Interstate Telehealth and Delegated Cervical Manipulation
A chiropractor licensed only in Vermont advertises on a New Hampshire radio station and a website that says 'New Hampshire patients: get adjusted from home.' A New Hampshire resident with acute neck pain and dizziness schedules a video visit. The chiropractor, physically in Burlington, Vermont, reviews the patient's MRI report, observes the patient's range of motion, diagnoses 'cervical subluxation complex,' and instructs the patient's spouse to perform a high-velocity cervical manipulation on the patient using a handheld device. He bills the patient's New Hampshire insurance for a chiropractic office visit and a manipulation. The patient later has severe neck pain and asks whether the chiropractor was allowed to treat her in New Hampshire. The chiropractor says he was licensed in Vermont, the visit was by video, and the spouse performed the manipulation, not him.
1. Was the chiropractor practicing chiropractic in New Hampshire without a New Hampshire license? Apply the location-of-patient principle and any telehealth rules.
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Yes-this is practice in New Hampshire. Licensure follows the patient's location, not the chiropractor's. The chiropractor diagnosed a New Hampshire patient, set a treatment plan, interpreted imaging, and directed a cervical manipulation during a New Hampshire visit. That is chiropractic practice in New Hampshire. The video format does not create an exception. Directing the spouse to perform the manipulation is an attempt to use the spouse as an agent; the chiropractor remains responsible. Advertising to New Hampshire patients and billing New Hampshire insurance reinforce the conclusion. A Vermont license does not authorize New Hampshire practice. The Board can pursue unlicensed practice and related violations.
2. What issues arise from instructing an unlicensed spouse to perform a high-velocity cervical manipulation?
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Instruction to an unlicensed spouse raises:
- Delegation: High-velocity cervical manipulation is not a task that can be delegated to an untrained family member. Even if New Hampshire allows certain delegated modalities, this is not one.
- Standard of care: Cervical manipulation with dizziness requires in-person assessment and caution; remote instruction increases risk.
- Consent: The patient needed to understand the risks of the spouse performing the procedure and the alternatives.
- Records and billing: Billing a manipulation when the chiropractor did not perform it may be false billing.
The chiropractor cannot avoid responsibility by saying 'the spouse did it.'
3. What should the Board consider in setting discipline, and what preventive steps should the chiropractor have taken?
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The Board should consider: unlicensed practice, patient harm, high-risk cervical manipulation, delegation to an unlicensed person, misleading advertising, and insurance billing. Aggravating factors include continuing to advertise after the risk was apparent and failing to refer for in-person assessment. Mitigating factors might include cooperation and no prior discipline.
Preventive steps: obtain a New Hampshire license before treating New Hampshire patients; verify where the patient is located at each visit; use telehealth only within the scope allowed by Board rules; do not delegate high-risk manipulation; arrange in-person evaluation for red flags such as dizziness; and ensure billing matches the licensed provider and service actually rendered.