K. Jeffrey Miller, DC, MBA;
James Anderson, DC
Editor's Note: Dr. Miller has designated Dr. James Anderson as the primary author of this article, the second of two on associateships, recognizing his substantial contributions to both articles.
Trust is a valuable part of any business relationship. It serves as the foundation for all business operations and ultimately long-term success for owners, employees and customers. This is especially true in the world of health care.
In chiropractic, one of the most common business relationships involves agreements between doctors who own a practice and associate doctors. Unfortunately, the agreements are often unsuccessful. One of the frequent issues that leads to a lack of success in associate relationships begins at the initiation of the relationship. Neither party really knows the other.
More Than Meets the Eye?
The associate usually knows if the established doctor has a busy practice, is liked by patients, what methods of treatment he/she uses and if the DC appears successful. While this information is important, it is in many ways superficial. For example, the established doctor may seem successful, have a nice office, home and car, etc. – yet may only be steps ahead of creditors.
The established doctor may know how well the associate performed in school and on boards; and may also have references from the associate's previous employers. However, the doctor usually has little information about how well the associate can adjust and manage patients – particularly the doctor's patients.
Verifying What's True and What Isn't
In reality, there is often a shortage of information from the standpoint of both parties. This shortage of information can be rectified, and the process is almost identical for both the established and associate doctor. The process involves examining the other party's business and personal routines. For either party, the person you are dealing with may seem to be the nicest, most trustworthy person in the world. However, it is necessary to verify your feelings of trust.
The verification process involves a series of background checks. The doctor should check the potential associate's background and the associate should check the established doctor's background.
This is an unusual recommendation for two reasons. First, the process is not a common procedure for either party in chiropractic. Large businesses usually have specialized human-resource personnel who handle background checks. Most chiropractic businesses are usually small and void of specialized human-resource personnel. Second, employees rarely perform an in-depth background check of an employer. It is usually the employer who performs background checks.
Both parties must learn to perform a few simple background checks that are available to anyone online. Hiring a professional to perform higher-level background checks is also warranted.
For the associate doctor, hiring a professional to perform a background check may seem an unobtainable or unreasonable expense. But consider this: Associate doctors often gamble their future on vague, unstructured and unwritten financial compensation plans offered by established doctors. The results of a professional background check are more tangible and assuring. The results of the checks will provide a measure of the likelihood of vague promises coming true.
For either side, the effort and expense described here should be considered the premium for an insurance policy that could save tens of thousands of dollars and tremendous heartache in the long run.
Request Information
Transcripts: It is routine in many health care fields for an employer to require a copy of an applicant's college transcripts. Associate candidates don't have to be straight A students, but their performance in school can be a clue to how they will learn, adapt and perform in a new practice.
Amount of Debt:: Almost no one graduates from any professional school these days without school loan debt, and the debt is usually significant. Employers should ask for a copy of the associate candidate's loan statements. The key here is the amount of the monthly payment – the one based on the routine payback, not a monthly payment based on interest-only payments or deferment.
Associateship compensation often fails to cover an associate's monthly school loan payment. The established doctor should realize an associate may not be able to completely pay bills if this is the case. The associate's stress and struggle will only lead to disappointment for both parties.
Sometimes the associate candidate may already have school loan problems. He/she may be having wages garnished and/or tax refunds and bank accounts seized for lack of payment. Still worse, he/she may have already defaulted.
When an established doctor is not comfortable asking for loan information or an associate is not forthcoming about the information, an alternative source of information is the Department of Education. Public records on school loan defaults are available online through the department's website.
Credit Checks: It is also common for employers to ask a candidate for written permission to perform a credit check. A credit history lists debts and documents payment histories. An idea of a person's financial stability or instability is obtained. This provides information on a person's ability to handle money.
Routine Background Checks
Medicare/Medicaid Exclusion: If a person has ever been banned from participating in the federal Medicare and Medicaid programs for abuse and/or fraud, he/she is listed on the government website https://exclusions.oig.hhs.gov/. Health care employers are required to check this website before hiring a health care worker at any level. Job candidates should check it, too.
The site allows you to search for excluded individuals by name. If a prospective employee is on the list, the employer may still choose to hire the individual. However, the excluded person cannot have any clinical or financial interactions with patients insured under federal programs. The employer must also provide documentation this policy is being followed. No definition of documentation is provided in the government regulations.
Thus, if hired, an excluded individual will only be able to work with a limited percentage of a practice's patient population. There are extra record-keeping requirements and the risk of guilt by association exists.
The associate doctor is not required to perform an exclusion search of the potential employer, but it is in his/her best interest to do so. If a potential employer has been excluded from federal health care programs, it says a great deal about his/her clinical and business practices. Associates can also suffer from guilt by association.
State Licensure: Every state board offers the public the opportunity to check on the status of a doctor's license. This is typically available via the Internet or by written request. It is easy to determine if a doctor's license is active and if the doctor has ever been sanctioned by the board. This check should be performed in every state in which the doctor has been licensed.
Better Business Bureau: The Better Business Bureau (BBB) and other consumer protection agencies track consumer complaints about local and national businesses. The complaints are often listed on the BBB website or can be obtained through written requests.
It should be kept in mind that these organizations are not regulatory agencies and that complaints to these organizations may be from patients who are avoiding paying a bill or have been forced to pay a bill.
Sex Offender Registry: Most states and the federal government have an official registry for sex offenders. A scan of these sites by both the established doctor and the associate candidate is absolutely necessary.
Detailed Background Checks
The final background checks listed here will likely require the assistance of an attorney and/or a private investigator. These professionals have access to records that are often unavailable to the individual citizen and they can obtain the information quickly. In addition to providing background information, an attorney can review and provide an opinion on associate contracts.
This may sound unnecessary and expensive, but it is always worth the effort and cost.
Lawsuits: Attorneys and private investigators can access court records regarding lawsuits (civil and malpractice), judgments, divorces, liens and other legal actions and sanctions. They can also access criminal records.
Taxes: Other records available to these professionals involve tax violations and penalties. Associates should know that a frequent sign of cash-flow problems in a practice is the inability to pay taxes.
Finally...
There are times that you meet someone you are considering doing business with who seems nice, legitimate and trustworthy from the start. It is OK to assume trust initially, but one has to think long term in these situations. This applies not only to established doctor-associate doctor relationships, but also all other aspects of business. Trust, but verify.
