Editor's Note:  This is part three of a six-part series about creating a wellness and fitness center from the perspective of an existing medical office or fitness facility. In the coming months, be sure to read the continuing articles on documentation, reimbursement and legal structure.


In the first part of this article series, I discussed the importance of case management for creating a successful wellness and fitness center. To get clients coming back, not just health care but for continued wellness care, it is important to keep patients updated and clear about their objectives. The best way to do this is is through documentation and a reproducible state of improvement. Human behavior backs this idea up. Humans will only continue a practice or process if they are getting results especially results they can measure and see. By managing a patient's case meticulously and allowing them to be apart of their continued improvement will make them continue to follow through. 

            However, a lot of practices and fitness centers cannot seem to fully implement this idea. Change is hard to do, especially with a business that involves many different types of people. But making the changes will allow your clients better service and results and keep them coming back to you.

            I recently heard Bill Esteb, chiropractic and patient advocate from Patient Media, speak at an event about being open to change. He told a great story about two sisters who, for years, had being trying unsuccessfully to duplicate their mother's beloved Christmas ham recipe. Even though they had the exact recipe, they could not seem to make it the same.  Every year they did exactly what the recipe said: First cut off the top two inches of the ham, marinade in various spices, cover and bake for four hours in a 350° oven. And although the instructions seemed simple, and they followed them meticulously, the ham was always missing something. They decided to pay a visit to the nursing home to visit their elderly mother to solve the mystery.

            After pouring over the nuances of spices and measurements, they were satisfied that they were, in fact, preparing the ham exactly as their mother had for years and decided the mystery would just have to remain unsolved. On the way out of the nursing home, one sister asked the mother about cutting off the top two inches of the ham and how that contributed to the flavor of the ham. The mother responded that she had only done that because her pan was too small for the ham to fit.

            The lesson: Don't do things day after day, year after year just because that's the way you've always done them. Occasionally, it's good to question why we do certain things. In practice, this exercise, when properly conducted and reflected upon, can lead to reorganization, change and growth.

            This process is critically important in patient case management as insurers and compliance authorities are constantly changing the rules related to documentation, coding and standards of care for particular conditions. Certain rules and technologies now available are making this process much easier and more accurate. Let's review them here.


Documentation and the Need for Functional Outcomes

Over the years, I have reviewed numerous documentation programs, procedures and techniques from dictation to touch screens and found one commonality: They are all only as effective as the health care professionals' ability to summarize the patients' experience of their aliments. When the dust settles, it is less about what the doctor finds or interprets from their evaluation and testing (still necessary parts however) and more about the patient's relative disability and experience of life in general given their condition or set of circumstances.

            This is the concept of documenting functional outcomes and functional evaluation. Simply stated, your standard orthopedic, neurological, x-ray, etc. testing will give you the "what and where" of your treatment, and functional outcomes will ongoingly justify the "why."

            Using functional outcomes makes documentation easier than ever before, and it's exactly the type of information that insurance companies want to see when requesting "more information" or requiring you to prove "medical necessity." This approach takes the distrust and animosity out of the equation because you, the health care professional, are not telling the insurance company what you have interpreted as the problem. (Remember, they don't trust you!) With functional outcomes, the patient (their customer) is telling them what they can and can't do as a result of their condition, and standardized calculations of severity and disability are produced, verifying an accepted course and duration of therapy which can be reevaluated (and goals restated) as care progresses.

            Functional outcomes also protect you from insurance audits that insurance companies are investing enormous financial resources toward in hopes of finding a documentation error and demanding their money back for several years prior. If you don't think this is possible, think again. In 2002, Blue Cross Blue Shield recovered $686 million dollars in the state of California alone, and they and other insurance companies now see "recovery" as a significant source of revenue.



            Proper coding has to do with completely understanding not only the patients condition, but the context of what that means to a third-party payer in terms of severity and expected duration and focus of care.

            This subject can get quite detailed in its explanation, which we cover in our seminars, but let me summarize here for a given, general example of a patient with a musculoskeletal condition with some neurological involvement. Let's suppose that Sally presents with neck pain that radiates down her arm when she raises her arm above her head. For those health practitioners reading this, it appears as though she has thoracic outlet syndrome. Coding this would present the practitioner with several options, but my advice would be to diagnose the neurological involvement first, the musculoskeletal involvement second and third and any complicating factors fourth. Doing this more accurately describes the complexity and likely need for more treatment and diagnostics than a musculoskeletal condition would alone. The scenarios are limitless here, and we have created a flow chart that helps practitioners choose the best order of diagnosis codes for a particular set and subset of conditions that insures optimum reimbursement and minimal rejections or requests for medical necessity.


Standards of Care

            One of the biggest concerns I have in terms of the survival of my profession (chiropractic) and also the wellness center practice is the relative lack of standards of care. From one practitioner to the next, the treatment for even common ailments seems to resonate more with the last seminar the doctor attended than any discernable standard. Long ago, we decided to have regular clinical staff meetings to discuss the case management of all new patients. My thinking is "the more opinions, the better treatment the patient would get." I soon found out that if not properly moderated, such roundtable discussions soon turned into a free-for-all, which almost never ended in a better place than where we started. Of course, this is the nature of such discussions, but when the recommendations started coming forth, I would often find myself baffled at how they had come up with their line of thinking. It is also part of what prompted me to begin to develop the practice management tools. The tools for standardization of care do exist in this profession, but emphasis must be on functional goals (functional outcomes) rather than a vague, "subluxation-resolution" model as proposed by some.


        Dr. Rick Perryman is found of Opinion Leaders and Health Coach Wellness Centers. He can be contacted by phone at 800.818.7170.