March 2007

Arizona bars IMEs from board

 WCA assists state group in passing model legislation

A chiropractic board taken over by IME orthopedic‑and medically oriented DCs determined to drive subluxation‑based chiropractors out of business.

Chiropractors whose careers have been destroyed because they forgot to initial their progress notes on one visit or used CPT code 99203 instead of 99202.

This is the current scenario in Arizona, according to many insiders who say the nightmare began when Dianne Haydon, DC, was appointed as one of three licensed chiropractors serving on the Arizona Chiropractic Board of Examiners on July 1, 2003.

Dr. Haydon's resume notes that from 1991 to the present, she has been involved in "chiropractic consulting, claims review and independent chiropractic evaluations." Such terms normally mean working for insurance companies to deny claims.

The situation came to an explosive head on July 1, 2004, when the second IME was appointed to the board. This time, the post was given to Steven Baker, DC, well known for many years in Tucson as a pro‑insurance IME doctor. Now, two of the three DC board members had direct ties to the insurance industry.

Critics began a careful examination of the board's activities and found that 80% of all complaints filed with the board came from insurance companies. Doctors throughout the state began connecting the dots and came to the inevitable conclusion that the state's board was dominated by doctors whose income was, at least in great part, dependent upon their relationship with insurance companies. These same doctors were hearing complaints against DCs filed by these companies, giving rise to accusations of conflicts of interest.

In response, the Arizona Chiropractic Society (ACS), led by Alan M. Immerman, DC, successfully pushed for legislation in 2006 to prohibit board members from concurrently working for insurance companies as IME doctors and serving on the board. The law is believed to be the only one of its kind in the country.

The group's investigation uncovered that the Arizona CBE spent $20,000 in an attempt to defeat this law ‑‑ a move seen by some as an effort to protect the incomes of Haydon and Baker.

"The tale in Arizona is just another tragic account of a chiropractic board gone wrong, a board that has lost its sense of direction, forgotten its basic mission, and determined that it is going to turn the profession into a sea of medipractors," Dr. Immerman stated.

Aiding and supporting the ACS in its efforts was the World Chiropractic Alliance (WCA), whose president, Terry A. Rondberg, DC, practiced in the state for many years. "I have strong ties to Arizona and am well aware of the problems that have existed in its board," Dr. Rondberg stated. "For years, I battled the blatantly anti‑subluxation‑based chiropractic attitudes of the medically oriented DCs on the board. This latest challenge is equally dangerous."

It was partly because of these biased attitudes that Rondberg and Immerman formed a state organization based on the principle of "live and let live," and then founded the World Chiropractic Alliance to promote that concept to the international chiropractic community.

Rondberg stated that, for the WCA, Arizona was in many ways a test case. "We need to clean the insurance industry reps out of our boards," he explained. "Doctors who work as IMEs to help cut claims for insurance companies have no business regulating our profession or passing judgment on doctors."

The WCA is also working to monitor similar situations in other states and has provided assistance in exposing and fighting abuses and discrimination by boards throughout the country.

Based on a statistical analysis from the National Practitioners Data Bank, the Arizona Board is among the most active in taking disciplinary action against doctors (the other 'most active' states are California, Colorado, Florida, Illinois, Michigan, Pennsylvania and Texas).

In a sample time period reviewed by the ACS, Arizona had 272 "adverse action reports" while its neighboring state New Mexico had only one; Utah, 28; Nevada, 12; and Wyoming, 1.

By early 2006, the problem with the Arizona Board had clearly reached a crisis point. Scores of doctors in Arizona had been harshly disciplined for what most observers deemed very minor violations.

Subluxation‑based doctors found that their record keeping methods almost always resulted in their being found guilty of "unprofessional or dishonorable conduct of a character likely to deceive or defraud the public or tending to discredit the profession."

The statement of guilt is placed in the doctor's file online for the public and reported electronically to the National Practitioners Data Bank, which forwards the information to all PPOs and HMOs.

The doctors suffer extreme personal and professional damage and are normally not allowed to participate in any managed health plans.

Ultimately, they can suffer loss of new patients and even the destruction of their practices, careers, and, in some cases, families and health.

Many doctors have become so intimidated by the board and the ever‑present threat of insurance company complaints, they have reportedly turned away patients needing chiropractic care if they felt there was any possibility of their claims being unjustly audited.

ACS members, including Immerman, increased their surveillance of the board, attending meetings and filing reports with their organization that were published in the monthly ACS News.

The publicity helped raise awareness that the problem was widespread and being combated by the ACS. Other doctors started stepping forward to share stories of their own experiences with the board.

In July 2006, ACS received a large packet containing an anonymous complaint filed with the Arizona Ombudsman's Citizen's Aide Office, an agency charged with mediating disputes between citizens and state entities.

The 70‑page complaint gave extensive details documenting the Arizona Board's use of intimidation, humiliation, condescension, sarcasm and unprofessional conduct directed at chiropractors who appeared before it.

It also uncovered instances of enforcement of standards of care that do not exist; unequal application of the law (such as one doctor receiving severe penalties for certain violations while another doctor received minimal sanctions for the same violations); arbitrary interpretation of the law (for example, requiring chiropractors to note time parameters and location of physiotherapy modalities, when this is not required by rule or law); excessive and unjustified reprimanding of chiropractors; and failing to conform to the intent of the Chiropractic Act, by imposing severe sanctions for minor record keeping violations when the chiropractor has done nothing to jeopardize the health, welfare and safety of the patient or the public.

ACS re‑filed the complaint with the Ombudsman and asked to be added as an official co‑complainant. The investigation is still underway at this time.

A key area of concern revolves around the fact that the Arizona Chiropractic Board can discipline a doctor for failure to comply with "recognized standards in chiropractic."

In 1995, the Arizona Association of Chiropractic (AAC), successfully lobbied for a mandatory continuing education bill that gave the board the power to establish and enforce clinical standards of practice. The AAC has an office across the hallway from the board and is seen as an ally of the board, not a watchdog of the board as is the ACS. Both Haydon and Baker are AAC members.

However, the board never defined what it means by "recognized standards." In reality, critics claim, the "standards" are set by board members in an arbitrary and capricious manner and can vary from one case to the next, from one meeting to the next. Rather than reflecting generally accepted chiropractic practice, they reflect the views and preferences of the board members.

Since two of the three DCs on the board have been long‑time defense pro‑insurance oriented IME doctors with extensive orthopedic training, this has been seen as particularly threatening to subluxation‑centered practitioners.

"The board's vision clearly is to turn the profession into a sea of medipractors," Immerman stated. "Only ACS stands in their way. ACS has tried to get the legislature to remove reference to 'recognized standards' from the law since it is undefined and probably indefinable in chiropractic, but the AAC has objected. Sadly, the AAC supports having orthopedic pro‑insurance IME DCs on the board force their standards down the throats of all state DCs."

The story took a particularly interesting twist later in 2006. Immerman reported receiving information from an anonymous source relating to several individuals with grievances against the board who had hired one or more people to sift through the contents of garbage found outside the offices of the board's three chiropractic members.

According to the report Immerman received, unshredded private medical records were found in the trash, resulting in 1,100 anonymous complaints filed with the Arizona Chiropractic Board against the three DC members for failure to comply with HIPAA patient privacy laws.

Although the board's website states it does not hear anonymous complaints, the board ‑‑ relying on the advice of the Ombudsman's office ‑‑ chose to deal with these complaints and dismissed all of them.

The source of original information ‑‑ whose identity is unknown ‑‑ reportedly informed Immerman that the medical records will soon be shared with the patients themselves, who will be free to file complaints with the board and HIPAA.

In the meantime, the ACS is continuing its efforts to fight board abuses and is working with state legislators to pass a bill giving the board the option of ordering doctors to take CE classes to address minor violations of the law, rather than applying more severe discipline. Group leaders hope this legislative remedy will bring some relief to the state.

(For more information about the Arizona situation, to subscribe to the free monthly electronic ACS News, or obtain a copy of the Ombudsman's complaint against the Arizona Chiropractic Board, contact Dr. Alan Immerman at aimmerman1@cox.net or 602‑368‑9496.)