By: Larry J. Laurent, Attorney at Law, Georgetown, Texas
Over the years multi-discipline medical practices have become increasingly attractive to doctors of chiropractic as a means of maintaining or increasing revenues which have otherwise been (or might be) reduced through the belt tightening practices by insurance companies in the areas of personal injury and worker compensation and exclusion from health maintenance plans (HMOs, PPOs, etc.).
The “multi-discipline” practice concept involved the “integration” of a medical practice with a chiropractic practice through the use of a management service organization (“MSO”), a management service agreement and a number of other forms of “interlocking” agreements between a physician’s medical practice and the doctor of chiropractic’s MSO. This type of combined practice was very effective for doctors of chiropractic who were interested in broadening the scope of their chiropractic practice by offering medial services provided through a medical entity, and which they were able to derive some limited particpatory income through the provision of ancillary services to the medical practice. While effective at the time, this type of “integrated” practice was extremely cumbersome and did not provide the doctor of chiropractic the value return on his/her investment he/she sought through medical integration.
Enter the 2017 Texas Legislature. On June 1, 2017 Texas’ Governor signed into law SB 679. SB 679 amended Section 22.056 of the Texas Business Organization Code to allow doctors of chiropractic to now directly co-own a medical practice with a licensed Texas physician. While this new law does not eliminate the prohibition against the corporate practice of medicine, it does now allow a Texas chiropractor to directly participate in the stream of revenue derived by a Texas medical practice attributable medical services (in addition to chiropractic services). Thus, this new form of chiropractic-medical “integration” has now become a very effective means of expanding a chiropractor’s patient base and production of additional revenue.
While the recent changes to the Texas Business Organization Code do now allow Texas chiropractors to directly participate in the, heretofore forbidden fruit of a medical practice’s revenue, the new law also imposes certain restrictions on what participating chiropractors can and cannot do while taking advantage of the latitudes allowed under this new law.
Specifically, any chiropractor seeking to integrate his/her chiropractic practice with a medical practice must co-own the medical practice with a licensed Texas physician (MD or DO). The new law does not allow Texas chiropractors to employ a physician within their existing chiropractic practice. The chiropractor and a physician must both own “stock” in the medical entity. Under the Texas Business Organization Code physicians are only able to practice as a “professional association” or a “professional limited liability company”. The preferred entity of choice should be the PLLC – inasmuch as professional associations do not receive the benefit of exemption from our State’s franchise tax. In addition PA’s are more expensive to set up and more cumbersome to operate in light of their required annual filings with the State Comptroller. The cost of setting up a PLLC is $325 ($300 filing fee and $25 for expedited service). A PLLC is simply a limited liability company whose ownership in limited to only licensed individuals associated with the type of services offered and provided through the company.
In addition, Section 22.056 of the Texas Business Organization Code expressly states that it is not intended to expand the participating chiropractor’s scope of practice – that is, any doctor of chiropractic “integrating” under this new law is still limited to providing services within the scope of practice of chiropractic, as defined by TBCE Rule 78.1. The new law does not permit doctors of chiropractic to provide any form of medical service(s)- e.g. administering/supervising vitamin B-12 drips, performing injections, advising of medical options, etc. Such medical services are still limited to providers holding a license to provide medical services (physicians, advance nurse practitioners and physician assistants). In addition, chiropractors participating in an integrated practice under the
new law still cannot interfere with the independent decision making of the licensed medical providers. Thus, any doctor of chiropractor participating in an integrated practice under the new law must completely avoid any type of action that could be construed to constitute the practice of medicine and should take extreme caution to avoid the appearance to patients and the public that the chiropractor of holding himself/herself out to be a practicing medical provider. Of course, the DC can still refer to himself/herself as “doctor” but must be extremely careful not to create an impression in his/her patient’s mind that the DC is a licensed medical provider. Remember, patients see and hear what they want to see and hear and can very easily be confused when both chiropractors and licensed medical providers are attending to their health care issues. A doctor of chiropractic practicing in a newly integrated MD-DC practice can perform an initial examination on a new patient in order ascertain what is causing the patient’s pain and medical issues – but that chiropractor cannot refer that patient for medical services, nor even intimate that the patient should receive medical services. Rather, the doctor of chiropractic may render an assessment of the patient’s condition based upon his/her examination, but must always advise the patient that the patient will need to be seen and examined by the on-site medical provider at the clinic. While a doctor of chiropractic can diagnose a medical condition – only a medical provider can suggest that the patient receive medical services and prepare a medical diagnosis. Chiropractors practicing under a new multidiscipline program must take special care when marketing and advertising the services that are available through their new multidiscipline practice. This is especially important when the chiropractor is doing dinner talks about what their practice can bring to their patients. The DC must ensure that all persons in attendance are aware that he/she is a doctor of chiropractic and not a medical provider (remember patients can very easily be mislead when they her you refer to yourself as “doctor”). Both the TBCE and the Texas Medical Board are taking enforcement actions to hold doctors of
chiropractic accountable to these serious limitations.
A chiropractor’s new MD-DC integrated practice can employ physicians, ANPs, PAs, PTs and any other form of licensed health care providers. All services provided through the multidiscipline program are billed under the multidiscipline programs federal EIN but must still identify the individual provider that renders the service(s) to the patient (ala line 33 on the old HCFA 1500).
Practicing under the new MD-DC integrated model does not alter the laws governing “incident to” services. That is, in order for any medical service to be billed under a physician’s name that physician must be on site (but no need to be face-to-face) at the time such medical service(s) was rendered. Doctors of chiropractic still are prohibited from billing any chiropractic service they provide under any other licensed provider’s name/PIN (physician or chiropractor – only exception is locum tenens).
Another caveat that must be observed by doctors of chiropractic who choose to open a newly integrated practice under Section 22.056 of the Texas Business Organization Code is that they must take special caution to wholly avoid any situation where they would continue to maintain their old chiropractic practice and “bounce” their chiropractic patients back and forth between the chiropractic practice and the new medical practice. This type of conduct would violate the Texas “anti-kickback” law and subject the offending doctor of chiropractic to both civil and criminal sanctions. Doctors of chiropractic can certainly continue to maintain their old chiropractic practice but, as noted above, once they “refer” a chiropractic patient to their new integrated medical practice, that patient must remain a patient of the medical practice.
In summary, Section 22.056 of the Texas Business Organization Code presents Texas doctors of chiropractic with a new and extremely powerful mechanism to both expand their field of practice (patient base) and expand their ability to greatly improve their revenue stream at the same time. One last note – any doctor choosing to utilize the opportunities now available under Texas law and pursue medical integration their practice – would be strongly advised to (1) create a compliance program for the newly integrated practice, and (2) engage an experienced chiropractic/medical consultant to assist them in dotting the correct i’s and crossing the correct t’s, in order to ensure their compliance with all applicable health care laws and regulations.