How Attorneys and Health Professionals Can Work Together To Serve Their Communities

Introduction and Speaker Background 0:00

Welcome to the practice upgrade Summit. I'm doctor Dennis Perman, and I'll be your host for today. Our next speaker is an accomplished health care attorney and compliance officer with 30 years experience representing a wide range of health care businesses and professionals. His clients include physicians, multi-disciplinary practices, pharmacies, medical equipment and device companies, substance abuse rehabilitation facilities, ambulatory surgery centers, and clinical laboratories. He also has an expansive track record in the development and structuring of MSO arrangements.

I'm going to talk about MSOs in a little while, and practice is integrating chiropractic clinics with medical services, having structured hundreds of arrangements throughout the country. He believes that legal services should be client centric and flexible to meet the unique needs of today's changing and volatile healthcare business environment. He has an untraditional and pragmatic approach to addressing complex health care legal issues, while understanding the needs of meeting business and mission objectives.

He holds a joint JD MBA degree from Saint Louis University, consistently rated by U.S. News and World Report as the nation's top health care law program. He's also certified in health care compliance by the Compliance Certification Board of the Health Care Compliance Association, and is an expert in integrated practices showing how not to get caught in a legal and regulatory trap. Please help me. Welcome to the Practice Upgrade Summit. Mr. Al Meier, al, thanks for being here with us. Thank you. Dennis, it's wonderful to be here.

Great to have you. So tell us, how did you get started working in health care in the first place? It was kind of by accident. I had a, professor, in my undergraduate studies who, stressed, a joint degree, type of, program. So in the law school and getting a master's degree in something. And this was in the late 1980s, and I discovered health care was a booming, industry. And now we know it's part of our economy. And, you know, I don't know if it was foresight or just an accident that I found, an opportunity to obtain, a master's.

And now the penetration, along with my law degree at, Saint Louis University. So I decided to pursue it. And, that opened up a lot of opportunities, both on the business side and the, law side. So it eventually evolved over the years into such a narrow space that, I raided and found

How Al Meier Entered Health Care Law 2:56

to represent, medical doctors and chiropractors and coming together and setting up those relationships. So, number one, they can meet their objectives from a business standpoint. And secondly, and maybe more importantly, being compliance with the laws, which, you know, in many cases are very vague and ambiguous and unclear. Okay. So, it's great to have an expert like you, in integrated practice. Tell us, what is an MSO. MSO yeah, the MSO stands for management Services Organization. And, that type of entity is such that it can, it'll operate or manage, an entity that provides medical services.

These entities are used, to manage hospitals and other types of health care facilities. So a group of owners or an owner, can be medical providers or laypersons. We'll enter into an agreement with a health care facility to provide, you know, a limited or a very broad range of services, that can include billing, collections, providing, medical equipment, office space, accounting, bookkeeping, legal, and pretty much everything to operate a medical facility except for the provision of those clinical.

Those clinical services. Yes. So, what this is really is a safety valve for chiropractors who may desire to enter into an integrated format but don't understand necessarily or different management. Details. This is an organization that would, oversee and make sure that the doctors and the chiropractors were working effectively together. That's that's correct. Fantastic. So, what why doesn't everybody do this? I mean, it seems like something that would be very advantageous for their patients, especially, and would really help the doctors.

What are some of the what are some of the reasons why people do enter into this kind of relationship? And what are some of the reasons why people avoid it? Well, I think you know the answer. The first question is why do people enter into this type of relationship is, mainly to provide their patients a much more wider scope of, of care. And, and I'll have the, the vision

What an MSO Is and Why It Matters 5:49

that medical services and chiropractic services can, operate and be provided in kind of a partnership with each other rather than, having a adversarial type, relationship that you know, there's certain things our Practic can't provide and vice versa. Another reason is because, you know, of our, healthcare system that, chiropractors, are not getting the best reimbursement, for their services and to bring in, a medical component or other type of healthcare discipline can help them, keep, keep their doors open and be able to provide these services, that many of their patients, value, a reason why people may not, get into, this type of an arrangement is, maybe pure ignorance, maybe not knowing these types of arranged means, exists.

I think that's, rather rare, because I think most, our practice, you know, that this is, something that can be pursued. I think fear is, one of the, restraints and that, you know, we don't know what's going to happen. It's it's the unknown, finances, because, you know, while, this whole process is quite simple, it's not easy. And to do it the right way and to implement it the right way, there has to be a financial commitment. And most times, that financial commitment is rather significant. So, you know, if if you're not willing to make that commitment, if you're not willing to, operate in a way that you know, a consult that you may have or an attorney who really knows this model, you're probably setting yourself up for failure.

Well, ignorance I don't think we need to address because first, I think most people who haven't been hiding under a rock for the last ten years know that chiropractors and medical doctors do work together and, I, I, I don't know that the financial piece is necessary for us to discuss right now because obviously there's a price of admission, no matter what new venture or I'd like to focus for a moment on the fear. Is it a justified fear? Is there an awful lot to this that some chiropractors might not be up to?

Or is it more, hallucinated fear that if you understand the ropes, know how to do it, that pretty much anybody who is reasonably skillful can pull it off? Yeah, I do think, and in most cases, that fear is unjustified as like it like you said, if, you know, I can create and I have created a kind of a cookbook to use to get this model started from, you know, the point of, you know, the, the germination stage and putting the ideas together to getting to a point where you can start, start operating.

And like I said earlier, it's it's simple. It's not easy. But I think if you were to follow the steps

Why Practices Enter Integrated Arrangements 9:39

to get into this type of model, I think a lot of those fears, can be addressed and can be mitigated if you have the right kind of guidance. Great, great. That's what I like to hear. So I'd like to get your comments on practice right now because obviously, the onset of the Covid 19 era several months ago has changed the landscape for pretty much all healthcare providers. What are you hearing from the people that you work with, how they're accommodating the changes in the marketplace, and what kinds of things they can do to succeed better?

That's a good question. I'm seeing a kind of, a broad spectrum. I'm seeing, on a positive note that many of my clients are entrepreneurial in nature and are seeing this as an opportunity to expand their services to, be more efficient in and what they're doing, and, and looking out for, you know, the opportunities that are going to arise after we get through this because we will get through this. This isn't a forever thing that that we're encountering now. So I have, a number of my clients that are buying existing practices, that are adding new services, primarily, telemedicine, which, prior to, the onslaught with Covid, telemedicine, the technology was there, to, to do this in a similar fashion.

We're talking here, but state laws relating to, practice medicine and scope of services, you know, we're way behind. And so from a legal and regulatory standpoint, I think the advanced five years, in just a few months and, there's going to be a lot more flexibility in providing, telemedicine services and remote type services, than there then there was, you know, six months ago. Great. That's that's it's encouraging to hear because you hear a lot of, a lot of doom and gloom, going on out there. And, the fact is, there is opportunity everywhere we look.

What are some of your chiropractic clients telling you about that? Well, they've some of them are implementing, the telemedicine model to follow up with their, patients who, will you may not need, an exam, you know, a, a hands on type exam, more of a follow up, type of evaluation, a follow up evaluation after receiving, an injection, regimen that may be provided by their, their local staff and, and it's and it's working out. In fact, I even have, some clients who are, in the stages of, implementing, mental health services through their practice and through, you know, either, telemedicine visit or in-person visits.

So it's it's really, you know, I think the sky's the limit. And, and being creative and proactive, is a means to, to beat this, this thing because I do have clients that are unfortunately, as we mentioned, that really haven't, engaged, any of these potential opportunities. And because of that, you know, when everything was shut down months ago, they experienced, just a tremendous loss in their practice. You know, greatly suffered in the. So, first, it's refreshing that you have this more expansive viewpoint on what practice looks like.

Too often what happens is chiropractors get put in a pigeonhole and, you've gotten to see, a lot of different applications of chiropractors working with medical doctors. Now, most of the time when chiropractors

COVID-19, Telemedicine, and New Opportunities 14:20

think of working with an attorney, it's primarily on a personal injury basis. Right. And I want you to comment on that. But I also want you to comment on the other opportunities that are available for chiropractors to interface with attorneys in order to create more service for the clients and more money for them. Sure. One of the the differences, I'm working for you. And, whereas, you know, a relationship between a chiropractor and a personal injury attorney, you know, it's basically, you know, I'm going to send you, my clients, you take care of them, you write up, whatever reports we need to demonstrate, you know, the severity of an injury, and that's the that's the extended.

So I'm engaged personally with, the client. So the chiropractor or other health care provider becomes my client. And so I want to engage. I want to get to know, your business, your, philosophies behind how you want to do business and what you want to accomplish if you're going to implement a, an integrated practice model. You know, after that, I would like to I usually try to continue the relationship because there are issues that pop up, you know, on a regular basis. And these, you know, for example, there are going to be compliance issues with, depending on what kind of services are going to be provided.

We have issues with the staff. Well, we have issues with kickback statutes. And also state laws may be implicated by the types of services that are being provided. So one of the things that that I offer after this, you know, I do this initial work, is, you know, I recommend a compliance audit. Usually, I'm available for advice and counsel on, you know, various laws, and regulatory requirements. So I can, you know, grow with you in how your practice develops. What does a chiropractor need to know or do in order to be a suitable partner in an integrated type of practice?

I think one of the things that a chiropractor needs to know is this is not the savior for your practice. This is something that I think enhances what you're doing. So, you know, in my, experience with my with my clients, I've seen those who may, may be struggling in their chiropractic practice think that this is going to be the magic pill that's going to, you know, get them to retirement. And that's not necessarily the case. Now, I think one of the most important things is to have a stable, relatively successful practice where you can add these things into your, scope of services and, you know, enhance the patient experience and also allow, you know, to enhance revenues and, and, you know, the efficiency of their, of their, operations.

Okay. Talk about some of the liabilities, that chiropractors might face entering into a relationship like this. Sure. I think the Pensacola needs to be careful not. You know, one of the things is not to cross the bounds of being a chiropractor and providing, being, alleged to provide medical services, medical diagnostics, and putting together a treatment plan for medical services.

Chiropractors Working with Attorneys and Compliance 18:58

A number of my chiropractic clients will do, an initial exam or history. And one of the things, for referral over to medical services, one of the things that I, that I stress is you need to make it clear that, you know, this is not, medical advice. It's not a medical diagnosis. I'm merely taking, information that I'm going to share with, the medical staff and the medical staff is going to, you know, give you a more thorough exam and decide whether or not, medical treatment is appropriate. And if so, what the course of action, is going to be.

And, as we mentioned before, the regulatory and legal issues relating to, stark law indicate that, that, they need to have, a basic awareness. And that's one of the things, I try to do with putting together compliance programs to educate, not only the, the, health care providers, but their staff, which I think is probably more important because they're the ones that are going to be submitting bills that are going to be, involved in collecting bills and, involved in, you know, maybe coding, the different procedures.

So just to have that awareness and to say, hey, some something might be going on here, let's, let's check with our attorney to make sure we're doing everything correctly. Okay. So, that's that's a little intimidating. I'm assuming that if the, management service organizations set up properly, then there's an appropriate pecking order where the right patients get funneled into the right services. Is that what the MSO actually helps do? Well, the MSO can help do that. But the ultimate responsibility is lies with the medical providers or, you know, the clinical staff.

The, members. So, you know, one of the things that the MSO, can and typically does provide is, services relating to compliance and legal, which would allow, the MSO to consult, you know, with, you know, an attorney or other expert, to get some advice and counsel on, on those operations. Okay. So so tell me a little bit more about the scope of practice. When a chiropractor decides to integrate, decides to work with a medical doctor. What different kinds of patients are typically attracted and how do they work together? And so, well, and there's a couple of ways that this can be done.

First, you know, it all depends on the, kind of the port of entry. And, if the port of entry is a, an exam by a medical doctor or, a nurse practitioner or a physician assistant, that person can say, well, I think you may benefit from some more, you know, conservative type treatment. And we're going to refer you to, Doctor Jones, our chiropractor, to, engage in, more conservative treatment before, you know, we do something that is a little more invasive. You know, for that, case. So, and what if the portal of entry is the chiropractor?

Would be basically the same, the same thing. And, the chiropractor would treat, the patient. And if the patient, was not getting, a positive outcome from that type of care, then, you know, he can be referred over to, the medical staff for an evaluation and, treatment, if, if necessary. So. Because in an integrated practice, they're on the same team, then it isn't like farming out the patient to an outside, source of care. It's all done in-house. So it's a convenience for the patient. Right. So there's a financial, benefit as well?

Yes. Okay. Cool. So, do most of the people who come to consult with you, are they looking for integrated practices or do they have an integrated opportunity? And they want you to oversee the legal business?

Scope of Practice, Ownership, and Legal Pitfalls 24:18

Most of my clients come to me, before they, start the process that they are interested in putting this together. Perhaps, they have a friend who's doing it. Perhaps they, engaged. Consultants, to help them through, implementing the model. And then now I would get involved, in the beginning, to put together, the proper legal structure, to allow them to get started. So, you know, I'm typically, the first, first thing that needs to be done is stuff that, you know, I would typically do for my clients, because if you're not going to be able to get started, treat a patient, start operations without having, a proper legal structure.

Well, that makes sense. Talk about ownership a little bit. Some states permit, chiropractors to own, medical, establishments and some do not. Could you comment on that in your that's awareness of this. Where there's for example, the state of Ohio would allow anyone to open up a, a clinic or an entity that's going to provide medical services. However, you know, you have to be very careful that, you know, somebody like me, opens up a medical practice that are not involved in any medical decision making whatsoever.

Now, I cannot encourage, a power practitioner or medical doctor. Hey, you need to, do these types of services because the reimbursements are much higher than what you're doing. So there can't be that that type of that type of interference. Other states will allow, a joint ownership between, chiropractor and a medical doctor. The same concept would apply. For the, you know, if I were owning the practice, I would apply to the chiropractor that medical decisions need to be left to the medical providers.

And there's a third, case where, a chiropractor or, anyone is not able to own an entity that provides medical services. And that's where we would implement, this MSO model that we've been discussing. That makes sense. That makes sense. So it's anybody who is desirous of creating an integrated practice would probably be able to do it. Oh, yes. As long as they, as long as they aren't terrified, as long as they, And the money. As long as they know about it. Right. And I think the most important thing is to follow the proper, steps to implement this, this model.

For example, if, you if there needed to be a medical doctor that owns, that was, that the practice that medical directors can't be a mere figurehead or subterfuge of this that person has to be involved and engage in what's going on. And that's why a lot of, people get in trouble when they just say, well, they can have somebody in name only and, and and forget about it. So there really has to be a bona fide relationship and that is just one of the, the crucial steps in putting this together and, avoiding, you know, having problems with, you know, from an illegal standpoint, from a regulatory standpoint, and maybe more importantly, avoiding, any disciplinary actions from, licensing board.

Well, you're also a compliance expert. So what are some of the pitfalls that integrated practice is have to deal with to make sure that they comply? There's a number of things. First and foremost, is, from a billing and coding, and documentation of medical records, and since, you know, those practices, the disciplines are together, under one roof, so to speak, both the chiropractic records and the medical records, will likely be scrutinized, at the same time. So, for example, let's say, you

The Future of Integrated Practice 29:38

have, a chiropractic patient who is responding well to chiropractic care, but the, you know, the, the, the owner of the practice or the manager of the practice says every person is going to get chiropractic care and they're going to get an injection. So, you know, in this simple example where a patient is getting a good outcome with chiropractic care, why then would that person need an injection when there's a good response? So that's why these they're they're in partnership with each other and both sides of, of, of the hallway.

If you will communicate with each other. And those records need to be, detailed in such a way that, that shows, the progression of care and how, you know, from chiropractic to medical, it was necessary to keep that progression. Well, you've been immensely generous with your, with your experience here. I really only have one more question for you. And I want to know from your vantage point, what do you think the future is of integrated practice? What you think doctors need to know. Chiropractors and medical doctors need to know to interface with attorneys like you to be able to create something that's, truly ironclad, bullet proof going forward.

I think the future is, is very bright for, these types of arrangements and, not only, you know, we we're going to have, you know, some developments in, things like telemedicine. And I think, you know, I think there's going to be some leniency in, cross state lines licensing. I think insurance companies are going to be, much more, accepting of less invasive procedures. And, and there's also opportunities, for cash, based services and, and the, these models, I think, can serve, you know, in a, in a myriad of situations, we can look into, you know, the traditional medicine model where, doctors, you know, will treat, you know, from injections or, not so much medications because pretty much all of the clients I deal with do not prescribe, even from, the medical standpoint, but I think there's opportunities that go beyond, a orthopedic or physical medicine type model.

There's opportunities to implement, primary care. As I mentioned earlier, there's opportunities to, integrate mental health. So I think we all have to, you know, in the health care business, I've been in health care for 30 years and I think as, attorneys, as business people, as providers, I think we need to think out of the box and think of, you know, how we can provide a good continuum of care, for our patients and still remain, financially viable. Because if we're not financially viable, you can't provide any services, that are of any value in the.

Well, you have been, a fount of wisdom for those who are, up until now, relatively unaware of the tremendous advantages and opportunities that are available or the forward thinking doctor of chiropractic to work with both medical doctors and attorneys to serve their communities that much better. Mr.. Al Meier, you've done a great job here. Thank you so much for being on the Practice Upgrade Summit. I'm done signing off for now. Thank you so much, Dennis. It was a pleasure.