Board’s Responsibility

1. Board’s Responsibility • Most healthcare professions overseen by a variety of organizations • Chiropractic (due to the independence and lack of full integration) does not have as much oversight • Boards have a fiduciary responsibility to assure health, safety, welfare & quality of care

2. The Need for BP • 85% of all healthcare is estimated to be scientifically invalid • If Dr. read one paper/day for 1yr-99 years behind • There is increasing demand for evidence in practice • Advent of pay for performance-Medicare

3. Current increased public awareness of fraud & abuse • PI overutilization- Payor complaints to BOR • Local DA prosecution of Docs for criminal charges • Attorney firms specializing in ins. Fraud to gain big insurance contracts • Medicare Fraud-coding, billing, document.

4. Current increased public awareness of fraud & abuse • FBI Investigations into multidisciplinary practices • Patient complaints to BOR

5. Fraud • Require deception • Intentional misrepresentation • Financial gain

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

7. Best Practices & Regulation How does the Best Practices effect our Boards? How may the BP be applied by the Boards?

8. Implementation • Training and certification course is being developed • Doc available at www.ccgpp.org • Comments requested from all stakeholders • Board consensus comments to dntaylordc@comcast.net or dliewer@fclb.org

9. How does this apply to the Licensing Boards. • BOR has to determine: • Appropriateness of care • Abuse of care • Overutilization of care • Fraud

10. Abuse • Incidents or practices of providers that are inconsistent with accepted sound clinical, business or fiscal practices • Excessive or unnecessary care • Improper or sloppy business practices • Poor clinical documentation • Improper coding or billing mistakes • Unintentionally mispresentation of facts

11. Fraud • Overutilization is fraud if it is proved to be intentional • How can you prove intent? • Individual case proof • Clinical evidence with support from external evidence based literature • Consistency across a number of cases • Documentation & appropriate clinical decision making based on the evidence • BP will provide the reliable source for the evaluation.

12. How can BP help? • Boards need some type of basis to demonstrate what is appropriate care to substantiate the decisions on case reviews • Must have a “preponderance of evidence” & it must be “clear and convincing” • BP is the answer as a resource!

13. How can BP help? • IME/ICE and Record Review Dr complaints • Improper opinionated denial of care • Improper parameters of dosage and frequency set up by opinion • Improper denial of modalities or other treatments- based on “cherry picking” literature

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

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

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

17. Evidence Based • Adjudicatory reviews and subsequent hearings will progress with a defined substance that licentiates will have to address • Diminished judgment calls-aids both plaintiff and defendant • Appeals will be upheld due to consistency of evidence that decisions are based

18. Practical Usage • Aids providers in substantiating med. Nec. • Allows negotiations on artificial stop care limits • Aids in enhancing quality of care by utilization of benchmarking as a baseline.

19. Practical Usage • Addresses underutilization • Promotes more equitable and fair payor judgments • Does not follow algorithms, includes pt individuality, and clinical experience and judgment of Dr. • Aids in clinical decision making on pt pop. • Allows focus on process of care and dose/response

20. Benchmark-Low Back • 90%-90 days- symptom improvement • 40%-6 months • 62%- 1year

21. Common Complicating/Risk Factors –Physical or personal • Age • Gender • Severity of Symptoms • Prior Surgery • Prior recent injury (<6mo) • Poor Body Mechanics • Falling as mechanism of injury

22. Risk Factors-Biomechanical • Biomechanical • Prolonged static posture • Poor Spinal motor control • Sustained trunk load • Frequent bending, twisting, lifting, pushing, pulling

23. Risk Factors-Psychosocial • Chronicity • Attorney Retention • Employment Satisfaction • Expectations for recovery • Participation in social welfare or disability program

24. Risk Factors-physiolog. Red/yellow flags. • DJD, articular inflammatory dz, boney dz • Spinal stenosis, or physiol. narrow canal • Osteoporosis, bone weakening disorders • Scoliosis • Neurological signs or symptoms

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

26. Implementation • Implementation Recommendation: Internal board policy or rule Not statute, or regulation.

27. Implementation • Training and certification course is being developed • Doc available at www.ccgpp.org • Comments requested from all stakeholders • Board consensus comments to dntaylordc@comcast.net or dliewer@fclb.org