Empowering Women in Chiropractic – Managing Moro Across all Ages & Stages – Monika Buerger

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Hello, happy Thursday. This is the third Thursday of January. Welcome to the amazing ChiroSecure, uh, platform. Big use of ChiroSecure again for giving us this opportunity to bring you, um, the Look to the Children’s show. So under house, Dr. Monika Buerger, hopefully you’re all doing fantastic. This, um, great, uh, third Thursday of January, 2121. So today I want to hang out a little bit. I’m getting a lot of questions and emails and blasts on social media and et cetera about what can we do for our little fiddle farts that are so stressed out these days. We are, um, we are in a time where not only the kiddos are stressed out with the adults are stressed out. So today I want to talk about how some things that we might see manifesting in our patient population group. And one of those is primitive reflexes.

So we throw this term around a lot, but one thing to keep in mind is this isn’t just for our little ones. This is really across all ages and all stages. And what I mean is, um, we’re going to see this happening in our adult population as well. And why is that so important? Why do you want to talk about that with on a peat based to show because our kiddos are going to feed off of their parents and the adults they’re around. So we have, um, adult stress ramped up anxiety, um, this unsettling, um, future that we’re trying to look at. So the kiddos are going to pick up on that and that’s especially true with during the prenatal period. So those pregnant mom was out there right now that are high stress. The, the, the, the, uh, the child will actually inherit mom’s stress patterns, mom’s stress resolve moms, um, the way she’s going to respond to her environmental stressors.

So I wanted to pick Moro reflex for, uh, this topic. Uh, the Moro I say is kind of the, uh, head honcho of the reflexes or the head honcho of actually of the sensory motor systems. And what I mean by this are primitive reflexes. Each primitive reflex kind of represents the maturation has part to do with the maturation, um, of our sensory motor systems and how we respond to sensory different sensory cues, sensory feelings, and the Morrow really represents maturation of all of our sensory systems. So the, the ability to respond in a good neuro, uh, integrity to all of our sensory environment, vestibular visual, tactile auditory, that moral reflex kind of runs the roost. So it’s a big kahuna. So when we’re in times of stress, when our resiliency goes down, those primitive reflexes can emerge. So a person, a child, a, the Mar reflects in particular integrates it should no longer be active.

So to speak after the age of about four months. However, if our overall, um, neuro adapted to their ability to handle stress is compromised because of infectious of traumas, whatever those re those reflexes, even if they were integrated, can reemerge. And this can be true with our adult population as well. It’s particularly true after, um, concussion, head trauma, et cetera. So, first lesson first take home. Pearl is we can use this information to assess all of our patients across all pages. And especially if you’re working a family practice paradigm, because if mom or dad are ramped up and stressed out, those kiddos are going to follow, um, and all stages of neural integrity. And what I mean by that is I’m going to show you different ways to assess the Moro reflex. Many of you are, um, first on the trust fall way, but I’m going to show you a couple of different ways, and I’m going to talk about different ways to integrate it depending on a person’s neuro functional capacity.

So let’s dive in and let’s have some fun. All right. So again, the more we flex sometimes has been in the past is referred to as the startle reflex, some will, um, there’s, there’s some controversy on that, um, on using it as the, the term, the startle reflex, it is a, it, the precursor to the Mar reflex, um, is called a fear paralysis reflex, and that develops in utero, and it should be integrated in uterus. We shouldn’t be born with it, but those two kind of go tandem together. And we work with them in the same manner, but again, the more reflects should disappear or integrate it at about four months of age. Um, if you see a little fiddle fart that six, eight, nine months a year old at a still very, um, start very easy, one telltale sign is when you try to go lay them down, they might be asleep and calm in the arms, but you’d go to lay them down.

And that head drops a little bit and they, they wake up and they start all, and then they’re inconsolable after that, they won’t go back to sleep. Um, they’re crying. They’re very much, um, dysregulated and disturbed. Okay. So that’s a telltale sign that that’s, that moral may be still too active. Um, if retained, this is very important. The moral tends to drive us in a more sympathetic dominant state, all the primitive reflex as well, right? Because they’re going to drive us back to that. The brainstem, that primitive part of the brain, these are brainstem reflexes. They don’t have cognitive control. It’s a reflux that makes me want to always break out into that song by the clash we flex. I won’t sing on this. So those would be that know me like the dummy in person I like to sing, but it doesn’t work out well, usually.

So anyway, um, so we, we shift, but the Morrow in particular leaves us in this fight or flight pattern. The Morrow is known as the first breath of life in the child. It’s responsible for that first breath of life in the child. When they’re born. I have seen clinically that, um, those little ones that are born, particularly with the cord around their neck or that, um, needed resuscitation afterward, or need oxygen or anything like that, having to deal with breathing that that Morrow tends to linger longer and tends to be more active throughout life. So just keep that in mind, if you’re looking at a history, um, areas that we want to look at from a spinal standpoint is looking at, um, uh, up regulate the parasympathetic nervous system. Since it will lead us into the sympathetic fight or flight shift, um, the respiratory diaphragm working the diaphragm, the rib cage can be huge because little, any individual that has this actively retained a Mar reflex might be breath holding a lot.

Um, they might not be expanding their red page. Um, well, and so we get some, uh, lack of oxygen, good oxygen flow concerns. This, um, also is very much tied with adrenal activity. When the adrenals tank out our immune system can be compromised. Um, we see things like allergies, eczema, asthma, um, and poor immune integrity associated with an active Mar reflex. So keep that in mind. Um, this can also really drive us into that limit, what I call limbic lock and load mode, and, uh, being held hostage by our amygdala, our fearmonger. So we can see anxieties and depressions and so forth associated with this constant Moro reflex, um, and very much, um, high, uh, muscle spasms, muscle spasticity, um, especially at the posterior muscles, the extensor muscles can be hypertonic and stress all the time, the posterior calf muscles. So these individuals, you might have them doing stretching routines as stretching routines, and you’re like, why can’t I get these muscles to relax?

They’re constantly stuck in that cortisol state because that morals fired up too much. So, um, Moro things like Annette, being able to unfold to not focus at one thing at a time, kind of that squirrel mode, okay. Poor impulse control, poor emotional maturity, um, easily distracted and that the poor impulse control and emotional maturity that comes because that prefrontal cortex is usually flipped off when we’re stuck in with these primitive reflexes. Um, so we’re stuck in that primitive part of our brain. So our executive functioning skills are not as great, um, aggressive, hypersensitive, anxious, startles, easy, a big one is having trouble paying visual attention to the center. They tend to pay attention to the periphery there everything’s distractive. So if we take this into the context of trying to sit and study or listen to in class, or as an adult, listen in a large lecture hall, we might be deferring our visual attention to the periphery all the time.

And, and so again, that squirrel attention. So we’re missing a lot of that information coming in. Um, they might crave sugar or caffeine, those stimulants to keep their adrenals driving because they’re, you know, burning out so much with their adrenals, um, things that, um, poor balance and coordination stamina we’ve talked, you know, brief some of this here already, um, blood sugar levels, blood sugar levels could be a big one because they’re constantly that sympathetic dominant shift. And, um, the adrenals are dysregulated, so they can, big times a blood sugar drops are between 10 30 and 1130 in the morning and three and four in the afternoon. So essentially after breakfast and lunch. So watch these individuals again, not just your kiddos, but your adults as well. Do we need to help supplement them with more blood sugar stabilizing snacks? Okay. Um, good proteins, good fats, et cetera.

They may be hypersensitive to light touch, sound, smell, or our sensory system, um, very troubled with adaptability. They want to make sure that they know what’s coming. They want to be the predictable situ in predictable situations. So, because they want to, they don’t change it. Routines is not a great thing because they want to know what’s going to feel like in the situation that they’re going to be presented in. So if they’re familiar, they know they’re going to be walking into their classroom and what that feels like, what it smells like, how loud it is and everything. But we switched that up and them and say open today, you’re going to go to Mrs. Jones class. Instead, they might come become unhinged because they’re always on guard and they don’t know what they’re going to feel like in Mrs. Jones is class. What’s going to fill out like to their brain.

Okay. Um, they can have trouble with hyperactive activity and fatigue. Um, because again, they’re being so drained. Tell me time is going to be a big, big milestone that we need. We need to look at with, um, helping to foster integration of the moral reflex tummy time. And then at about three months of age or so when they roll onto their side and they kind of kind of come together to midline, moral reflex is a core, it’s a core base centering reflex. Um, those of you that if you work on any energy or shock residents, a lot at solar Alexis area. Okay. So let’s go into some ways that we can evaluate the integrity of the Mar reflex. So let’s remember, I always say when I’m teaching, the more a reflex mimics an infantile response, that’s the it, the more active it is in that individual.

So in the, in the infant, we know that, um, they are going to inhale and everything extends. And then the exhale, like a, like a sigh of relief, the exhale, and come in into a flex position. So the Mo when you’re doing these testing patterns is T evaluations. You look for how much do they mimic that infant towel reflux? Okay. So it’s a good idea to get your hands on some little fiddle, farts, some newborns, and test that Mar reflex, you’re holding them. And basically you can drop them and you should see that inhale and then exhale. And they settle and come to come to inflection. The Murray flex was, has, um, been much associate with the vestibular system because of that change. It had movement. However, they’ve done some studies where they, um, basic what has basically shown that it’s very much associated with vestibular and proprioception, especially of the upper cervical spine.

Okay. So it’s an extension based stimulation that we’re looking for, that if it’s still active, we’re going to talk. We’re going to look at a few different ways to, uh, to look at this. One of them is actually in a supine position. You might not get these little fiddle farts that are, um, that have such an active Morrow to want to do the trust, fall maneuver, where they’re standing with feet together. I think I put a little video in here or a picture of that. Um, but that while they’re standing be preferably feet together, good posture. Cause we want to load up the system, especially at proprioception arms would be flexed elbow, slightly up the side, their head extended, and you ask them to fall back and you look, if they can, they do it with ease, do they hesitate? Um, do they, do they do this?

And then come back in. So the more amendments that mimics that infantile response, the more active it is in that individual that you’re evaluate. But I want you also to look at things like, do they flush? Do they have a sympathetic response? Do they get red? Do they get sweaty? Sometimes what I’ll do? Let’s say I’m doing the trust fall on a eight or 10 year old or an adult. Um, just make sure you can. You’re strong enough to match their body size. If you’re going to do the trust fall one. Okay. You can handle them if they, that dead weight comes back at you. Um, but my little fiddle parts I might say did that. And they, I see no action of their arms, no reaction. They just fall straight back. Okay. I will touch their PA. I’ll say, let me feel your hands. I want to feel that, are they breaking out into a sweat? Am I, am I picking up any sympathetic response? And I’ll also ask them, did that, um, how did that make you feel? Did that give you butterflies in your belly?

And some of them say, no, that was fun. Some might say you little, you know, and I’ll say little butterflies, medium, or a lotta meaning. Did that feel? Give them a feeling of being anxious. Okay. So you want to dig a little bit, um, you want to look for the overt signs, but you also want to did, like, is it maybe hanging out a little bit? Another thing you can do is you can walk into a room and you can either come from behind. If, if you feel it’s appropriate, if you know this person or, you know, they’re old enough, you think they can handle it, et cetera. And you can see if you can start a limb boot, um, or you can see, um, when you, some people say is, um, when you run up to somebody and meet them face to face, and if they’re equally to embrace you or they’re like freaking out, okay.

So those are some, some other subtle signs you might look for that is this moral hanging out a little bit, the older person or adult you might ask, how do you do somebody scares you? Or if you are, um, walking in front of the cards and we slammed slams or horn, do you like startle? And it’s hard for you to settle afterwards when Morrow integrates, it’s taken over by what this, what we call the stress reflex, where if I’m sitting here at a cafe, having a nice glass of wine with somebody in relaxing and conversing, and all of a sudden, I hear a loud crash behind me. I should appropriately take a breath in my shoulders. Go up. I turn, I look, I’m available, able to evaluate that I am safe. I’m okay. And I can come back and I can pretty quickly relax and calm down again with the adult, with the oldest child, do they startled?

And they have a hard time coming down and, and, um, self-regulating afterward. So those are some other things we want to look at if looking for an active Mark. So another way to test, we can do that the trust fall, but you can also have the person, the little fiddle part’s supine have, you know, a rolled up. You’re going to see on here, the rule that pillow under her shoulders. So you want the head about four or five inches off the table or the floor, depending where you’re at, put your hands underneath them. Their arms should be out to the side elbow, slightly bent with palms down legs extended and be fairly relaxed. And what you tell them is first of all, do it with the eyes open. Um, when I, as soon as I dropped your head, as soon as I let your head fall, I want you to cross your arms across your chest. First of all, make sure they can do this. Make sure they can, they know, understand the directions and they know how to do this. They can use both arms in a coordinated fashion

To do this. So

You simply hold their head. And at a given point, just drop it down and you see how fast they can react. Do they initially splay out like tomorrow and then come to midline appropriately? Do they hold their breath? Do they grimace? Do they flush? Are they sweaty? How active does that? Their motor pad, their response mimic an active model reflux. So this is another way we can do it. And then there’s also what we call the duck and pigeon walk. So what I’ll do is if I am not sure, or I see a very slight then thinking that’s kind of the slight active model, but I’m not sure I’ll put them in a duck and pigeon walk. And oftentimes you’ll pick it up here. And what that is is you have them stand. You have their elbows bent at a 90, 90 degree. As you see here, her thumbs are pointing inward and then her feet are pointing


And you have them walk about 10 feet forward and 10 feet back up several times. And you see if they can keep that posture. The thing you’ll know is that they’re there, their thumbs or hands want to come out of that position. And, um, and then the pigeon walk, his feet are turned in toe to toe and thumbs are turned out and can again, can they keep that posture as they walk forward and backward? And so this sometimes will bring out that, um, that moral, that you’re not sure if it’s linear in there or not. So I do this on my older kiddos and my adults, if I’m not seeing, if I’m, if I do the trust fall, um, and or the supine, and nothing’s really sh I’m not sure. I’ll see if I can bring it out this way. So those are three ways we can evaluate the moral along with the things that we talked about, of, of, uh, history, questions, and presentation that might be indicating, um, an active Morrow.

And then look again at your history. Are they complaining of anxiety? Are they complaining of inattention, um, sleep issues, blood sugar dysregulation, look at those as well. So tie those into the picture. So how are some ways? So this is a pretty, um, standard exercise to help integrate Morrow. But again, we want to bring this across all ages and all stages. Not everybody can do this, right? So I’m going to hold your breath. Don’t hold your breath because it’s part of Morrow. Um, I’m going to show you some ways we can modify things to help those, those individuals, depending on their age and their functional integrity, how we can modify this. So I have this little one in, in a chair. You can do this either supine, or you can do it in a chair depending on their capability. And we, I call this the Venus fly trap.

It’s like that plant, right? That you drop something into and it eats it up. So I call it the Venus fly trap. I think some people call it the star flower. Okay. So you’re gonna see it called different things, but this little one’s in a chair everything’s extended. Okay. Palms facing outward. And then the first thing is they cross one leg. They cross the same arm on that side, and then they roll up. Now what I tell, because you also want that head to come into flexing and what their whole body to come in into flection. Okay. So what I tell them, as I tell them, um, cause you want the pump when they’re doing this, you want the Palm space in their face. So I tell them that pretend your hands are like butterflies. And that they’re always facing the butterflies are, are, are facing you.

Okay? And they’re flying right here because I want those palms open. And as a side note, sometimes you’ll see individuals that have an active, retained Morrow. They they’re fisted they’re there. They don’t relax their fists open. So palms open facing you. All right. Um, and then as they they’re going to cross and they’re going to roll and they’re going to kind of take the butterfly wing to their nose and then the unroll uncross. Okay. Um, and the reason I liked that I like having their eyes on their hands as well, because you’re now you’re getting some hand eye coordination built into this. Um, so it’s, it’s kind of killing multiple birds with multiple stones. So you have them do one side first and then unroll and uncross. And then the other side crosses over and they roll up. Now again, I start them out with these basic movements because that’s all they may be able to do.

And then I can add breathing with it. So as they extend the inhale as a flex, the exhale, and it’s great to do like a five count breath with that. So as a extend five count, inhale as a flex five-pack five count by point. Exhale. Okay. How many do you do on each side? It depends on the, on the person. Do they cook out? Do they get kooky brain after three? You don’t want to push the goat. So to speak on these because you don’t want to drive them into a sympathetic state where they don’t like doing these, especially with their kiddos, their excuse will be, Oh, this is dumb. This is stupid. This is too easy. When actually it’s really hard on our brain. So, um, you might be able to get three on each side for the first week and then they can do five and then they can do 10. You need to step them up as tolerable. Okay. Because who wants to feel cookie? Now I want to show you over. This will play okay. On the child that can’t do this. How can we start laying the foundation to help them do this?

Can you do this? Maybe your right leg comes over to your left. Okay. And then do you remember your right hand? CO’s over on top, but your left. Okay. And can you roll up into a ball or you can do a roll, everything up and the head comes up too. There we go. Awesome. Okay. Unroll and unfold unfold. And now the left side comes on. Talk. Is it like paper? Kind of, can you put the website on the top? The left hand on top. Okay. Remember it’s like, butterflies are looking at you. It’s like your hands are butterflies because you want always the palms to be facing the face. Okay. Okay. So that gives you just again, how do we modify these things? Right? How do we make it applicable? The other thing I call it’s called clamps again, Morrow is a centering. It’s a core reflex.

So I use, um, hold on. If you’re out there. Okay. I’m going to show you actually with little babies to how to do this. Okay. We’re going to modify it for the little, little, little, little ones. Okay. But clams are, um, I use either, you’re going to see two different versions here. You’re going to see me using a deflated plated physio ball. And you’re going to see me using a beanbag chair B back because we want to mimic, we want to get an action that they can carry out that gets them into that center. All right. So this is kind of fun. The boys, especially like it. Um, so I’m going to show you. Okay. Ready, buddy. Okay. Everything comes up and squeezes it. Here we go.

Beautiful. Beautiful. Ready to go again? I think I have it ready. Okay. So you want their arms and their legs to kind of come up, see how the end phases here has legs. There’s those bits spread apart. You want them that kind of squeezing that whole, the upper and lower extremities. And then you’ll see this guy. Awesome job three, because especially this, the second one that I showed you, that little guy would, can not figure out right. Left more reflex. It’s going to be, uh, uh, uh, right left body, right. Left brain, upper lower body, upper lower brain brainstem to frontal lobe. Okay. So they can’t figure a lot of this. These kids can’t figure this stuff out, so we’re helping them and we’re playing a game at the same time and they love it. Um, so how do we modify this with the baby? Okay.

Okay. So with the infant, with a positive Mara, we can do the same type of things that we did with the older child. We’ll just modify it. So we saw that video clip where we had the little toddler and we had mom had him sitting in at her lap and we put the ball and we call it the clam. So what we can do with the little ones is get the small step in and we’ll okay. We have our quality

And we just use that boom. And we just modify ends up squeeze. Okay. And then maybe get her attention and then, and roll up and squeeze. Okay. So we’ll do that three to five times, and then we can do a model

Venus flytrap as well, where just like you saw in the video with the older child where we’ll just

Do the, um, maneuvers for them

And then roll them up and roll and I’m cross. And you can have the parents do at home again, three to five times on each side with the little ones it’s really easy to do for just one person, because they are so small, so modifications depending on functional capacity, age and size. So there’s some tips for the Morrow, with the iPad.

Jeez, gotta love that hair in that video. Hi, wild hair day there. Um, now what I want to say is, um, you saw me do the clams with that older child. The other way I’ve had them like, like a three-year-old where I’ve had them, where sit in mom’s lap and they’re facing out. And we just use a big step down, a big Teddy bear when they’re step animals or a big physio ball or whatever. Okay. And you just kinda put it into their core. And mom, um, mom would help them maybe squeeze with the arms and dad or me depending where they’re at would help him curl up with their legs. So they’re the comfort of mom’s lap. The object is coming out to their core and they help them squeeze. And what I found, especially with my autistic kiddos is they end up really liking this.

And sometimes they’ll end up dragging that step down and what’s mom or dad, or the physio ball. And, and they want this done because with some of them, it’s very calming actually. Um, I’ll give you one more thing. The other thing you can do with the older individual is you can have them in this position. So again, they, the unused arm is out the side, Palm up, you have the arm and the leg at a 90 90 position. You want them in a 90, 90 position. And you’re simply again, in, in the picture here on the left, I’m pushing into their core and they need to resist me. You’re not using more than 20, 25% of your body strength. Okay? You don’t want them overpowering you. And a lot of the kiddos will try to overpower you because it’s harder for them to do more of an isometric push.

So you’re pushing, you’re, you’re re having them resist as you’re pushing in. And then on the other picture, you see I’m Abby, I’m pushing out a wave from their core, and they’re supposed to try to maintain that position. So not easy to do. Um, and so what I do is I’ve done some cheat sheets for y’all. I, what they like to do is like this little dude, how he likes to rest his he’s resting his hand on his head. They like to cheat. Okay. When we’re in the sympathetic dominant shift, it really shuts up our prefrontal cortex and motor control and motor strength is off. So I I’ve used these little plates where they have to try to entice them to keep that position. I’ll show you this real quick. Right.

Keep that one bent. So we bounce a little bit like this there and bounce that place. Okay. That goes, this goes

Up. Okay. Bounce that plate. Okay. Right. Push in. Where do you push outward? So don’t let those plates drop. Oh, you’ve got to keep up. Awesome. Okay. So that gives the older kiddo a challenge. I’ve also used slink from, for the little kids slink from toy story. It was a perfect stuffed animal to, to rest on their leg. And then I said, don’t let slink flaw fall. Okay. So these are just ways again, to have some fun modify things, to get where you want to get with the little kiddos. And so again, you start with the easy stages and work your way up to harder, do harder maneuvers. So I think we had a pretty good fun time for you enjoyed this. Um, please reach out to me if you have any questions, this is going to be a big one right now because people are in, um, again, second a spider flight mode.

And, um, we want to help to be able to, uh, pull out all the red stops in addition to adjusting them, getting lifestyle management, diet regulation, blood sugar regulation. Um, look at that more reflects in a little bit can go a long way. So again, thank you again, ChiroSecure. You’ve been amazing for the chiropractic profession. Um, what would we do without you? Thank you for letting me share this information and be sure to check in on the first Tuesday in February with the amazing Erik Kowalke and his amazing information. And I’ll be back the third Thursday of February until then keep changing lives, keep changing the future.

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Empowering Women in Chiropractic – Playing the Compliant Discounting Game

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.

As we jump into those slides together, uh, we’re going to be able to see what we’re going to be working on. It’s your vet from games, university. So glad to see you. And as I stated, we’re going to be playing around with the complaint discounting game today. Sometimes it’s a little bit difficult to know exactly what you’re going to do, and we’re going to get started with those slides so that we can get moving quickly. As you know, I try to keep it power packed and moving fast as we go. So as we start the slides now, uh, we’re going to be able to move along and get those things underway. Are you ready? Welcome to 2021. So today, while we’re talking, we’re going to discover how we can do legal discounting options. So many times here at KMC university is I’m bringing in clients who are coaching my own clients or just doing consultations.

Overall. We noticed a lot of issues in the way that people are discounting, even with some of their compliant coupon offers that they think they have, just because someone told you to do it and they’re getting by with it down the street doesn’t necessarily make it okay. We always need to verify those things, make sure that they dot all the I’s cross all the T’s as far as any federal regulations, any type of other things may be going. So always want to make sure we have that in place. We’re going to also recognize where you may have some inconsistencies in your patient fee schedules learn how to properly implement some hardship agreements in your office and men. It may be appropriate to use something more like a professional courtesy policy. So again, these are the things that we’ll be covering today. Um, as we move into the rest of our slides and I do walk them, you, I do appreciate Carver secure giving me these opportunities to speak to you and coming to you again from KMC university.

So as we talk about this one person said, very famous person said, your fee is your fee is your fee. And you know, with real estate it’s location, location, location, but when it comes to having compliant fee systems in your office, it is your fee is your fee is your fee. And we want to always make sure that we’re abiding by those rules dotting our I’s again, crossing those T’s just so we can be compliant rest at night. Don’t worry about the fee police to come get you and say, Oh, that’s wrong. And we’ll figure out who some of those players may be. And then we need to figure out where are the discounts coming from? So we’ll have some that are imposed that are like some of our regulated contracted. And then we may have some of those that are a little bit more elective in nature.

And we’ll talk about those. So we’ll get a clear understanding about that as we go along today. So as we continue to move forward, I’ve kind of wanted to start with some of the dangers and pitfalls that you could fall into. If your fees are not compliant in your clinic. So oftentimes we’ll see inducement violations. We’re not necessarily doing it to induce some may be, but we’re not necessarily doing some of our practices to induce, but it’s what necessarily our intention was. It’s what the perception is by those governing entities. Many times, anytime we have an issue in our fees or any other area with our billing, it’s no balls into the next area of false claims act. Nobody can afford these things. Number one, you don’t want to have recoupments number two, you don’t want to have any issues with, um, what you’re going to be noticing.

Um, when you’re sending over to a pair and they’re saying that’s inappropriate, or we’re going to find out somebody else who’s playing some really dirty tricks lately. Um, as we go along and then the anti-kickback violations, we need to make sure these are not being identified with our office. And we’re going to learn how to safeguard that as we go along. So Medicare vocabulary goes inducement and remuneration. So when we’re talking about that inducement, that’s influencing someone to come in and, uh, maybe giving away something for free. That’s, uh, maybe higher than the value that’s allowed or we’re giving away discounts through our waiving of copays deductibles and things like that. You may not give any item or service away that exceeds $15 or $75 aggregate, um, to a Medicare patient. This really falls over into federally funded patients. And what happens is when it falls over here, generally, you’re finding a lot of the payers piggybacking on this and saying, Hey, you know, we can’t do this for, uh, for our patients either, or our patients.

You need to have fraud, waste and abuse in place because you’re dealing with us. Everybody’s moving to this model. But right now we know that there are penalties imposed from federal entities when we do inducements and the remunerations waiving copays and things like that. So it’s in the regulation. We have the, the patient solicitation, anti inducement provisions. You can see it here on the screen, someone who’s offering or transferring to a Medicare and Medicaid beneficiary, any remuneration that the person knows should or would likely influence their decision to come in. This is applicable to Medicare and Medicaid. We know that VA, uh, moves over into that and we have some other programs and you’re talking about the affordable care act. And some of those things, you gotta be very, very careful. And why said you can’t afford it? Look at the bottom sentence. It says up to a $10,000 penalty for each wrong for act.

Oh, all right, well, let’s get it stopped. Now. We can’t afford to be over here in playing in the non-compliant game. You know, where it’s like playing Stratego, we’re playing chess. We got to move our pieces just right. We can still get to the other side and win what we want to win, but we avoid being captured and avoid the bomb when you’re playing Stratego. And we just want to make sure that we’re matching the right places together. And we’re still moving towards our goal of being profitable, getting our patients in the door and not scaring them off. So as we go ahead and move to our next slide, we’re going to talk about again a little bit more about that remuneration. We’re going to waive your copay. I had a local dentist, um, asked me several years ago when I was working in the local clinic.

He said, what my office thought we’ll do is we’ll have a doctor or even our staff members get treated. We’ll submit it to their insurance, just to help them meet the deductible. And I’m asking you to do that for me. I know you do a write off for doctors and, but I want you to submit it because I know you’re going to write it off. And, um, I want that way. It’ll help me meet my deductible. It’s not going to hurt you guys. I’ll still pay the bill. Uh, he did not like my fight back. I said, I can’t do that. I can not waive your deductible or copay. I don’t have any financial, uh, hardship in place or anything saying that this is okay for you. And he got a little Tifft. He said, I do it at my office. I can’t help what you do at your office.

We can see it’s usually way well laid out, especially in our federal programs, but we can also find it in our commercial programs. So always be sure that you’re just, again, dotting I’s and crossing T’s that we’re playing our chess pieces or our Stratego pieces. Right? And we’re being a little bit more intuitive where those bombs may be laying there waiting to capture us. So we’ve got to be so careful. We had a poor guy, all the one chiropractic. He was in Iowa. And this is out. We’re not, this is not something we’re displaying of one of our clients. This was something published. You can go find it on the department of justice website. Yourself probably could do it through the Google search of any type of search engine would bring this up. But while he was doing, he’s like, Oh, my poor Medicare patients.

They can’t afford a STEM. I hear this all the time. I’m not joking. I am not kidding you one bit. I hear it constantly. Well, they can’t afford it. Medicare doesn’t cover it anyways. Why does it matter? All I have to do is pull this up on the screen and say, this is why it matters. They feel, even though your intent was to help them out, they feel your intent was to influence them to come to your office because maybe Dr. So-and-so down the street is an offering that, but you’re sitting here going, yeah, Yvette, the doctor so-and-so down the street is offering that. I’ve never talked to them. I don’t know what’s going on there. And we can’t help if they’re doing it wrong, it doesn’t make their wrong BR right. So we’ve always got to be careful, but this poor guy in his innocence and just trying to be nice, ended up with the $79,919, uh, payback that he had to do.

And you can see there after the highlighting, it hit the anti-kickback statute. And the false claims act happened between. And look at that span of time, they looked at, they looked at a long span of time. You can pull it up and read a little bit more. But, uh, the thing is, is that you’ve just got to be so careful. And as you know, the old saying goes, don’t let your good be evil spoken of always make sure that if you’re going to do good, you can do the good or you find the legal way to do the good. And we’ll talk about that. So the biggest thing that this member rev represents is that we want to avoid dual fee schedules altogether. This is not something that you want to have in your clinic. And I’m going to just kind of hit the nail on the head here in a minute.

When I tell you why a with somebody you’re not expecting it to be somebody playing tricks, I told you earlier, they’re playing these crazy tricks on everybody, but we want to figure out what is the dual fee schedule, because it can misrepresent charges to a carrier. I had the pleasure to do an onsite back in October, we talked about it a couple of times, since I was here, they were just having the patients pay $55 here. I’ll take your credit card right here, $55. And they were billing the insurance company 150 I’m like, how did you know that was their co-insurance their copay? Oh, well, we just do it. Uh, we’re out of network. I just sat back. And I said, well, that will stop. It has to stop. Now we have to clean this up. And, uh, needless to say, they’re probably one of the top producers with one of the medical discount plans.

I’m going to talk about here in a little bit, because we got that straightened out for them. Again, false claim act violations. And then it may very well violate your provider agreements. Think about it. You know, we’ve got blue cross patient Lang here and blue cross representative behind him, PI patient here, PI representative behind them, cash, patient, ear cash, patient behind them. Everybody has the same thing. Everybody goes to the front desk together. You will bill your insurance. Two 50 we’ll bill you two 50 and that’ll just be 50 today. Same service don’t work it. And very well may violate your provider agreements, but keep watching here. It is the PAI complex. I cannot stress with you how much this is happening. We had one of our members call him the other day. What do we do? Oh Lord, what do we do? Well, we’re like, well, first may we do a consultation with you to see if we can get this worked out together, figure out what you did, figure out what needs to be cleaned up and what we need to stop.

And we looked at it and what had happened is they had Geico, give them a call and say, I don’t have insurance. I was just calling to figure out if you have a cash break for your patients. Oh yes. If you don’t have insurance, your visit will only be blocked. Next check. That’s what they send. And guess what? They reported them. They reported them for having a fee schedule that they were giving to cash patients that they weren’t giving to them. There was no legal reason. So everybody starts with the same fee. There was no justifiable legal reason on that next line for a deduction that said they should get something. There was nothing regulating it, nothing contracting it. They were just giving it because that’s the way they do their cash patients. Well, state, farm, and Geico doesn’t understand why that doesn’t pass along.

So we ended up having some pretty major issues. There got to clean it up, got to write some policy. Luckily we were able to work on it a little bit creatively with them. Uh, obviously some reeducation of the staff up front at the front desk and how they’ll answer the phone needs to take place. But overall, their feast systems need space systems needed to become compliant. So we talked a little bit about those impose discounts, the ones you can’t do anything about. You signed the dotted line, you get the dog and pony show that comes along with it. So those are the regulated, which is more like your Medicare, your worker’s comp, some personal injury, no fall and Medicaid. Can’t do anything about it. It is what it is now. Your workers’ comp and personal injury. Mainly your personal injury can differ from state to state.

Sometimes you can expect your full, uh, reimbursement of whatever your charge is. Other times you’re going to be part of some type of regulated or some type of contracted because you’ve got a silent PPO or maybe they’re pigging backing on some other type of pair. Then we have those contracted discounts, which are, I signed the dotted line because I want to be a provider with blue cross. I signed the dotted line because I want to be a provider with Aetna. This payer, that payer, these are those you can avoid. These are the conundrums you can get into, especially when you have those per diem payers that say I’ll pay you $65 a visit, no matter what you do. We have people all the time trying to circumvent that we’re like, Hmm, go back first, read your EOB. Did it tell you it can go to patient responsibility.

Now, go back and read your contract. Look at your medical review policies. Make sure that you know, what you’re doing is appropriate. This is why you can’t take your fees lightly in your clinic. They have to be every I dotted and every T crossed in order to be compliant and be most profitable. I think when you’re looking at impose discounts, one of the most profitable things you can do for your office is one take the services that you do and find out does that payer exclude them. Aetna has a very long list of CMT services. They consider experimental and investigational. Are you on that list? Does it even make sense to go in is everything you do on that list of experimental and investigational that’s one step. The next is if they won’t give you your fee schedule or a fee schedule prior to enrolling with them, ask a peer down the street, Hey, what does it look like for the fee schedule for this insurance company?

Know what it costs for you to be profitable in your clinic, and then gauge if you can go in before you sign the dotted line. Because remember once we signed the dotted line, we are now either regulated, contracted with an imposed discount. Can’t do anything about it. So you get out and with Medicare, we know you can’t get out how to give that commercial one more time. So that relationship with the payer and network, it really starts here. The doctor joins the payer, the patient pays the premium. They have an insurance card, you have this type of agreement. Everything comes back to the central hub of that payer and that network telling you what you can charge. That relationship is between the provider in the patient. But again, a lot of times we’re relying upon that and that requires the enrollment of the doctor and, and the enrollment of the patient into that plan.

So again, this is going to be part of your imposed, contracted, regulated, uh, type of discounting. That’ll go on. So we’ll skip over to the next part, which everybody’s probably wondering why are you taking so stinking long to get to this part about it? I need to know how I can do discounts. You told me what I can avoid. Now tell me what I can do, because now that you scare me to death, I need a way to deal with these patients that are cash, or maybe don’t have a great insurance plan. Maybe don’t want to use their insurance plan. Maybe have limited benefits. So let’s go there together. There really are. There really is one fee in your office that is if your spinal CMT for a nine, eight, nine, four, one is 55, then it’s 55. Then it’s 55 and it’s 55 next payer.

It’s 55. Everybody starts at the same level. Now the next line down. Why? Why is it not 55? Tell me why it’s not well, because it’s regulated. Okay, great. Well, because it’s contracted great. Well, because they’re a cash, they’re a cash patient. Okay. Can we talk about that cash patient for a moment? How large is that discount with discount by half, sometimes 75% wrong answer. We’ve got to make sure that’s within spec. Although the federal government has some rules that we believe are five to 15% on a time of service discount. Do you know that your state or your payers may have something to say, but again, we’ve got the actual fee next line down. Why shouldn’t they pay that fee? And we’ve always got to make sure we have checked with every entity that we’re doing that appropriately. So again, the discounts go imposed an elective.

We’re on the elective side. Now these are the ones that are at your discretion that you decide to implement in your clinic. As we move down, we’ll go the other direction. We can see that those are elective fees could be your five to 15% time of service savings, financial hardship, professional courtesy, or maybe your discount, medical plan participation, something like Cairo health USA to where they are set up in most States, I believe the only state is Washington, where they’re not in where you can offer your patients a compliant discount, go to bed at night and know you did it right? Setting up your own fees in your office. So even though it may fall in kind of that contract land, it’s your fees that you picked. We already know insurance. Isn’t going to pay you your full fee. You’re not going to chase your tail with this cash patient.

Why not give them a little bit of a discount? Uh, so they don’t have to pay you 565. Maybe they pay you 200. Plus the joining fee to Cairo health, which covers them and all their dependents for an entire year. It’s crazy. It’s like Costco or Sam’s, but these are the elective discounts that you can do, but you have to do them right again, dot the I’s and cross the T’s. So again, actual fees, discounted fees, or where are we going to focus our attention? And here are four possible fee structures that will help you pass the muster. When it comes to doing this compliantly one charge your actual fee. My fee is my fee is my fee. And if you’re cash, that’s my fee. That’s my fee. Absolutely. You charge it to the insurance company. They come back and say, write it off. You write it off.

Everybody going out the door gets charged the same. That is super compliant, no issues. Everybody pays your actual fee. You’re not discounting. You could charge a reasonable time of service of five to 15% for your federally funded patients. Always make sure to see if your state has a more strict role. Whichever is most strict rule, real rule and be the one that you’ll have to implement for your office. But when you find the state may be more lenient that may apply towards those outside those federal programs. So charge a reasonable time of service discount. Five, 15%. For me personally, I would not want to think about this as federal. You get 15, this is you. You get there. I would pull out my hair. I would either do five to 15 based on my bookkeeping savings and or do something like Kira health. Make it simple.

Don’t complicate it for your patients. We’re already in uncertain times with money and they don’t want somebody feeling like they’re jacking around with their money. They want to know this is what it is or this is what it is. You can pay our full fee. You can join this discount medical plan, and this is what your fee will be. Which one would you like? Let them make the choice, give them a choice. You could use a network-based legally discounted fee of choice ups, Kira health. And then you have those legal options with the hardship indigents policies for those patients who qualify. And I did say qualified. So these are the ones we’ll look at Cairo health, a little bit hardship, professional, and then billing for family members. I’m not going to cover a slide specifically on billing for family members. I just want to cover it verbally with you today.

Please know that with Medicare and many payers, they restrict you from billing, your immediate family members, and they do give you a list of what that is defined as they saved your mother, your father, brother, sister. And they go on. It’s a list probably if you’re looking at the page about that long, that tells you who you should not be billing to the payer. A lot of times we find family that I’m kind of tempted to help exhaust a deductible for their family members, or I’ll just send it in. I need a little extra cash family’s demanding to pay. Please look at these rules, please make sure you’re dotting your I’s and crossing your T’s. So the compliant time of service discount, it is based on viable bookkeeping savings. Pick one of them. What does it truly look at your overhead? What does it truly saving you to not have to send the claim, chase the claim, get authorization for the claim.

Go back and get authorization again, to see them for five more visits, chase your tail, wait, uh, appeal. Do all that. Send a statement. What are you really saving? Are you saving 5% great? Are you saving 15% great. Write a policy. There’s your time of service discount? It’s often, um, found that a lot of people are using something that’s not within those guardrails. And it’s unreasonable when we get up into 50% or, Oh, I just have a flat rate for cash patients. Can I ask you what you’re billing the insurance? Well, typically about $180. Okay. What is your flat rate for your cash patients? Oh, it’s 50. They just come in whenever. And the other one I hear that makes me want to scream is, Oh, well when they’re with their insurance, we just always use the nine, eight, nine four one. And when they’re cash, we just use the nine, eight, nine, four.

Oh, I’m like, Oh Lord, you can’t play with your codes. You can’t play with your fees to make it fit what you need. So you gotta find what you need and get it to fit what you have to have. So understanding again, that when we’re using these time of service discounts, there are guard rails, and they really should be because it’s a time of service be paid in full at the time of service, maybe lingering just a day or two after, but it’s got to have some parameters on it, not loosened it. So that relationship, when we talked about Cairo, health USA kind of works like this. I love them. By the way. Uh, before I came to KMC university, I said there were a couple of things I wouldn’t live without and practice. And that was Tusa Cairo health and KMC because they helped me to get to, you know, to the knowledge I have today.

They a part of how I got here. And when I joined Caro health, what I could do was now legally offered discounts. So at the office I served last, we were a specialty clinic. Uh, I know a lot of you say, Hey, all of us are specialty clinics and we truly are, but we did something that no one in a very large geographical region did here. We have pizza. People travel in from thousands of miles away. We have people that traveled in from States. We had about a five state surrounding area that came to this practice. And, uh, so we needed to make sure that we had some way to compliantly offer them a discount. So we looked at Kira health USA, and here’s in that specialty niche. Our typical first visit was $565. It’s just what it was. We knew when we bill blue cross and blue shield for those services, that would qualify that generally we could get back somewhere around three 70 when we build Aetna and we’re coming down closer on two 25 and we’re like, number one, we’re not chasing it.

We’re not having to get authorization. Um, that’s we want to just count more than 15%. What can we do? We went with Cairo health and how it ended up being that $565 visit came down to $200. All the patients had to pay that day was $249. They’d paid 49 to Cairo health. They paid 200 to us and they didn’t pay five 65. And they kept getting all the discounts that we made available through Cairo health. From that point forward through the rest of that year. So doctor joins, he sets his own fees of what he wants it to be. You can do discounting for multiple family members. You can set it up that, Hey, I want to cap these visits here. Or, Oh, I want them just to be this percentage off, or I want this service to be that don’t include that in my cap.

As you see, I’m telling you all kinds of things you can do. You can’t do that with Medicare. You can’t do it that with a payer where you can order it and have it your way. But with Kaiser health, in many ways, you can have it your way compliantly and your patient has an option. If they don’t want to pay 55 and they want to pay 35, then they join Cairo health. If they say no, then they really said, I’ll pay 55, no problem cash check or credit card, but the patient joins. And again, they, and all their dependents are covered. This relationship is about between that doctor and the patient. And we have compliant discounting. I cannot tell you and stress to you enough. This is a huge Savile. When you’re looking at discounting in your practice, the other one may be that professional courtesy.

Did you know that you actually need a policy when you are treating your staff members for free? Please don’t play that game. If I’m going to help them meet their deductible, please don’t do it please. You can’t waive the deductible. Their insurance is banking on you to collect that this is part of the plan they chose. But if you’re going to treat them in your immediate family members for free habit in your professional courtesy, um, what about others in the community? Maybe it’s all the first responders. Maybe it’s ministers. Maybe it’s all other doctors define that, put it into policy. But for the love of the Lord, don’t be like what that doctor asked me to do. He didn’t get me to budge, which was no. We offer this service for free. I cannot charge your insurance for something we offer for free to you, nor will I help you meet your deductible.

The only way I could have done this was told him you are going to forgo our professional courtesy. And when that bill comes in and it tells us what your deductible is, we will have to assess that charge to you. So keep in mind, this is one legal way. You just gotta make sure you’re dotting your I’s and crossing your T’s and no isn’t for all your friends. And the quick way, we’ll just do a bunch of professional courtesy. No, they’re still dotting of I’s and crossing of T’s that need to take place. What about hardship first visit, take their word. I can’t afford it. Okay. Well, we offer hardship for people who can’t afford service, and we kind of can get by with taking their word the first time, but not after that, we actually have to verify don’t just take the word and my office.

I had one way you could qualify if you were on government assistance and you could show me proof of government assistance and I checked it on a consistent basis, then I would qualify you. I did not think about some of these other things to implement. Ours was just pretty short and sweet. We had Cairo health and we knew we could fix most problems and we have payment plans. So we knew we could fix most financial considerations for patients, but that was one consideration. And when I did it, it’s like, you can come for $25 a visit. If you’re having an exam, it’s another 25. If you’re having x-rays that’s another 25. So the most they ever paid was 75, but that’s the way my hardship was set up, but I couldn’t just offer it because they said they did, especially if they’re coming in with their Prada shoes and their Gucci purse or their nails are always done.

I’m not disqualifying those people. I’m not saying they’re in a financial hardship, but I’m saying we have to use a systems of measure to verify this. Or then this is not having an I dotted and T crossed. We do know that those federal poverty guidelines are about to come out. They’re just right out of. They’re always a little slow for some reason, but once they come out, we’ll be able to see what those federal poverty guidelines are and what percentage that particular patient falls under. You have the ability to set that up down. You can see this as one of our forms, by the way, that’s in the library. If you’re a library member, you can find this in the office management section one, and that’s going to be in less than three. And you’ll be able to go in there and tweak. You can see any of that great out areas, something they can do, but you can set what your fees will be.

Put your exclusions in there and make sure that you’re able to just do this appropriately, going by those guidelines. Again, a little bit of leeway with you on what you want to set up. There’s any questions on this? This is a bigger topic than what I’m able to cover here. Definitely let us know. And just a little bit of role playing. So let’s say you treat Medicare part a and part B patients. So are you enrolled? No, we already talked about it many sessions ago. We can’t see the Medicare part B patient. If you are, you’ve got to charge the appropriate fee for the excluded services. Even if they’re a, QMB a duly eligible, you still on the excluded services have to, you’ve got to bill on behalf of them. Your collections will be based on their co-pay, their co-insurance deductible, figuring all that out.

There’s one of your regulated then what about the part C if you’re not enrolled, we fill, these are cash patients to your office. You can see down at the bottom that we have cash paying patient, not insured. We have actual fee, um, or that discount medical plan. They get a super bill. Make sure if you’re giving a super bill and you’re doing discounts that there’s a line item that shows what that discount is. Don’t send that patient out the door with, Oh, it was a hundred dollars and you only charged them 50 because they’re going to get paid to come in your office. If their insurance, as an allowable higher than your 50, they will actually make money coming to you. So it needs to have everything listed there that shows that actual financial transaction that you have. What if you’re not enrolled with the insurance plan, then you have that cash play game that you can do again.

But over here on the other side, you’re going to be abiding by those contracts, looking for deductibles, obeying those rules of medically necessary and active maintenance and all that type of stuff. But you’ve got to bill, according to them, you sign the line. You’re there. You can see a little bit with the non par and the par there at the bottom. What about worker’s comp? Well, with some worker’s comp, you have to be enrolled in order to treat them. So please make sure there’s a lot of rules in my state alone that you got to jump through hoops. If you weren’t the first person who saw that patient a little bit of here that you can look at, but if you’re one option with PI patients, if you feel like you’re always getting stung by it, make them cash patients. When they get paid in their settlement, have the lawyer incorporate what they already paid to you.

That’s probably one of the most simple ways to get rid of the problem of lingering bills. So this is what it looks like when you’re done setting up your fees. We’ve got the doctor’s actual fees up here. Next rainbow down is our contract and fees are regulated fees in our hardship fees. And when it all starts coming together, we can see that Cairo health USA, that legal way to do a discount gets the fall in the green it’s right there. It’s part of our contract. And we got to pick what it looked like. Imagine that it wasn’t $9 for a therapy, unless you want $9 for a therapy. I have seen reimbursements be that low or say, Oh no, that’s bundled. Oh no, we don’t pay for that. On the same day, Kyra health USA is a great work around, especially with, for high deductible patients.

You can see that you’ve start piling in those other things with Cairo health, you’ll have those cap fees or your discount and name it. What you want it to be, make it that way. It includes everything. Oh, no includes everything. But this, this is you. It’s an elective discount. You get a set, a lot of it up. Then you’ve got some of the other things that come down in there where you’ve got this hybrid of Medicare and Cairo health. What the same service cannot have medic cannot have Cairo health, but we know Medicare only covers spinal CMT. So there’s a bunch more, we could apply that to. So it makes a very beautiful product for those patients. And then down at the bottom, we have our hardship fee schedule. This makes it all look beautiful. One pretty rainbow everything’s in there. Everything’s compliant. Nothing’s out here on the perimeter.

That’s kind of not okay. We fit all of our discounts nicely into this beautiful rainbow to where we can rest at night and be compliant. So you’re free to choose, but you’re not a free free from the consequences of your choice. So be careful when you’re doing fee changes in your office, making sure that you’re doing it by dotting I’s and crossing T’s. If you’re a member, if by chance you didn’t have this in your, a member, we do free schedule a fee schedule consultations, either help you, uh, get Kira health USA put in place at which we will. We’ll take you all the way up to it. Almost being implemented, just what they have to do at the very end, or if you’re not interested in that we still do. If you’re a member, that’s something we did. So it’s free for you as a member.

Um, the very next thing I want to show you are hot topics. And then we got to go hot topics. One, one that ABM form had to be implemented. Look at the bottom of your form. If you’re an Anon version, six 2023, starting January 1st. If you’ve got more questions about what you do about the one signed in December or November, you’re glad to give us a call. But as far as the new ones being signed, ABM must be implemented. When you’re looking at box D your mandatory is spinal CMT only don’t have anything else on it. And know when to issue it, big issues going on misconceptions, going on in this industry regarding how to use an ABN appropriately. And it can get you in big trouble because when they pull your records, they pull the ABNs in M coding went into effect. January 1st one code is gone for the new patient.

Do you know which one it is? You should never be using the nine nine two one one. That’s an established patient, but there’s one of them went away. The change in the coding methodology, how you’ll get to it is all lining up over on the medical decision-making. And although the AMA and all those rules have come out and said, Hey, history and exam, you can do it. If it’s warranted for us as a profession, it is warranted because that’s how we establish the medical necessity. Everything is built off the history and the exam next down Medicare fee schedule update. We had a big 10% drop this year. It was a huge disappointment and the middle of COVID and everything’s shutting down practices. It shocked everyone. However, we saw about as quickly as those one up on the website, they got pulled back down because the COVID relief came a bias about sort of bipartisan act that removed the full 10% gave us back 3.7, 5%.

The reduction is still sitting at six two five. And I’m just telling you if you want to be a part of the solution and not have to sit back and accept the problem, contact your state representatives. Remember it’s time to verify benefits again. And if you don’t remember why I go back and listen to a couple of my sessions a little bit ago, one more thing. If you are a KMC university member, please keep in mind. You’re going to be seeing a lot of stuff coming from us. Go in this spring, don’t put your head in the sand or not look at an email cause there’s a new website launch. You’re going to go to the, our website. You’re going to, uh, what happened, make sure you’re paying attention. And if you have any questions with what we’ve discussed today, feel free to give us a call. Uh, we’re always here to help. We’ll be more than happy. That’s (855) 832-6562 or info@kmcuniversity.com next week. Make sure you’re here because Janice Hughes will be presenting again. It seems like she follows me up a lot, but I think that’s really great. And I’ve watched these people and they’re wonderful if you miss these, just let us know we’re here for you. Good to see you. Thank you for spending some time with me again today. Bye-bye

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Empowering Women Chiropractic – Tips for Tiptoers – Monika Buerger

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.

Now here’s today’s host Dr. Monica Buerger. Hello,

Welcome to our December. Um, ChiroSecure Look to the Children’s show. We are going to have some fun today. We’re going to keep you on your toes as we talk about Tiptoes. So why did I choose this subject? Um, first of all, let me backtrack. Thank you, ChiroSecure once again for giving us this amazing platform and opportunity to share with the world, um, the importance of chiropractic pediatric, uh, for kids and, um, to help other docs out there, um, gain some extra pearls of wisdom during this time. So tiptoes, why did I choose this subject? Because I get a lot of questions on, what does it mean? Why are they still tiptoeing? What do I do? Um, all that and more so let’s dive in and let’s have some fun and talk about it. So again, I want to thank ChiroSecure for, um, always being there for the chiropractic profession, excuse me, my froggy throat.

So tip toes, we tend to see this in little kiddos. Um, and if I slip into my endearing little, um, version of my little fiddle farts, I, I use that as an endearing expression for these kiddos that we work with. So, um, my apologies, if I slip into that, um, we tend to see tiptoes common up until about the age of two, and that is considered, um, fairly normal. But if we see this consistently and beyond that age, what might we need to want to look at what possible differential diagnosis is? What associations? So let’s dig into that a little bit. First. Certainly we want to look at muscle tone, either low tone or hyper tone, and we want to, um, rule out cerebral palsy or multiple dystrophy. So those are two top things you may want to consult. Um, outside of the chiropractic profession, have the pediatrician take a look, et cetera.

So those are two things on the top of the list that you want to make sure that isn’t involved. But what we didn’t know about neuro-development is when we have a hijacked trajectory of development, so to speak that this is one of the possible competence Atari gate mechanisms that we might see with little fiddle parts is a tip toe or altered gait pattern. So autism and ADHD happened to be on the top of that list and alter gait patterns of which one is tiptoeing can be associated with both of those labels. Um, sensory, definitely sensory processing disorder. So that’s SPD sensory processing disorder or processing dysregulation. And we’re going to see how all these kind of tend to tie together actually. So within the sensory processing world, three particular sensory systems have been associated with altered gait patterns. Tiptoe is one of them. The other gait patterns are, would be like a wide based waddle or wide based stance.

And the reason that we might see these altered gait patterns in those with processing disorders is because they’re trying to upregulate sensory input into their world so that they know where they are in space and they can modulator move about safely through space. So the three big systems within that sensory processing realm are vestibular. Um, the, the ability to maintain ourselves upright against gravity and know where we are in space proprioceptive, which we’re going to get that input from our joints and muscle spindles. Um, and actually you get some proprioceptive input from the vestibular labyrinth time and visual. So those are three big sensory systems that three big kahunas that all work together. Um, and they, they are really responsible for us being able to modulator ourselves upright against gravity and have good postural control, postural stability. So if we don’t have that, we will innately, or that the child person, child little foot apart, we’ll try to upregulate that to their CNS.

And by being on their toes, they get more bounce of the world and, and, um, more input coming up, particularly vestibular and proprioceptive. Um, so you’ll see them have that little bit more bounce in their step. Kind of like trying to be Tigger. If we look at our Winnie the Pooh characters. So, um, sensory modulation can be a reason that they are on their toes. Now, likewise, they might be, um, hyper tactile. They don’t like a lot of tactile input, so they might be up on their toes in certain environmental situations. And we’re going to talk about some history and some questions we want to ask parents, um, on the timing and the consistency of this altered gait pattern, but we’ll get there.

Um, neurogenic bladder bowel, and the world of neurology have been tied with altered gait patterns like tiptoe tiptoe in particular. So we want to look at their, um, bladder and bowel control. And in the autism world, gut dysbiosis has been associated with many neuro expressive patterns. One of them is tiptoe. So we want to look at gut dysbiosis. So if we start with, we start other than CP and MD, if we start looking at these next, um, considerations, they all kind of tie together. Okay. Because we know in the world of autism ADHD, um, we can throw in here developmental coordination disorder, a lot of labels, actually, they are often associated with processing disorders. They’re going to have, they are going to have some form, some extent of processing disorders. Those three systems are big key systems, the vestibular visual proprioceptive in regulation that we see dysregulated in this population groups.

Then we often see bladder bowel and dysbiosis issues with these population groups. So you see how I’m just kind of taking you through a journey of looking at the big picture, all those things that might be involved. It’s really not as simple as saying they tip toe because of one thing, it’s usually a systems wide approach. And that’s what I’m trying to walk you through. So in the world of autism, um, tiptoe walking is often associated with gut dysbiosis. Um, and it can lean a little bit more towards reflux because they’re trying to, um, in fact, there is a maneuver that many talk teach to adults about reflux and in the morning, first thing in the morning is drink some water and then kind of bounce on your toes, kind of jump up and down and bounce on your toes to try to pull that. Um, if you especially like have like a hiatal hernia or something, so think gut dysbiosis, but lean towards the side of maybe reflux and GERD issues. So now if we take that next thing in line, when we talk about primitive reflexes, a couple of primitive reflexes in particular have been associated with tiptoe.

And if we look again, if we take you through the journey, say, okay, with developmental considerations, they, these individuals, these little fiddle farts in the autism or ADHD or development or coordination, any label we want to get them oftentimes have processing issues about issues and retain primitive reflexes. A couple in particular, you want to look at, um, tonic. Labyrinthine is one of them that is associated with tiptoe walking. Now, the tonic labyrinthine is kind of considered a, um, a, a dural tube or cranial sacral rhythm associated with cranial sacral rhythm abnormalities. So for us in the chiropractic world, we definitely want to look at, um, the upper cervical, especially the occiput and the sacral areas and looking at neural tube tension and, and addressing, um, not just with adjustments, but maybe some cranial sacral therapy as well, trying to get that dural tube, the tension off the dural tube, the tonic labyrinthine reflex is one of those associated with the craniosacral rhythm as is the symmetrical tonic neck reflex or the STNR.

Um, so I just want you to keep a couple of those things in mind. You also might find it ASA occiput with these kiddos. Um, and when they’re have the ASA occiput and their eyes are looking above the horizon for brain compatibility, for us to be able to process our world and be in sync with our world, all these sensory systems are imperative. Um, and that visual system is, is key. And we want to have our eyes on the horizon. Our eyes want to be parallel to the horizon if we have an occiput, or if we have dural trench in causing that ASR occiput, our eyes are going to be, um, we might have what we call midline shift superior midline shift. Our vision is our eyes are paid attention to above the horizon. And so we want to, we’re not sure where we are in space.

They might not be sure where they are in space or having to navigate through space because of that visual security. And so you might see the tip toe from a biomechanical reason, as well as a visual compensatory reason or processing compensatory reason. So keep that in mind as well. So look at the occiput in particular, the moral reflex can play a role in tip towers because Mara reflex it. Um, Maura is associated with a hyper defensive sensory mode, and when we’re on sensory defensive mode, that is going to shift us to a sympathetic dominant state and, um, keep our cortisol kicking, keep those adrenals pork butt cranking. And when that happens, we might not, we might have trouble with, um, the onboarding, the development, um, of pastoral reflexes and one called the tendon guard reflex. Essentially what happens is the postage courier muscles, especially the posterior leg muscles, um, contract because of all this cortisol kick.

And so that’s, we’re getting shortening of the posterior calf muscles and Achilles tendon. And so they really can’t elongate those ones. This is where this is one thing we have to be mindful of this whole picture, because so many of these kiddos can get scheduled for an Achilles tendon release, which is a huge major sure. Or ordeal, and that may or may not mitigate the problem, but the core, the roots of the problem it’d be a systemic wide approach. So, um, that’s another reason why I wanted to bring you this information. And then the Ben scheme, you do want to look at a retain Babinski, but Bensky, it can be, can be active, um, through the first couple of years of life. And that’s, that’s why maybe toe walking can be seen for the first couple of years of life. The bisky gets integrated by, um, it’s helped to get integrated by a, um, the belly crawling by belly crawling.

And I call it the toe dig when we’re learning to belly crawl, you take, as you’re pushing off on that, back on the, on the leg, that’s propelling you forward that toe digs into the ground. That’s I call it a toe dig and that helps to integrate that, but Minsky reflex. So if they skip belly crawling, um, that can be a factor as well. So keep that in mind. So if you see a little fiddle fart, that’s not going through their motor milestones, um, they’re not rolling. They’re not tummy time rolling. And then belly crawling and doing that toe, dig propelling off their toe, pushing forward. You know, that’s the thing that you want to try to help, um, navigate and employ that they’re doing that. But later on, they may present with this, um, compensatory gait mechanism of toe walking tots, tethered oral tissues, tongue tie.

Again, this is such a complex issue. It’s much more than breastfeeding and speech. So way beyond that, the tongue is considered the, um, Rutter of the city. Okay. It says it’s a tethered restriction, it’s a fascia restriction. And if we have this restriction, it can, it can go from cranium to toes and it can constantly be this anchor pulling us down and it can cause neural tube tension. So we’re right back down to dural tube tension. Um, so you might see a compensatory mechanism and, and by the way, with tots, it’s very much associated with various learning and neurodevelopmental struggles. Um, and with that dysbiosis, neurogenic bladder and bowel and retained primitive reflexes. So once again, you kind of see the whole global picture that we’re talking about here. And definitely we want to look at subluxations again, look at those, look at the cranial sacral regions in particular and that creating neural tube and, um, that ASMR occiput. Okay. Hang on a second. I just have a question here.


And absolutely they can be locked in a flection type pattern because the brain, because of dysregulation of, uh, circuitry due to poor processing problems, they can’t, the brain might not be able to inhibit those Fletcher, the flexor muscles. And so they’re locked down. Um, the vestibular systems big in this whole role-play and the vestibular system is going to activate your extensor muscles. So this is a great question because they can be locked down in a flexor based position because, um, of distortion of sensory input, especially the stipular sensory input that they can’t get there, that they don’t go to the extensive patterns. So it is a very systems wide approach. So thank you for that question. Hopefully I answered that question, um, to your liking. Okay. So we want to look at history because we want to look at the whole picture here. So we’ll go back to that question on step into flux, into flexor pattern.

Tommy, time’s a big issue here. Not only do we want to see Bailey climb, but oftentimes the precursor to that is going to be our tummy time. And if they don’t like tummy time, they might not go to these progressive milestone patterns and thus belly crawling, tell me, time is going to help us, um, activate those extensor muscles and that mystical division. And oftentimes we see kiddos that have labels autism, ADHD in particular. They didn’t like tummy time kiddos with tots, with tether or restrictions. Um, oftentimes don’t like tummy time. Lack of getting through these milestones will pro um, prevent these primitive reflexes from integrating. So again, look at the systems wide approach. Oftentimes those little fiddle parts that don’t like tummy time also have gut dysbiosis reflex is a big one. Okay. So hopefully this shows you that systems wide approach.

So we want to dig into deep history, lots of times with these little kiddo kiddos, our observation and our detailed history is going to give us a lot of the red flags and give us a pathway in which to dive into first. So we do want to look at, um, gestation, what was mom’s stress, stress level right now, this is a big one. Um, and we’ve talked about, we’ve talked, um, I can’t remember which month we did it, but we did talk about prenatal stress. So you can go back and scroll through either, um, our intersect for like educational seminars, Facebook page, or Cairo Securus, Facebook page, and look back a few months when we talked about prenatal stress. Cause this is a huge one. So we want to look at gestation. We want to look at mom’s stress level. Did she have trouble conceiving? Did she need help conceiving, um, what was that birth experience? What was the mechanism of birth? Was it C-section, were there assisted devices such as forceps or section cup assisted devices are associated with things like plagiocephaly and torticollis, which if we add that into the mix and the history, we can see, we can see why there might be a number of these previous associated, um, issues, because we know that with those types of birth experiences and with those assistive devices, there’s a predisposition to pleasure separately and toward a call us and thus developmental considerations.

Um, we know that prenatal stress is associated with dysmaturation of the autonomic nervous system, which is going to go play right into the role of that question of, is there maybe dysregulation in the brain? Can the brain not turn off those flexors because of poor processing and poor neural circuitry? So we know that prenatal stress is, is definitely an issue here. So we want that good history. What is mom’s current stress level? That’s a big one as well, where they, um, preterm. We know that preterm, we know that prenatal stress is also not just associated with dysmaturation of the nervous system, but, um, um, neuromuscular development. So there might be competence, compensatory mechanisms there. What were there, depending on the age of the little fiddle fart. I mean, if they’re coming into you at age five, eight, whatever, and they’re still having this tip toe pattern, what were their early developmental years like?

Did they like tummy time? Did they roll in a corkscrew fashion at the appropriate times? Did they, um, did they belly crawl? Did they creep on all fours? Did they have an injury? Did they fall off a change, a table down the stairs, all those things we need to look at early development and then a past medical history and family history in the ADH literature, they look at idiopathic toe walking. They don’t, there’s no known reason for this toe walking pattern, but they do see it with ADHD that if a family, a family member, um, especially the dad, excuse me, had a history of idiopathic toe walking, excuse me. Um, the little, the little foot apart, the offspring may also have a history of idiopathic idiopathic toe walking. But what we have to take into consideration is oftentimes our ancestors, the way they process their world and respond to the stress in their world gets hammy, doubted it, it goes, it actually kind of, it follows the DNA pattern.

So those stress responses follow, uh, we call it inter intergenerational inheritance. So it would stand to reason that if we have a family history of ADHD and toe walking, that the offspring is inheriting their parents load and the response to their processing, the way they process their environment and their stress mechanisms. So that would could potentially to this altered gait pattern as well. So we want to dive in and get a good history. Um, at what age of the toe walking begin, has it been there from when they started to learn how to walk it, did it, um, all of a sudden become an issue? Is it both feet want to get into that, into that gait pattern? Was there an injury? Was there a tipping point? No pun intended. I didn’t, I just did that one in there. Was there a tipping point of Tictail? Um, do they get an infectious load? Did they, um, have an accident? Was there a time point that, that, that, that pattern started? Is it variability of toe walking on certain surfaces only under stressful conditions, only when they’re more tired when they, um, are sick. Is there a pattern to this? Again, if they’re on different surfaces, like grass or sand, they may have a hypersensitivity to tactile input. And so it’s just, it’s not a biomechanical issue. It’s a compensatory issue to that particular environment. So they may be hyper sensory in that tactile system.

Is it going on uneven surfaces up and down stairs where they might have a display of what we call gravitational insecurity, not being self-aware and comfortable in those environmental conditions that may tip you off. I’ve got another, I’m just, I’m just full of them today. Um, that may tip you off that this tip toeing is compensatory to particularly gravitational measurements because of lack of distibular integration processing. So we want to, you know, we want to dig in a little bit, um, how much time are they spending on the tiptoeing? Uh, are they able to get into a flat position? And sometimes that may be when they’re more comfortable, calm environment. Okay. So again, look at these patterns. Are there any associations of, uh, pain? Okay. Is it maybe a biomechanical issue, um, that is resulting in this walking pattern?

So on your examination, we definitely look at muscle tone, hyper or hypo. You want to not only asking your history, but the observe this little fiddle fart, or depending what age are coming in. Do they have language delays? Do they have speech delays? So this is, this is important for a couple of reasons. Are, are, if you have the, uh, are, are they, um, have they been in speech therapy a lot, are kids with tongue ties, oftentimes have ongoing language delays and speech delays. We also know that speech delays are very much associated with, um, poor, fine motor development.

So is this altered gait pattern dune due to number three on here, fine and gross motor delays, which is also associated with poor link with language delays. So you want to look at tethered oral tissue. You want to look at muscle tone. You want to look, what is their fine and gross motor skills, observe them in your office, have them do various finding most finding gross motor tasks. Can they do sequential finger touching? Do they have the pencil grip that should be there by one year of age? Um, what is their gross core control? Can they balance on one leg? And they tandem walk some very simple screening procedures. Can they hold their core stability on a unstable surface? Um, like a, um, a balance pad or something, get a sense of what their finding gross motor skills are. Visual tracking is going to be give you a sense of their fine motor control.

Um, so these are some things we can tie together into the whole picture. Again, again, we want to look at processing dysregulation. You may want to screen for your primitive and postural reflexes. Again, those reflexes in particular that we want to look at, if they’re integrated would be more on tannic labyrinth by and the Bensky depending on the age of the child coming into, have they developed their postural reflexes, posture, reflexes don’t fully develop, um, until that age three or three and a half, but those would be the Oculus head writing when you lean them in one direction, do they does their head right to the midline? Because again, our eyes want to be on the horizontal on horizon. So when we put them in these positions, do their eyes, do their, their eyes compensate right to the midline. Um, do they not, do they have good postural control?

Do they have a tongue tie? Here’s a little caveat. Sometimes it’s hard to, if you’re not, especially if you’re not well versed or are used to that, please be mindful that if you’re in a state where you cannot enter the oral surface or a cavity, keep that in mind. Um, but here’s a general rule of thumb. It’s easy to find a lip tie, just having them lift their lip up and see if they have a lip tie. They’ll have a tongue tie. And so often if you’re not seeing that tongue type, um, visually it’s because it’s a posterior tie and it’s hard to distinguish. So look at the lip tie. Do they have a lip tie that’ll kind of tip you off that, um, look at the range of motion, of course, spine and pelvis. One thing I want you to also think about in your cranial work is look at the speed annoyed as well because the speed annoyed, um, represents, uh, it’s counterpart is the pelvis. So addressing, um, the Spino and can be huge in this cranial sacral rhythm and this dural tube tension. It’s also going to very much help you with, um, the visual system. You’ll find that kiddos with visual processing and especially fine motor visual scanning. If you work that sphenoid, you can get a lot of bang for your buck out of that. So you want to look at the range of motion and hips, knees, ankles the spine.


I’ll get this question just in a minute here. Um, and spine and pelvis leg, leg, discrepancies, foot deformities, et cetera. So I have a question here. Um,


Are there any challenges you can do to better, um, insight into treatments?

Um, let me try to, I don’t have my glasses on here. So, um,

I would say I’m thinking the question is any challenges, any tests

We can look at? Um, okay.

So, um, with regard to Babinski in particular or anything in particular,


In particular. Okay. So let’s look at, um, let’s look at tonic labyrinthine reflex, tonic, labyrinthine reflex. We’ll go through a few of the reflexes. Tonic labyrinthine reflex is a flection extension reflex of the head. So with you can either have them stand with their feet together and have them close their eyes,

Look down,

Have them hold for 10 seconds and then keep their eyes closed and look up. So you go into flection extension, you can see how well they can hold their core postural control. You can, um, see whether they dig their toes into the, they do this barefoot idealistically. If they dig their toes into the ground to try to maintain their core stability, do they sway? Do they sweat ADP? Do they sway laterally? This gives you an idea of how the integrity, if that tonic labyrinthine reflex is still too active, the other way, if they can’t do that, um, one of the exercises we will do for the little kiddos, the younger population is I call them, um, the, the bird nest and the flying bird. So the bird nest would have be have them supine rolling up and grabbing their knees and wholly with their head flexed and holding that position, rolling up into a ball.

Essentially, I call that the bird nest, um, and hold for 10 to 20 seconds. See if they can hold that position, then flip them over, um, prone and kind of do a modified Superman. I have them put their hands on their shoulders. So these are the bird wings, their feet, their legs are zipped together, they’re together. Um, and so they hold their legs together. There’s zipped together, arms are appear, and they come up into an extension position Superman. So you can use that as another test to test the integrity of the tonic lab and find can they do those? So flying like a bird arms on shoulders, feet zipped together, come up into extension. Can they hold that for 10 to 20 seconds? And then supine, they roll into the ball into the bird’s nest. Now I also do that as an exercise. Okay. So if they have a, I might do the tonic labyrinthine test standing, okay.

Eyes closed. Like we talked about flection extension. They don’t do that. Well, then I have them do the flying bird and the bird nest as an exercise to help integrate that tonic lab with line. The other thing you want to check is you want to check, um, the integrity that the, the, um, other gas drops and the soil is how tight they are. So do a straight leg raise and Dorsey, flex their foot to see if they can, if, how tight they are. Um, so you might also have them doing stretching, have parents do stretching or the kiddo do stretching themselves and try to elongate, um, the gastroc and soleus and stretch those out a little bit. Um, for Morrow, again, we want to look at moral reflex. You can do that standing and do that trust fall gate and see if they have a retain Morrow.

The closer a primitive reflex mimics the infant tile reflux. So the closer that they have that display of impetus more reflects the more engaged it is, the more active it’s staying more cortisol’s kicking out. So if that’s positive, I’m going to look at a couple, again, depending on the age, I am going to look a couple, maybe nutritional Def deficiencies that keep us hypertonic iron zinc, magnesium big ones. And because when they had, when you were on this Morrow kick and in sympathetic shift, we burned through these nutrients faster. So check those out as well. And if they have a positive Morrow, I may have them be, um, doing the, um, I call them and Venus fly traps. I think I’ve heard them also called starfish exercises where they cross the same arm and same foot. So if my right arm’s on top, my right foot would be on top and roll up into a ball and then unroll and uncross.

So that can be good for the Morrow. Um, uh, definitely you can strike the Hill, look at Babinski if they’re older than two, two and a half, um, and to mitigate Babinski, you can do that same kind of brushing. The other thing you can do, I’m going to do this using my hand, cause I can not, I’m not flexible to tip my toes up to the screens to show you what my toes, but if these are my toes, you can put one foot, one finger underneath and have the toes curled over kind of toes latched on here and try to have them keep their toes flexed while you put resistance against them. So that’s another way you can help mitigate Babinski. Okay. Um, does that help with that question? Let me know. So those are some things we can check. Those are things we can do to help mitigate.

If they’re, if they’re there again, you’re going to check your spine, your pelvis, check your speed annoyed, cause that spheroid will mimic the pelvic, um, the, the pelvic alignment. So that’s why craniosacral work is, can be so important. I would check also, um, look at doing, because of that mustard division’s off. I would also look at doing maybe ear poles and seeing if, um, add that with the speed annoyed. And then of course the palate, the hard and soft palate, especially heads, they have tethered oral tissues. Those are going to be really, really important there. Okay. So those are some things I’d like you to look at on examination. And I think we’ve covered any more questions that I’ve got out there. Please bring them on a, wait a second or two. Nope, no more questions. Okay. Well hopefully you enjoy this information. Hopefully it helps you again, looking at the big picture from a neurological standpoint, from a neuro developmental standpoint and from a neuro nutritional standpoint, big things that are deficient in the prenatal period, um, are going to also affect neuro development.

And again, magnesium zinc iron are really, and, uh, chronic muscle contracture, um, and Coleen Coleen is a fun one. Coleen deficiency in a prenatal period is said to, um, is known to disrupt sensory processing development processing, especially processing speed. About 70% of mamas are said to be low on Choline, and this will translate into the neuro-development of the offspring. And, um, so that’s a big one to look at, look at as well as calling you get Coleen from egg yolks and it is essential for a cell wall, membrane, integrity and synthesis. So that’s another big one. That’s a hand-me down during the prenatal period that I would look at, um, possibly as an issue as well. So I’m going to wrap it up and leave it there. And I want to wish all of you an incredible holiday season and thank you again, Kyra secure for, um, always being there and having our backs and those of you out there enjoy may you have a lot of peace and some downtime, some time to regenerate and rejuvenate and, um, take on 2021, like, uh, in a totally different way than we’ve taken on 2020, hopefully.

So until next year I will see you in the new year. So Merry Christmas, happy Hanukkah, happy Kwanza, happy new year, um, and may peace and many blessings be your way. I’ll see you in January the third, Thursday in January and Dr. Erik Kowalke will see the first, the first Thursday in January and, um, blessings to all of you, we’ll see you then

Please subscribe to our YouTube Channel (https://www.youtube.com/c/Chirosecure) Follow us on Instagram (https://www.instagram.com/chirosecure/), LinkedIn (https://www.linkedin.com/in/chiropracticmalpracticeins/) Periscope (https://www.pscp.tv/ChiroSecure). Twitter (https://twitter.com/ChiroSecure) If you have any questions about today’s show or want to know why ChiroSecure is still the fastest growing malpractice carrier for over 27 years, then call us at (866) 802-4476. or find out just how much you can save with ChiroSecure by visiting: https://www.chirosecure.com/quick-quotes/malpractice-quick-quote/.

Empowering Women in Chiropractic – Client Case Management – Leadership to increase your impact!

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.

Hello and welcome to this week of growth without risk. My name is Dr. Janice Hughes, and I’m excited to be one of your hosts for this week’s show. Um, my role is to support ChiroSecure and particularly to bring cargo secure, some ideas input, and you as the listener, some concepts related to practice management, you know, or an essence growth of your practice this week, coming up to the end of the year, already thinking about our goals and looking into 2021, I really want to support you to have potentially this incredible year. Now I say potentially, because what happens is if we keep doing the same things we’ve been doing, we’re obviously going to get the exact same things, the exact same results that we have now for many of you, if those results are excellent. Terrific. The issue though is if you don’t continue to grow, if you don’t keep expanding, what tends to happen is even doing the same things.

We often, suddenly aren’t getting as much impact, but for many of you, I really want to focus this week’s episode on the fact of how do you lead a patient? How do you guide a patient? We might call that management of a client. So client management, and how do, how do get them through what we know is the full potential of their chiropractic care, because I know what happens after coaching thousands of chiropractors for years, I know that unfortunately, in North America, as an example, that we still tend to have a very low PVA. Some years we statistically see that is that a typical PDA or patient visit average is eight visits. So what that is telling us is that a lot of you, you start working with a patient. In many cases, you do really, really excellent work. And yet you’re not really sharing with them or guiding them through all the opportunity that chiropractic can provide them.

Now, what are the ways then that we do? So I want to share with you today, what I consider our three different pieces or categories of this patient management, or I would prefer to call it even patient leadership. So, number one, I like to call that your education number two is multiple scheduling and number three is consistent and regular re-evaluations. So let me go through those and break those down. So number one, talking about this concept of education, a lot of that, and there’s lots of different, phenomenal practice management groups and coaches and educators out there. And what I want you to know is that all of the different systems work, actually, it’s really finding what works most authentically for you. And because I prefer to say, what are some things we can work on right now? The one thing I want you to understand with this educational piece is share why, why chiropractic?

What is your objectives over a certain care plan? Where are they now? Where are you trying to move them to? So that’s a key piece instead of this going week to week to week, or let’s schedule you for a couple of weeks and see what happens. You know, you’re not languaging it like that, but in essence, I want you to see that that’s what happens if we don’t really educate someone, you know, if we don’t say, look at, you know, working with us, here’s our objective. And here’s the timeframe, the period that we’re going to work on that for some of you, it’s as simple as starting with things like the language that a typical case like yours is going to take anywhere from two to four dozen visits. Having people understand that it’s not a quick fix. Now, I’m not saying that you have to suddenly run a practice where you schedule all of those appointments.

But what I want you to know is if you don’t share from a leadership perspective, really where you’re going to try to take them through their care. You’re not even going to get them really being congruent or consistent with six, eight, 10, 12 visits. So it’s really imperative that you start to share what you’re doing and why you’re working together. Almost like, you know, in a business world, we call that kind of your, your objectives. And then your review of have you hit your objectives in practice. That’s kind of the same thing. You know, why are you working with them? What are you looking for? And then how will you measure that? Now it comes time that you’ve shared this idea, this plan, and then we now want to take them out front. So part of, for you as the doctor, your report of findings includes and frequency of care so that they understand the necessity of the repetition.

So I asked you, you know, why can’t you just get adjusted once or twice and have that all change. Now, I’m not gonna say it has to be set in a certain way, but you really want to make sure that you’re having that patient understand that sometimes we talk and talk and talk in a report of findings around a whole bunch of issues. But the reality is, is that to make change from where they’re at and you clinically have gone through that, here’s where they’re at to get to a different place. What’s that going to take? So the consistency and the repetition of the visits is imperative to make that change. So I want you to make sure that you’re really defining and helping your support team, your amazing chiropractic assistants, that someone walks out of the report of findings up to the front, or you’re taking them up to the front and that they even understand why they’re here for a series of visits.

So let’s talk about now we take them up front or you’re trying to schedule them, or you’re asking your team to multiple scheduled them. Let’s face it. If you are in a full active clinic, a lot of times the front is saying, well, wait a minute. I can get there next couple of weeks, nailed out, but that’s sort of it well that if we’re not careful has us go week to week to week, or we’re now showing a patient that we’re not even really taking serious, the recommendations that we’ve just made to them. So I would prefer that we all learn some strategies around the second point, which is how to multiple schedule people. So the same thing, I’m not suggesting that you need to schedule out a year of care or even those two to four dozen visits. What I’m going to suggest though, is that you think about that first piece of their care plan and make it more than four or five visits, because what honestly are you going to completely change in such a short period of time?

So let’s take this idea of even moving from eight visits to 12 to 15 visits, because we do, we need the consistency and the repetition of care. Now, many people are going to be out of say pain or challenges that brought them into your office, even before that. So communicate that we’re going to get you out of some of the intensity of this acute phase, and we’re going to move you then into what we call reconstructive. We’re actually going to get to the root of what’s really going on and what has created this acute exacerbation. So now we want to be able to multiple those people out. So I know even some of you, well, how’s my team going to do that, or how am I asking them to do that? Well, there’s things like, again, recognizing that, you know, is this the better time of day for you?

What we’re going to do? I noticed the doctor has recommended that we do three visits a week over the next six weeks, including a re-examine let’s nail down the time of day. And then we’ll get your appointments in for the rest of this week or your next appointment. And then I will have for you, or even email to you the entire list of your visits. So I’m not suggesting that you also need to do that with them right in front of you to schedule out that eight, 10, 12 visits. But I like that they’re in your calendar. Number one, it’s just, it’s more complete. It’s also showing the patient that you’re working with them through that whole first phase. So there’s ways that we can help for you to be able to communicate this in the report, use your education and the report of findings to show people why help your team understand the second point that I’m talking about, which is multiple scheduling those appointments.

This is also so much more powerful for you because then you’re automatically including when you will do the re-evaluation. Now, when I see a re-evaluation again, every one of you runs a different kind of practice. It might be that if you use some technology scans or different, you know, test results from pieces of technology that potentially you’re scheduling them the visit before you would sit and just spend a couple of moments anchoring back to the progress, you could have those tests redone. Particularly if you have someone on your team that does that work for you, then you’ve got that all pulled together on that reeval. And re-evaluations again, they do not have to be a long period of time. You’ll notice in the sessions that I tend to do, or some of the things that I talk about, it’s just a lot more clarity of your communication.

So from my perspective, every one of our re-evaluations is talking about here’s where you started. Here’s where you are now. And here’s the next state. Even if you’re a little hesitant to say, talk about, you know, care for their lifetime, it’s still moving them into what is the next stage of the care and the possibilities for them with their health. This is more imperative now than it has ever been coming out of all the crazy pandemic phase. People are looking for health options. They’re looking for who can help guide me to make incredible health changes. I hope many of you are experiencing the boom that a lot of people are looking for. Great health advice. That’s puts you into a coaching role, you as a chiropractor, not just the physical adjusting, but guide them and lead them through these stages. So that’s where a reeval is so critical.

It’s not about an amount of time or that you have to spend an incredible amount of time. It’s that I want you to think about what is your key objective it’s to anchor the changes that have been made, where they are now and what your recommendations are. Even heaven forbid, someone isn’t going to follow those recommendations. You’re still clear on showing them what are next stages for them. Why is that important? That there’s next stages. So then point number three, I’ve kind of encapsulated into all of this, which are though consistent. Re-evaluations, you know, so remember the three things I’m talking about and I’m kind of weaving them all in together are incredibly strong. Education is imperative for really good case management. It’s a given from my perspective that each of you listening is an incredible practitioner. You deliver an amazing adjustment. I know you make great changes for people.

A missing piece in many cases is the strength of this education sharing. Why chiropractic plays such a key role at multiple phases of their healthcare plan. So we’ve talked about the education and then literally multiple scheduling people through a first phase of care up to, and including that first re-evaluation it’s interesting years ago, I used to talk with practitioners a lot about how you even move from say that first phase of care into multiple phases. You know, people that are with you for a lifetime care practically is that you then even have to be able to, you know, build in or plot out on paper. What would I do at multiple re-evaluations? So let me ask you this question. What would you still do or educate me on if I was going to be with you for 60 visits this year, just take a little time and think through, you know, instead of overwhelming people in the very beginning with almost too much, because I know how much expertise you have, but could it be that, that first phase that I’ve just talked about is really moving them from acute care into reconstructive care.

Then during this reconstructive, which is a big opportunity of care, can you start to talk about the other things that you love that you’d love to expose them to is that stress factors is that impacting their nutrition. Some of you have products or other services that you could include and then engage in those care plans. So what are the things that you would do through say six or seven or eight days as of care, so that you could almost have a better plan, a better structure to the kinds of care that you’re delivering and it’s those kinds of things then on a re-examine that you can also talk about the next piece or over the series of the next few phases of care. Here’s the pieces that we’re opening up still a big challenge for us chiropractically is what we’re often doing is still talking that pain, get them out of pain, dysfunction, and we’re not finding the language to communicate or educate about all these other opportunities that are available.

You know, it’s interesting because for another project I’ve been working on a book project with some great chiropractors, we’ve really been talking about the sort of whole industry, the longevity industry, and already, currently there are 1 billion people on the planet that are in retirement. And it’s interesting to start to study, you know, what are those people looking for? They are honestly looking for health and wellbeing. They’re looking for the kinds of things that you as a chiropractor offer and provide think about over the next 10 and 20 and 30 years, how many more people are coming into this retirement. You know, people are looking for longevity, not just, how do I get myself out of pain. I’d really love that we help you. Chiropractically position yourself more for that. Now in the short term in 2021, I’d love you thinking about this case management or leading the patient, guiding them through this initial phase and then into the subs, subsequent phases of a care plan.

So again, number one was great. Education. Number two is even working in getting your team support to multiple schedule people so that you’re not having to every week at the end of the week, talk them into next week’s care or after a couple of weeks set up the expectation that now they’re out of pain. We don’t have any other visits scheduled and we don’t have any further plans for them. And then the third piece was the regular consistency of these re-evaluations. I share a lot of this because let me give you an example that myself, even in practice, I was a really strong educator and communicator, but I made a lot of mistakes where I even forgot with some of my incredibly long standing patients to build in some re-evaluations people who’ve been with me for a number of years. You know, I use scan technology, the insight millennium people who had great clear scans, and now we’re still under what you would call really, you know, that wellness phase of care.

And what I started to find is all of a sudden you lose those people. And it’s like, well, where, how did that happen? If they’ve already been under care for several years, what am I not doing? How am I losing them? So I did a little survey. I called up a couple of my previously phenomenal patients and, and really asked that question, you know, how could I have served you more effectively? Why were we all of a sudden not having you in the clinic? And what I found is that a lot of them were languaging it in different ways, but sharing with me that I’d stopped sharing the vision with them. I hadn’t done a rescan. I hadn’t done re-evaluations after someone was under care for a couple of years, what was I doing? I guess in my mind, I thought that going back to some of the basic baseline tests was actually pulling them maybe more back to symptom care.

But what they were telling me is that I was losing them because I was no longer sharing the vision. So I want you for 2021, you know, growth is already available to you even within your existing patient base. How do we maximize that by multiple scheduling people and reevaluating your people? You know, the new year is a great way to talk about what are their health goals? How could we help you have that conversation about new goals for 2021, even asking a patient to on their next visit, you know, talk about their goals, have them go away, think about it, write down two or three goals and bring those back. Another thing, right, even in your visit is saying things like looking at this whole upcoming year, would you prefer to do the next simple kind of change that we’re going to talk about in the area of your physical health, your mental health, you know, nutrition, what area can I help you the most with?

It’ll be interesting for you to see what patients say because you and I both know you have a lot that you can be sharing with people. So growth without risk is that you already have people in your practice. You don’t have to go out and always think about the next new patients. Let’s help you educate within case management is actually case leadership. So I want you to think about that. And I want to just take this opportunity at the end of our session today to say thank you again to ChiroSecure for the opportunity of being one of the hosts Dr. Hoffman and his team support myself, other leaders in the profession, but more importantly, they support you. They provide phenomenal services and resources like these shows. So please don’t hesitate to reach out my wish for all of you is an incredibly happy, healthy, you know, holiday season with your family. No matter what way that you celebrate, please celebrate in great health and let’s look forward to an amazing and incredible 20, 21 have a wonderful day

Please subscribe to our YouTube Channel (https://www.youtube.com/c/Chirosecure) Follow us on Instagram (https://www.instagram.com/chirosecure/), LinkedIn (https://www.linkedin.com/in/chiropracticmalpracticeins/) Periscope (https://www.pscp.tv/ChiroSecure). Twitter (https://twitter.com/ChiroSecure) If you have any questions about today’s show or want to know why ChiroSecure is still the fastest growing malpractice carrier for over 27 years, then call us at (866) 802-4476. or find out just how much you can save with ChiroSecure by visiting: https://www.chirosecure.com/quick-quotes/malpractice-quick-quote/.

Empowering Women in Chiropractic – Upping Your Game in 2021

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.

Hi, it’s Yvette from KMC University. I’m glad to spend some time with you again today. I know a lot of us have wanted to say goodbye to 2020 as quick as possible. So we only have 30 minutes today kind of like usual. And we’re going to be talking about upping your game in 2021. It’s going to move fast. We’re going to cover several topics, but hopefully today is just something that’s going to help you to, uh, kind of seat in into some things that you may want to consider doing for your practice. Maybe generate some thoughts, maybe, uh, caused you to pause and say, wow, I never thought of doing that. That’s what all this is about. We’re going to go ahead and jump straight to the slides today. And like I said, we’re going to cover upping your game in 2021 saying bye-bye to 2020 and just getting this all behind us.

And I know we’re all looking forward to a fresh new start. So what we’re going to cover today, we’re going to talk about the importance of verification on that very first visit, which we covered several times ago, but we’re going to talk about it again for the beginning of the year. I know, I know not enough time in a day to do all that you vet great thing is, as you saw, we’re going to talk about some time management too. Um, we’re also going to talk a little bit about the importance of team training. So if I’m going to tell you, you have to add in all of these verifications all over again, I’m going to definitely stress. You need team training and some time management. And then I’m going to give you just a little snippet at the end of some high, very high points.

I’m telling you a little snippet at the end about what’s coming on January 1st with those ENM code changes. It’s huge. It’s massive. Nothing’s been done since 1997 and here we are 2021. Imagine that, and there’s a lot of changes. So let’s go ahead and jump straight in to what we’re going to cover. And you’re probably saying, Oh gosh, why in the world is she going to talk about verification again while I’m coming from a different angle? Last time I talked about it, we talked about how important it is, um, when establishing a patient to the practice. But it’s also important at the beginning of every year. Maybe even when a patient starts a new episode of care. And the reason really is simple. It’s called being proactive and making sure you get all your little ducks in a row, I know doing the same thing over and over expecting a different result is insanity, but I’m telling you in this environment, we’re in right now with all the changes that’s happened with company and just in general should have been doing it.

The first of 2020, any of this had happened 2019. It’s needs to be your model moving forward and a proactive stance because you don’t want to go in the hole. One have to be reactive where you’re paying somebody three times to do something, pay him the first time, second time to fix it. And the time lost while they were having to fix it. So we really want to be cautious and utilizing our time to the best of our ability and proactive. Um, uh, being proactive is probably one of the best investments you can make. Now we all know, again, like I said, the definition of insanity is doing the same thing over and over and expecting a different result and it can feel that way with verifications, but can we think of it a little bit of a different way today together? That would be, what about this?

An ounce of prevention is worth a pound of cure. Uh huh. So it’s a little bit of a different way to spin it and maybe create some optimism. When we have to think about taking on another task. Sometimes it’s dreadful because we have to sit there on the phone for so long, become the master at master tasking. I’m going to tell you that now because it’s multitasking because that’s just the catalyst to be enabled, to do verifications by phone because remember KMC university doesn’t think that we do them by the portals. Those are eligibilities and not verifications. So the answer is quite simple about why we’re going to do it again. We have open enrollment period going on for both the patient and some change time for doctors Medicare right now we’re in that open period until December 31st, where a doctor can elect to change their participation status.

Now a chiropractor can never let to not be enrolled. So enrollment’s not a question with Medicare. The chiropractor has to be enrolled that’s in their guidance, in their regulations. You can’t argue with it, but what you can do right now is say, I don’t want to be par anymore. I want to be non-par Oh, I don’t want to be non-par anymore. I want to be par and I will tell you that right now, if you’re needing to enroll, what’s probably the perfect time, but you got to go in par for this to happen. So not trying to influence your decision, but during this public health emergency, some people call it a PAG. You can do a rapid enrollment with, uh, with Medicare, if you’re going in as a par provider. So do keep that in mind, if that’s something you’re needing to do, um, definitely get on that as quickly as possible.

It was extended until sometime in January. We don’t know if it’ll get extended again, but things are changing. We’re in open enrollment period, not just for providers with Medicare, but we’re also an open enrollment period for a lot of employee. Um, employer driven plans. My husband comes home every year and he knows I’m the expert on it. And he wants to know which plan should we change plans. And it’s like the plumber that has the horrible plumbing that don’t want to talk about it anymore at night. And I’m like, do I have to talk about it? Because I don’t just check a box and do this so quickly. I want to do the math. If I stay up here and they give me HSA and I have this and my copays that on the average of what we spend, where everybody’s sitting at that, I mean, you’ve got some employers that they’ll do it at the end of the calendar year.

Others will do at the end of the fiscal. Lot of fiscal years are usually that ending in June, starting new in July. I have seen it March. It could be anywhere because that company picks their fiscal year. But those are your kind of your common places. You’ll see it. So open enrollment for employees to select new plan options. Maybe they can’t afford something. Maybe they found out that they’ve got more illness and they want to have less payment out of their pocket and just not in a position to do it. Otherwise. How about the open enrollment for Medicare patients? Of course, Medicare patients can get in. And when they turn 65 by a couple of other qualifiers, uh, throughout the year, but I put this here because we have to think about the Medicare advantage plans. They can switch they’re in that period right now, where they can switch.

I don’t want traditional Medicare anymore. I want this Medicare advantage plan. Um, I don’t want, uh, this Medicare vintage plan. I want traditional Medicare right now is their time to make that change. Why do you think all the commercials are out there about this Medicare advantage plan? We’ll give you this medical drug coverage, all of this. Everybody’s trying to vie for business right now. So we’re in open enrollment with Medicare. So we need to figure out who did they pick? Because it inevitably, if they decided to go to a Medicare advantage plan, when you get the claim back, if you send it to traditional Medicare and didn’t do your due diligence of verifying, because the Lord knows they’ll hand you that red, white, and blue card, no matter what they really have, you’re going to get something back from Medicare, a and a denial saying this is not covered.

It’s covered under a capitation agreement, which generally means, uh, they have a Medicare advantage plan. So there’s another reason. And when we think about being late on, then submitting to the right payer, you’ve got to think some of these payers have a very short, uh, very, very short, timely filing some 90 days. So by the time you would expect to get any OB back, maybe from, let’s say, blue cross, and you just sit there and wait and you wait and you wait and maybe you don’t have great. Follow-up maybe you’re too overwhelmed, short staff by that point there when Aetna’s timely filing. So this is why this is such a pivotal year. Every year is pivotal, especially when you think of all these things, but especially this year. So maybe the employer needs to cut costs. They may do that a couple of ways changing a plan, or they may switch the third party administrator.

They may have always used blue cross, but Cigna came up with a better offer. They may have always used Aetna, but blue cross came up with a better offer. They have been impacted by the public health emergency this year and just impacted by increasing expenses. Overall year after year, you will see employers change a different plan. So what if they keep the same? Let’s say the same third party administrator. They keep blue cross, but because they need to cut costs, they decided, well, we’re going to exclude this now, or we’ll only cover this many of this. And before you get headlong and telling a patient, well, you owe 40 a visit not to realize the employer changed it. Patient didn’t realize cause they were paying attention. So many reasons why this is so important. What about those patients on the affordable care act? The Obama plan marketplace plans, where they have the option to change.

I know that my daughter’s mother-in-law, she just changed her product because another one had raised its rate. So she selected on the marketplace to go a different route. So if somebody didn’t verify again, not just asking her, but verifying what does that coverage? We would have told her that she, the doctors would have totally missed it, build the wrong payer. And I believe she selected one of those plans that had a 90 day timely filing. So look how much that’s going to impact her caregivers. If they’re not paying attention. What about job changes? So I have a child that works at a particular, a place, although the building is the same. There’s several contractors inside that building. So maybe as a job assignment ends with this contractor, they then get hired by another contractor. And then that contractor has a whole nother different plans. So we can see the necessity.

These are just a few of the reasons why you should obviously, uh, you’ll have better reimbursement. I mean, we can go that direction on talking about the positive impacts of your office. I think we can all see right now we can’t afford to get behind. We can’t afford to build our own company. Money’s tight for everybody. Everybody just stay on top of it, take a few extra miles. It’s like if I had to let people go with COVID, we just don’t have the time. I’ve got a few employees left. I used to have this many, you know what? That’s the reason you do good team training. So instead of this taking one employees, 80 hours, you divvy this out over the employees because they’ve all been trained well cross-trained we had a situation the other day when somebody came to KMC university and said, I believe they were one of our members.

And they said, can you help us? Please said our biller has been out with COVID and we don’t know how to set up billing. We can’t set up billing. She’s still in quarantine. Won’t be back. Any time soon, money stopping up. They were dependent upon that. They have been that impacted by COVID. So with that, without the training and the cross-training money came to a screeching halt, that’s why team training to increase training is so important. If something changes, if somebody wins the lottery like Kathy likes to say, or, you know, a health challenge or even death comes about and can your office function, if not, there’s a problem. So we look at what has been published by this Michael at [inaudible] where he talks about, if you believe training is expensive, you truly don’t know the cost of ignorance and how true that is. I did an onsite back in October and this became very real to me.

I already knew the impact of not training, but I saw it. So plainly in front of me, when I stood up in front of a room of CAS doctors and trying to find the common ground in that room. And I couldn’t even say nine, eight, nine, four zero. I couldn’t say CMT. I barely could say the word adjustment. How in the world do you expect your patients to know what’s going on for you to get scheduled for the right type of visit for you to get collections in for you to build right for you to do anything, right? If your team has not been trained, you are setting yourself up for failure. If you are skipping the most important element, and that is team training, don’t leave yourself, sitting there empty handed. If you’ve got a staff member wanting to control everything, you got to break that barrier.

What if something happens? I at one time was a hoarder of information in my head and I realized the impact that I likely left when I walked out with all the knowledge in my head by no means would I ever want that for anyone? And I’ve been the recipient of walking in on offices like that. Actually one, the office manager suddenly passed away and nobody knew what to do. Uh, you can’t leave yourself that vulnerable, but we can see that ineffective training costs money now for bigger companies like about a thousand people, that’s about 13.5 million a year. If you bring that down to your practice of five, you’re talking about 5,000 a year in a cost for a small business, and you’re going to have high turnover. So really I think the costs would go up significantly when you really have to factor all things.

But according to the HR magazine, if you invest about $1,500 on training for your employee, you’re going to probably have about 24% more profit. This office that I went to in Pennsylvania was a disaster with their collections, absolute disaster. And until they allow the training to get in there and get out of their own frenzy, they’re going to continue to struggle. Now, the minute that we get training in there to learning in there, to understanding in there, we can not make a change. We have to get understanding. So let’s think about the old story. Everybody tells it a little bit differently, but it goes a little bit like this husband and wife sitting down for dinner, she decided to cook a ham ham and potato dinner for him. And he loved him. His mom always fixed it for him, seems similar in its taste. But something very odd happened in the process of preparing it.

The wife cut off the ends of the ham and she stuck it in the oven. Just like she has every time, just like mom did just like grandma did. She’s going to follow that family tradition because it’s mouthwatering great. And husband’s kind of sitting back perplexed. Like, did she cut the ends off the ham? There’s plenty of room in that pan on the one in the world was wrong with her and it gets the best of him. And he’s like, Hey, we have got to call your grandma and ask her what the secret is behind it. Does it allow more juice in, what does it do? Really? What happens when you cut the ends off to the hand? Cause it really kind of say something my mom. So, you know, maybe, maybe we all need a cooking lesson together. Just picks up the phone. Hey grandma, it’s me.

I just wanted to call you. I fixed the hand today. My silly husband wants to know why we’ve always cut the ends of the ham off. She goes, well, did you use a good size pan? Oh yeah. There’s plenty of room in my pan leftover and the whole thing would have fit in there. But I mean, once I kind of done, I had plenty of room and she goes, Oh honey, honey, I guess the training that you needed, you didn’t really get, you only heard it by experience. I am so sorry, baby. You probably just threw away a good amount of money because the only reason I cut the end off to the Hamm was because my pan was too small. And so we have gotten to leave the ends on the bacon, some on the end of that thing and bring home the bacon.

We can’t keep leaving money on the table because maybe we had a staff member. We thought knew it all that didn’t know it all. That’s what I ran into in Pennsylvania. Um, maybe they’ve only had training because of what they saw in the software. You’re going to merge to a new software. This is where we see a lot of issues and we have to step in and fix fee schedules and fix all kinds of stuff here. We actually have a protocol for one particular software where we go in and fix fee schedules and have a whole training protocol around it. You can adapt it to any of them. But, um, but when we’re talking about the training that comes from staff to staff, you’ve got to ensure that it’s correct because it could be costing you money. And what you thought was a good land of profit, maybe much less than what you could be getting.

So make sure that your team is properly trained and not just because they saw it, but because they learned it and then it got from a different place of learning it. And it went all the way to an understanding. That means if everything falls apart in this world and we leave being able to submit claims electronically, you can pull out one of those good old CMS, 1500 forms, no cheats in the system. The system died, everything went away. And, but that’s where our model, Oh, God money stops because we don’t understand what it took. You could change to any software in the world. You could go to being on any piece of paper. And as long as you understand what it takes, it will happen. We see that this with doctors, with the anamar systems, they don’t have an understanding of what it takes. If you told them to put it on paper, or we look at their paper, we realized how wrong the paper was.

How would the world do you ever expect them to get it right in the EHR? It’s because there’s no understanding. Anyway, you go be it going from paper to EHR or back and forth. You have to have the concept down of what it takes to document what it takes to bill, what it takes to modify what it takes for this code. How you have to point here, how you have to do that, how you have to schedule for all their appointments, how you have to schedule this much time. You see what I’m saying? How it can so negatively impact your practice. You can afford that. No one can afford that. So the, the ends on the ham and bring home some more bacon and get the right kind of training to this tape. I sat in on the day and I thought, you know what?

I’m just going to throw together a few ideas of why I think this is just off the top of my head today. I didn’t pull it from anywhere. I just thought, you know, how important is team training to me? How often important is it? Or should it be to offices? Now, those of you who are KMC university members, you fully recognize that little purple cube. That’s the one. When we’re doing an orientation or, or guiding you in the library to something with a new employee, we’re like, do not pass, go do not collect $200, go straight to basic CA training. Let us know when you’re done and tell us what their job role is. And we can tell them where else to go work. You know, we can work with them one-on-one and a lot of times we take brand new staff members and train them.

But let’s think about how this works. So team together, each achieves more. We don’t want Sally being the lone ranger, everything in her head, but we also don’t want Bonnie having to do everything because no one else has been trained. So when we do proper team training, it fosters team spirit. It’s a well-oiled machine. We have accurate and effective outcomes, things that are positive for this office, for the patient, all around things are just brighter. We’re all working toward a common goal. We’re not scattered everywhere, just thinking, okay, I guess I have to do it this way. And this one over here does it the other two hours of the day. And she does it the other way. And so they sit and they pull at each other, no, be consistent. So we’re all working towards a common goal training to learning, to understanding. I, it was just an eye opener for me recently, with those I can train you, but if you never learn it and then if it doesn’t go to understanding, it’s a waste, make sure they understand that there’s nothing wrong with that.

Like even in our basic CA training and throughout our library, there’s a lot of self-assessments where as an office manager, you could go back and look not to say, I can’t believe you don’t know that, but to say, Oh, okay, she needs some more training there. So just realizing opportunities for training you’ll have increased productivity. They know what they’re doing. They’re not sitting back, scratching their head, trying to make it up or figure it out. You’ll have increased profits. Uh, one, because you’re not going waste so much money on payroll and there’ll be more productive and they’ll know how to chase that down. Better increase patient retention, increase patient satisfaction, which then generally moves run on over into the land of referrals. They’ll all have the same basic knowledge with cross training. They’ll have jobs, specific training for what they have to do through cross training.

They won’t be the only one you’ll have much less staff turnover. People would just want to know what they’re doing. And if you don’t have your stuff together, don’t expect them to have their stuff together. Don’t expect somebody to come in and be your miracle staff. Because if it’s that, man, you didn’t have it together either. And I, I generally don’t become that harsh, but that is the truth. And we see it every day. People relying on a staff member that they hired from off the street. I’ve walked into offices where they’ve hired from maybe just a local bar. Maybe they’ve hired from a restaurant, maybe from a gas station, just because they like personality. Be very cautious unless you’ve got a lock type training program and compliance in place, know what you’re doing. And also because you’ve got to satisfy this compliance requirements through HIPAA OIG, OSHA, CLIA, all of those that apply in our offices, we’ve got to have our real structured plans and they need to be trained.

And it establishes your practice culture. Not everybody. If we’re having a very somber practice, not everybody’s chip here. And for having a very chipper practice, nobody’s looking a bother. Everybody’s matching that practice culture because they’re well-trained and they’re on that target together. And all I could do is put an, because I ran out of room, it’s pretty simple. You can see the value in what it will be and what does it really isn’t for you? So let’s look at this together. We got 50% increase in efficiency. Oh my gosh. We all could use that. We have a much faster turnaround time on a claims. Our reimbursements are up significantly and we’re getting paid for what we do because the staff knows what to do. When the insurance doesn’t cover this, they know how to behave. If they bundle it, they know how to use the CCI, edit modifiers.

They know how to diagnose these points and we can be so proactive. Of course we have insurance companies that get a little crazy on the side, but you know, but we know how to deal with it. Right? Absolutely. And the best way to do this is through time management. So we talked about verification, doing it at the beginning of the year. You bet that’s going to be burdensome. Okay. Then train some other staff members. Okay. Then what about the time factor? Schedule it, manage it. If you’re doing an app passively, then time is managing you. Nobody has time for that. As the lady said on Facebook and nobody got time for that, we want to make sure that we’re managing time. So it’s not managing us because one thing you don’t want to do is, well, Patrick, Leah Lynn Lencioni. I’m so sorry. What Patrick Lensioni said.

If everything is important, then nothing is quit. Making everything important. Uh, often had to tell doc, he’s like, come home and change the furniture. It was almost weekly. It was at least once or twice a month. I said, you know, if I come and help you move the furniture that you’re going to be losing money because we don’t get paid for me to move furniture. We get paid for you to work claims. And if everything’s important, then realize that there’s a lot. That’s going to have to go by the wayside. And more than likely it’ll be in your back pocket. We also know that interruptions all Deere. I threatened at that last office. I said, okay guys, I’m changing my name. So if you can guess what my name is today. Then I’ll answer you. My name is not your vet. My name is not Mrs.

Noel. My name is not, Hey, you mom, whatever. It’s not that if you can guess what my name is and you can interrupt me otherwise, I’m not going to, I’m not going to hear you. And really all I was saying, Hey guys, please cut down the interruptions because everybody, it wasn’t just the staff. I had a window right by my door, Vic slender window. And our check-in area was right there. And people love to talk with me. I love to talk with them, but I didn’t have time. So everybody you’ll find everybody wants a piece of you. You just cannot, uh, take the protection off your time because time is of the essence and it takes more time to do things and we can’t let those moments be stolen. And doesn’t mean we become cold and insensitive, but we guard those. So a person generally gets about seven interruptions per hour, generally takes about five minutes per interruption.

I’ve never known one to take that small of amount of time. Then they end up spending about four hours a day in interruption. So they work eight hours for you. And you’ve done interrupted them that much. That’s four hours. Maybe you interrupted so much today. It was a whole eight and 80% of the time. And so little or no value. And we find out if we really start saving those things that are truly important, maybe setting up communication Benz. I had to do that at that recent onsite, up in Pennsylvania, where I set up communication bins. And we used a piece of paper to communicate. It’s not that I don’t want you to talk, but don’t for that. We’re a doctor run toilet paper.

Oh, combin. Or

I told them, I said, I want a white board. I want something up on the wall. That’s the wishlist. That’s right. The order list. And if you know where on toilet paper, if you know we’re on a paper towel, if we need post-it notes, stick it on the board, quit interrupting people. Be smart about your time, these smart about what you’re giving your time to make sure that you’re managing the time and it’s not managing you kind of look at this here. When we think about those things that are urgent, not urgent, urgent quad, one urgent quad three, a non-urgent quad, two quad four. You can see that there’s some, that’s super important. The building’s burning down, go get everybody out. And some that maybe aren’t that or broken, you know, things, maybe a short-term focus of something. Maybe just somebody called on the phone.

Uh, his doctor, I need to talk to him. Actually. He’s seeing patients right now. Could I take a message or I can have him call you back on a break that was wife calls. I had this happen. I need to speak to him right now. One of the kids has swallowed paint center. Um, I immediately, I put him on the phone. You have to know and manage their time also and not let everybody get to them. I commonly would’ve saw, I saw somebody going towards Doug. I’d say he’s with a patient. You’re going to have to wait. Actually, if you could schedule a time, people come in and want to market this. You will need to schedule a time to talk to us. Um, we have administrative time set aside and that’s, what’s really important is to really figure out what’s important. What’s not important.

What can wait and what can’t wait and really managing that through a process of managing, focusing, avoiding, and then limiting, uh, really find out from each other. Is this truly important? And it needs done right now or by when do you need this? Tell me when you need this by. I don’t, don’t just tell me you got to have it right now. And if you said yesterday to them, can I tell you that could be a lack of planning on your part or a lack of follow-through holding their hand to the fire and saying, get it done, but be cautious that you’re procrastinating, which causes havoc, which pulls them off of their task. Try to keep a calendar going or something that always keeps something in advance abuse so that you are aware, keeping tickler files going, um, keeping things in outlook. However you keep your calendar, keeping it somewhere to where it doesn’t sneak up.

Maybe get alerts. I use my phone sometimes pay your car payment five days before it’s due. So if I don’t want to do it that day, I hit remind me tomorrow, remind me tomorrow. And I never go past, but it lets me know it’s coming up so I can be prepared. And we always want to make sure that we ask by when do you need that? That’s something we’ve learned very valuable here at KMC because there’s a lot of times we can think it’s an emergency to us, but when is the do or die and be ready to give those answers to your staff. So time management and really getting that into play really starts before that patient calls goes to that whole cycle for reimbursement, you can see this is a lot of reimbursement stuff. And if you aren’t keeping the cycle going and you’re constantly just getting caught up in one of these or another, it’s going to blow the cycle and you can’t afford it.

Because look over here, you’ve got the receiving and posting of payments at about the seven o’clock and one, if you need to appeal it that whole side, if it’s lacking and you’re lingering too much on the right, you’re going to completely miss your money. So some of the important things to remember are time will not change. Time goes on no matter what you do, as much as we’d like to stop it. I commonly say I went off of this life, uh, life cycle I’m on right now, this, so I need to let me off, let me go do something else. That’s sometimes I feel overwhelmed by life in general. Find out are you wasting time? I do. Sometimes when I feel very overwhelmed by it, I find something else that needs my attention. Um, that’s just transparency set a time related goal. Uh, Kathy told me one time, she said, think about it this way.

What can I do in one hour? Don’t set goals. I mean, you’ll have longterm that be realistic in them implement a time management system use tools that you can to help manage that time. Buzzers alarms, nothing to go off loudly, but something to remind you, Hey, you said you were doing this for this timeframe. It’s not done. Put it back where it was with all your notes. And then when it comes back up on your schedule, you’ll do it again. Prioritize, prioritize, prioritize, just like with a real estate location, location location. When it comes to time management, it’s prioritize, prioritize, prioritize, delegate. When you can install proper routines, set time-related tasks and then be, uh, be systematic about that. Always make sure you’re saying aside of administrative time, doc, they do need to talk to you and to put your head in the sand and never talk to them and never asked for followups.

Never still have your hand in that practice is a disaster set aside times where they can ask you set a time aside times that they know you’re going to go to that convent and get those things out that they need you to address. Have a time that everybody can set aside for training to handle tasks that are out of the norm and things that just eat things away, but things that are not part of the business itself, like I’ve got to touch patient like that. This is the followup that prevention know that that staff member, if you think that she has a lot of time in a day, I will tell you, they usually don’t. Especially if you’ve got a one CA office, this is a list of just some of it. Very minute, that phone rings and you never know which hat you need to put on.

Um, a lot of different things that they have to go through and having systems and training in place, speeds it up for them. One great way to manage this is to identify all your tasks that you have to do daily, weekly, monthly, and then as needed. Put those in columns. If you’re KMC university member, this is in the third party billing and collections, the follow-up system, the very first lesson. This is a time management tool kit, but you can see daily, weekly, so forth. You spread them out. Then you get your calendar up there. Again. This is part of that same tool where you start saying, okay, all those are on that weekly. I’m going to, or daily, I’m going to put them on Monday, Tuesday, Wednesday, or they have to be done weekly. So I’m going to put that on Thursday and then you list out everything and put it into a framework.

Then when you go onto the next piece of that, you’re going to then say, well, my reactive calls and my proactive calls go here. I’ll do verifications here. And when my time is up, my time is up. You’re going to be efficient about it. You may be able to say, well, I’m going to do insurance verification and posting, uh, because I can multitask while I’ve got the phone on speaker, until they up, I can do this. Always make sure you’re not just sitting there and stay hot. It’s insurance verification time. I’m not going to do nothing for 50 minutes while I went on to pick up the phone. No, no, no, no. Make sure that you’ve got things in there that will keep your time moving. Finally, I told you I was going to cover just a couple highlights, uh, of M coding. Obviously we don’t have the time.

Uh, just so you know, KMC university is doing a training tomorrow. You’ll need to call us to get set up for the ENM. Coding changes. Massive, massive change. First one, since 1997 coming about January 1st, right along with that new ABN form, make sure you were aware of it. I put this year here because there’s some things I don’t want you to hear, uh, and take it as that’s how you’re going to move, but let’s talk about those. You will hear straight right out of the way it’s coming out of my mouth. It will be effective January 1st, 2021. Everything changes. It’s the first time since 1997, uh, then we go to the nine, nine two zero one is going away as a chiropractor, nine, nine, nine two one one should have been gone a long time ago. The minute you walk in the door, you’re already at a nine, nine, two and two, and the old model. Um, now what I don’t want you to hear, I don’t want you to hear, what’s not being said here.

A lot of the code

Selection is going to the medical decision-making and time component. So while a lot of us may jump up and down and say, if I just say what I’m going to do, if I’m, and this is my thought, and I ordered this test, Ooh, look at that. Where did I get? And I spent this much time with them and afterward claiming all that up, right?

There’s my code, please.

If you’ve heard nothing else I say today, you have to hear what I’m saying. I don’t want you to hear that. I said medical, decision-making focus there and how much time you spend with them and you’ll make more money. They’ll tell you what code to pick. Listen to me, chiropractors, physical therapists, whoever’s listening today. You still have to support medical necessity, which is still going to come out of that chief complaint out of the dysfunctions, out of your written treatment goals out of the exam, that’s how you’re going to support medical necessity for the long haul. A lot of this really made probably just general medical doctors, where that’s all, they do feel pretty happy. It pulls some of the burden off, but it didn’t say you don’t have to have it. It said, when it’s medically necessary, you pull the during the exam. Let me tell you something right now, chiropractors.

It is medically necessary. Every time you do one, because you have to establish the medical necessity for this, uh, this, um, span of care that we’re doing this episode, please do not hear that and go running and think you’re scot-free on having to do the exam and the history. You’re not because that’s how we, as a profession, support the medical necessity for the continued care. Um, and the medical decision making and time again are going to be a lot of the components, but you can’t skip it, even though it says only if it’s necessary. It is for medical necessity. So hot topics. I want to leave you with these, the ABN form. We discussed that my first couple of times I was with you has to be brand new. You should be on version a for 2023, six 2023. Um, make sure that you’re doing it appropriately.

There’s a lot of people still doing it wrong. If you’ve got everything on your ABN, if you’re doing it once a year, you better give somebody a call and we’re a good place to call for that. And I’m coding effect. Medicare open enrollment deadline for you to change from par to non-par is going to be December 31st. If you thought you wanted to get in on that, you’ve already do that. Now, Medicare new enrollment, uh, COVID emergency only valid. As long as this public health emergency is going on. You’ve gotta be willing to go in as par. And if so, um, it can, um, speed that along. A lot of people were getting in. And just a few days time, you still have to go through the process of getting everything into them for the, uh, permanent enrollment. Um, but make sure that you’re doing that upcoming events tomorrow, KMC university, doing the last minute, waited on some of these last minute things to change.

Are you ready for that? January 21st, um, the January, 2021 eight coding changes for more information, (855) 832-6562. And then if you have any questions, just feel free to reach out to us at any time. Uh, we’re here. Any questions that came up today? If we brought up a thought or if something just comes up for you organically, let us know, uh, Connor skier next week. Please join them as, uh, Janus shoes. We’ll be presenting. I’m sure that’s always a great time for you guys. I definitely appreciate you letting me join you today and we’ll look forward to talking to you and next time I’ll be with you again in the early part of January, have a great day. Bye-bye

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