One of my three sons recently shared a story with me regarding an experience with a chiropractor, which stimulated me to write this ethics article. According to my son, he called a chiropractor's office and asked if his insurance was accepted at the office. He was assured by the office manager that his insurance would cover his chiropractic services at the office. Consequently, he made an appointment.
Following the initial history, examination, and report of findings, my son was advised to meet with the office manager. The office manager then advised my son he would need a series of treatments at a cost of more than $1,600. In addition, he was advised that the office did not accept insurance payments and that he would be required to pay cash.
At that time, my son decided to leave the office and seek services from a different chiropractor. While leaving the office, the chiropractor stopped him and asked why he was leaving. My son explained to him that he was told the office accepted his insurance, but in reality the office did not accept insurance payments. The chiropractor then advised him that he was not required to accept the treatment program and that he could pay cash for adjustments.
I am wondering if chiropractors commonly use this approach to attract new patients, which appears to be unethical at best. It is my opinion that what my son experienced was a "bait-and-switch" scam.
Bait and Switch: The ploy of offering a person something desirable to gain favor (such as political support), then thwarting expectations with something less desirable.1
Dissecting the Bait and Switch
My son asked if his insurance would cover the costs of the chiropractic office visit when he initially called the chiropractor for an appointment. At the time of his phone call, he was advised by the office manager that his insurance would be accepted for his care.
After the examination was completed, my son was advised that his insurance would in fact not be accepted by the chiropractic office, but that he could pay cash and then send the bills to the insurance company and collect from his insurer.
Following the initial examination, the chiropractor's office manager attempted to sell a package of treatments for cash only.
My son was upset and disappointed with the chiropractor because it was his opinion that the DC's office manager had participated in a bait-and-switch scam.
Since my son's mother is also a chiropractor, he is neither naïve nor uniformed regarding chiropractic services and need for care. In fact, he advised me that he always informs the chiropractors' offices that he is the child of DCs. I realize that professional courtesy is rarely offered by chiropractors and I do not expect chiropractors to offer free care to my children, but I do expect them to offer ethical, evidence-based, patient-centered care to them.
More Than an Unfortunate Anomaly
During the past 50 years of my chiropractic experiences as a student, practitioner and professor, I have become aware of practice management companies teaching chiropractors to use a cash-only practice model. Of course, a concierge-type practice model, which accepts cash only, is ethical provided prospective patients are advised prior to scheduling their initial visit.
Gleberzon reported that some unscrupulous chiropractors have been known to attempt to convince patients to pay in advance for a large number of treatments (so-called block fees) that may not be clinically necessary.2 He quotes Paul Carey, executive director of the Canadian Chiropractic Protective Association (CCPA), and the largest malpractice carrier in Canada:
[There are] two main concerns that people seem to have regarding chiropractic care. One is that chiropractic care often appears to be on-going without rationale. The other is that chiropractors seem to be more interested in money than they are in providing evidence- or logic-based health care.3
The Potential Consequences
It is my opinion that this type of behavior damages the image of the provider and the profession. Richard Jaffe, Esq,. reported that when a chiropractor recommends medically unnecessary chiropractic services, the doctor also may be found guilty of fraud:4
When chiropractic care extends beyond 12 visits, it becomes increasingly likely that individual services are medically unnecessary. Services provided among the first 12 [visits] in a course of treatment to a particular beneficiary by the same chiropractor were approximately 50 percent likely to be medically unnecessary. That likelihood increased to approximately 67 percent for services between the 13th and 24th and to 100 percent for services beyond the 24th.5
Ten years ago, Conwell, Sherman and I wrote that informed consent is a process and dialogue between the doctor and patient during which the patient has the right to know what his or her problem is (diagnosis); what therapy the doctor plans on providing; and the risks, benefits and alternatives to the proposed treatment plan. Consent cannot be obtained through fraud or misrepresentation, and it is imperative that a practitioner use plain language in describing the risk, benefits and alternatives to the proposed care plan.6
If chiropractors are suggesting a large number of treatments without rationale, a lawyer may consider the activity to be fraudulent. While unethical behavior may damage the image of the chiropractor and the profession, fraud may lead to more severe legal outcomes for the chiropractor and possibly the involved employees.
A Protocol to Protect Yourself
In order to protect your professional image and develop long-term, happy patient relationships, I strongly recommend you avoid baiting and switching by following an ethical and legal protocol:
Clearly state your office policy regarding the acceptance of third-party reimbursement prior to scheduling the patient for the initial visit.
Complete the informed consent process prior to rendering services.
Properly document examination, diagnosis, treatment and response to care.
Demonstrate medical necessity for the performed or recommended chiropractic services in the patient chart.
References
"Bait and Switch." Merriam Webster.
Gleberzon BJ. "The Interface of Jurisprudence, Ethical Practice Management and Chiropractic Care for Older Adults." Topics Integ Health Care, 2010;1(2).
Carey P. Canadian Chiropractic Protective Association. Communiqué, Summer 2005.
Jaffe R. "Are You Committing Insurance Fraud by Doing Expensive, High-Tech Testing?" Dynamic Chiropractic, January 1, 2006.
Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis. Issued by the Department of Health and Human Services, Office of the Inspector General, June 2005. OEI-09-02-00530, pp. 11-12.
Lehman JJ, Conwell TD, Sherman PR. "Should the Chiropractic Profession Embrace the Doctrine of Informed Consent?" J Chiropr Med, 2008;7:107-114.
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