The Franchise Quota and the 36-Visit Care Plan
Dr. M is an associate at a Hawaii chiropractic franchise. The regional manager, who is not a chiropractor, sets monthly targets: every new patient must receive three X-ray views and a 36-visit care plan; associates receive a bonus for each visit beyond 12. At a staff meeting, the manager says, If a patient says they feel better, tell them that is the subluxation masking the problem. Dr. M's patient, a 44-year-old warehouse worker with acute lumbar strain, improves after four visits and asks to stop. Dr. M writes a 36-visit plan anyway, adds chronic subluxation to the chart, and bills insurance for the extra visits. Six months later, the patient's insurer audits and the patient complains to the Hawaii Board. The manager tells Dr. M to delete the old notes and re-enter them to match the plan.
1. Identify the professional-conduct and billing violations in this scenario. Which decisions belong to Dr. M, not the manager?
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The core violation is allowing a non-chiropractor's financial targets to dictate clinical care. Diagnosis, the need for X-rays, the frequency and duration of care, and discharge decisions are the chiropractor's responsibility. The manager can set business goals, but cannot require a 36-visit plan for every patient or require a chronic subluxation diagnosis that the clinical record does not support.
The charting and billing are separate problems. Adding chronic subluxation to justify visits is a false diagnosis. Billing insurers for visits that were generated by a quota rather than medical necessity is fraudulent billing. The 36-visit plan for a patient who improved in four visits is excessive treatment unless Dr. M can document objective findings, functional deficits, and a rational trial of care. The proposed deletion and re-entry of notes is alteration of records, which is itself a disciplinary ground and can turn a billing dispute into a credibility catastrophe.
The manager's statement about masking the problem is a red flag for a scripted misrepresentation. Dr. M cannot use it. The decision to continue, modify, or end care belongs to the treating chiropractor after clinical reassessment and patient discussion.
2. Describe how the Board complaint will likely proceed and Dr. M's rights and obligations at each stage.
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The Board will likely open an investigation after receiving the patient complaint and possibly the insurer's audit. Investigators may request the patient record, billing records, X-ray orders, and employment or contractor agreements. Dr. M must cooperate, preserve all original records, and not alter the chart. The original notes, including any inconsistencies, should remain intact; corrections should be made only by dated addendum, never by deletion.
If the Board finds sufficient cause, it will issue a notice of hearing and proceed under HRS chapter 436B. Dr. M has the right to counsel, notice of the charges, an opportunity to present evidence, and cross-examination. He may negotiate a settlement, but any admission should be considered carefully because it can affect insurance and employment.
Obligations include truthful responses, production of documents, and no retaliation against the patient or staff who reported the conduct. Dr. M should not contact the patient to persuade her to withdraw the complaint. Possible sanctions include reprimand, fine, probation, required ethics or recordkeeping CE, practice monitoring, suspension, or revocation. The insurer audit may also lead to recoupment and fraud referral.
3. What should Dr. M have done at the four-visit mark and when the manager asked for deletion?
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At the four-visit mark, Dr. M should have documented the objective improvement, the patient's functional gains, and the patient's request to stop. He should have discussed options: discharge with a home program, a short trial of additional care only if objective findings supported it, or referral if symptoms persisted. A 36-visit plan was not justified by the record. If the patient requested discharge, Dr. M should have honored that request, provided a summary, and explained return precautions.
When the manager asked him to delete and re-enter notes, Dr. M should have refused and preserved the originals. He could have written a dated addendum explaining any legitimate correction, but not a reconstruction designed to match a predetermined plan. He should have reported the pressure to the franchise's compliance officer or, if that was futile, to the Board or legal counsel. He should also have reviewed his compensation arrangement: a bonus tied to visits beyond 12 creates a conflict of interest that must not influence care.
The practical lesson is that the clinical record must be created contemporaneously and honestly. Once a quota drives the note, the note no longer protects the patient or the chiropractor.