The Wellness Spa Quota, the Technician, and the Pre-Printed Letter
Dr. Okafor has signed an independent contractor agreement with AlignWell Wellness Spa, which is owned by a non-chiropractor, Mr. D. Mr. D sets a quota of 55 patients per day and pays Dr. Okafor a bonus based on supplement sales and average visits per patient. He has asked Dr. Okafor to do four things: (1) hire an unlicensed 'spinal technician' to perform routine adjustments on maintenance patients for $45 cash; (2) bill 98941, 97140, and 97012 on every visit regardless of the services actually rendered; (3) bill a new patient consultation for each returning patient every 90 days; and (4) sign a pre-printed letter stating that each patient requires 12 months of care, for use in a pending personal injury case, at $200 per letter paid by the referring attorney. Dr. Okafor is three months into a two-year agreement and needs the income.
1. Analyse the three billing practices and explain the exposure they create for Dr. Okafor personally.
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Core rule. Every code billed must describe a service actually performed, documented in the record, and medically necessary for that patient. Volume, quotas, and payer expectations are irrelevant to that determination.
(1) The technician's adjustments. Billed to an insurer, this claims a chiropractic service that was not delivered by a chiropractor, and it is also unlicensed practice. Both the billing and the underlying act are problems.
(2) The same three codes on every visit. Billing 98941 (spinal manipulation), 97140 (manual therapy), and 97012 (traction) as a package regardless of what occurred is classic upcoding and billing for services not rendered. Payers treat this as fraud; North Carolina law provides civil and criminal exposure for knowingly presenting false claims, and the Board treats it as unprofessional conduct.
(3) Consultations every 90 days. A consultation code requires a distinct evaluation and medical decision-making, usually for a new problem. Relabelling an established patient's routine visit as a consultation misrepresents the encounter.
(4) Personal exposure. Dr. Okafor signs the claims and holds the licence. 'The owner set the policy' is not a defence; a contractor can be disciplined, excluded from payer programmes, and pursued for recoupment and penalties. He must refuse, in writing, and get the refusal out of the practice.
2. Analyse the request to hire an unlicensed 'spinal technician' and the bonus structure based on supplement sales and visits per patient.
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Unlicensed adjusting. Spinal adjustment is the core chiropractic act and may be performed only by a licensed chiropractor. It cannot be delegated to an unlicensed employee, relabelled 'routine maintenance,' or converted to a cash service to escape scrutiny. Dr. Okafor would be responsible for each adjustment performed under the arrangement and could be found to have aided unlicensed practice.
Bonus structure. A bonus tied to supplement sales creates a direct financial interest in recommending products, which compromises clinical judgement and conflicts with the duty to recommend only what the patient needs; it also raises fee-splitting and inducement concerns. Paying on average visits per patient rewards retention rather than outcomes and pressures the doctor toward unnecessary care.
Quota. 55 patients a day with one doctor cannot be examined, adjusted, and documented to a defensible standard; the quota is the engine that produces both the billing and the delegation problems.
Options. Renegotiate to a fixed salary or a fair clinical arrangement with no volume or product incentives, keep all clinical and documentation decisions under the doctor's control, and be prepared to leave. Document each refusal so that the pressure is on the record.
3. What is wrong with signing the $200-per-letter document, and what is the correct way to address the attorney's need?
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What is wrong. Four problems compound.
- The letters are pre-printed, so the opinion is written before any patient is examined - the conclusion does not come from evidence.
- A fixed 12-month necessity claim for every patient is unsupported; necessity is individual and must rest on objective findings, response to care, and measurable goals.
- The $200 payment comes from the referring attorney and is tied to producing a favourable opinion - that is a kickback and creates a clear conflict of interest.
- Signing a document prepared by an interested party to support litigation is a false statement if it does not reflect the doctor's independent judgement.
Correct approach. Decline the fee and the template. Write a narrative only from the actual record: initial findings, diagnosis, treatment rendered, objective response, prognosis, and any remaining restrictions. Charge a records or narrative-report fee that is the same regardless of what the report says, set in advance and not contingent on content. If the records do not support 12 months of care, say so - and if asked to change an opinion, put the request and refusal in writing.
Reasoning. The doctor's opinion is the product of an examination, not of a purchase order; independence is the only thing that gives it value in a courtroom or before the Board.