (a) descriptive terms and (b) identifying codes. The foregoing is used to report medical services and procedures, as well as to provide a uniform language that accurately describes medical, surgical, and diagnostic services. The use of CPT provides an effective means of reliable nationwide communication among providers, patients, and payers.

The listing of a service or procedure and its code number in a specific section is not restricted to any specific specialty group. Any procedure or service in any section may be used to designate services rendered by any qualified physician or other qualified health care professional. CPT indicates that the terms -"Physician or Therapist" and "Provider" as identified in CPT are interchangeable to refer to someone licensed to perform health care services.

Select the name of the procedure or service that accurately identifies the service performed that is adequately documented in the medical record. Do not select a CPT code that merely approximates the service provided, and that if no such procedure or service exists then report the service using the appropriate unlisted procedure or service.

Suggestions concerning introduction of new procedures, or the coding, deleting, or revising of procedures contained in CPT should be made by contacting the CPT Editorial Research & Development.

The Final Rule for transactions and code sets as part of the Health Insurance Portability and Accountability Act (HIPAA) identifies CPT codes and modifiers as the national standard for health care plans and providers to electronically transmit: Physician services; physical and occupational therapy services; radiological procedures; clinical laboratory tests; other medical diagnostic procedures; hearing and vision services; and transportation services including ambulance.

Does the involved payer reimburse for supervised therapeutic procedures?

Payers often set their own standards for reimbursement of health care services and determine what will be paid, who will be paid, and how much will be paid. Standards may vary from payer to payer, and may differ from those standards established by the provider's own regulatory licensing board. Accordingly, it is the responsibility of all practitioners (e.g., chiropractors) to be familiar with both the payer's billing/coding and their state board's standards and seek to abide by those standards that impose the stricter requirements when seeking reimbursement! By adopting a policy of compliance with the stricter standard the provider will always ensure that he/she is protected from claims of improper billing practices.

Medicare, and other payers following Medicare standards, indicates that therapeutic procedures supervised by (unqualified) unlicensed staff are not reimbursable! Payers with such standards do not pay for provider services, at provider rates, when such services are administered by non-providers. Further, these payers do not maintain that practitioners can not delegate therapeutic procedures to unlicensed assistants but are asserting that such services are not covered and, therefore, they are not reimbursable - BILL THE PATIENT! Medicare Benefits Policy Manual, Chapter 15, Sections 220 and 230 specifies:

Therapeutic procedures are medically necessary only when they require the professional skills of a qualified practitioner, are designed to address specific needs of the patient, and are part of an active treatment plan intended to achieve a specific goal.

Medicare pays only for skilled, medically necessary services delivered by qualified individuals, including therapists or appropriately supervised therapy assistants. Supervising patients who are exercising independently is not a skilled service.

Providers can not bill and seek payment for one-on-one codes (e.g., therapeutic procedures) administered at the same time as other procedures were rendered to the patient, or to other patients.

A physician may not delegate physical therapy services (e.g., therapeutic procedures) to unlicensed persons and report them as "incident-to" services unless that person has the education and clinical experience equivalent to a physical therapist.

Incident-to a physician's professional services are defined (Benefits Policy Manual, Chapter 15, Section 60) as services or supplies furnished by auxiliary personnel as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness that are billed to Part B by the physician as if they personally provided them.

Some within chiropractic have differing opinions as to the appropriateness of the delegation and billing of therapeutic procedures. Illustrative of this is the following written opinion of a chiropractor to whom a colleague was referred subsequent to requesting assistance from a State Chiropractic Association regarding the issue discussed herein:

The auditor is confused, to say the least. As a doctor, you can delegate to whomever you wish to perform those [therapeutic procedure] services. You simply must be in the building at the time services are rendered to supervise [sic]. You do not have to perform the treatment yourself, nor do you have to stand over them and watch. This auditor may be confused with what some insurance companies are pushing for and have proposed, i.e., they require the doctor to do it. However, as far as I know, no insurance company has any policy in place to prohibit you from delegating to staff. As far as statute goes in Xx, if an insurance company did write that into their policy, we would have to go to the Xx with complaint. The P.T.'s would love to have those rules in place as well. Short answer is the auditor is wrong. Maybe some other state he/she is familiar with has that as a rule. Not here though.


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Many providers today are choosing to outsource their billing. The billing process has become much more involved over the past few years and for many it makes sense to outsource. Between the software updates, required electronic filing of claims, NPI numbers, and other changes, it has become nearly impossible for providers to keep up.

However, if you have only ever used one biller, or one billing service, then you might not really know what you should be expecting from them. We have providers who use other services ask us sometimes "Should my billing service be doing this for me, or is it something I need to do in my office?"

It is good to clearly know what your billing service should be doing, and what your office will be responsible for. That way you can keep things running smoothly. Not all billing services do things the same way and that is ok, as long as you know what yours is doing and it works for you. We actually provide different services for different accounts depending on the needs of the office. For example, we do not normally get involved with obtaining authorizations, however we have a couple of clients who cannot handle getting them from their office so they pay us extra to take care of that for them.

But there are some things that all billing services should handle. Billing is not just the act of submitting the insurance claims and waiting for payment to come. A good billing service will submit the claims, electronically whenever possible, check electronic reports for denials and bad batches, and follow up on unpaid claims. They should also take care of any denied claims.

If they are not checking electronic reports and doing regular follow up then you are losing money and so are they. Electronic reports will notify you if there are issues with any of your claims or with entire batches. If they are not reading them then they are not fixing those issues. For example, an electronic report will return a claim if the ID number is not right. Maybe it is a simple typo, two numbers got transposed, but if the electronic reports are not being read it could be a big problem. What if it is a patient that comes in once a week? None of the claims are going thru because the ID number was not fixed.

Many insurance carriers today have time filing deadlines. Some are very short, like 60 days from the date of service. If regular follow up is not being done then money can be lost due to timely filing. Follow up reports should be run every 4-6 weeks and all claims over 30 days should be checked on.

There are other things that billing services can do to keep your accounts receivable running smoothly, but those are the basics. If you feel that your accounts receivable is not what it should be you might want to consider meeting with your billing service and asking what can be done to improve the situation. Tell them you would like a report of your accounts receivables. What are your figures over 30 days, over 60 days? They should be willing to provide you with reports of what is outstanding and why and it should not take more than a couple of days for them to make the reports available. If they are unwilling to provide you with this information then you need to consider why.

I am not trying to rat anybody out. I am just trying to make us all accountable to providing the best service possible so that billing services do not get a bad name. We hear too many stories of bad services and it makes providers leery of outsourcing when it is a viable option.



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Medical professional liability insurance is another name for medical malpractice insurance. There are two types of medical professional liability insurance, claims-made and occurrence policies. There are advantages and disadvantages to each of these types of policies.

Claims-made insurance policies are one year long policies that are renewed each year without interrupting the coverage. Any claims made during the claims-made policy period will be covered, no matter when the incidence actually occurred, as long as the incident occurred after the original purchase of the claims-made policy. This means coverage is retroactive back to the first policy. This type of medical malpractice insurance is cheaper in the first few years of coverage as it is less likely claims will be made in the first few years of coverage. Premiums increase each year up to five years, when the reach the approximate cost of the occurrence policies.

Once a claims made insurance policy is cancelled, no further claims are covered. However, tail coverage can be purchased to cover any claims that occur for a certain amount of time after cancellation.

Occurrence medical professional liability insurance covers all claims that occur during the coverage period, regardless of when the claim is made. Because there is no way of knowing how many claims will eventually be made due to actions occurring any given year, the premiums for occurrence medical malpractice insurance are not necessarily cheaper in the beginning like they are with claims-made policies. This type of insurance covers the doctor forever against claims that result from the period in which the policy was in effect.

Both of these forms of medical professional liability insurance are very expensive, so there are currently a lot of organizations working on proposals to solve the problem of compensating any patients with legitimate medical malpractice claims without doctors having to pay huge premiums for liability insurance.

Some of the proposed solutions for the medical professional liability include capping non-economic damages, trying medical professional liability cases in a tribunal system outside of the main court system, use a no-fault system for compensation, using alternative dispute resolution methods like arbitration and medication, and using screening panels to review cases and determine whether or not cases should proceed to court.

Doctors need to have medical professional liability coverage in order to protect them from medical malpractice claims, which could otherwise bankrupt them should they occur. Doctors can lose a lot of money even on medical malpractice claims where they are not at fault, as they have to prove this.




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