Policy Statement

Policy Statement Board Policies and Guidelines (Chiropractor)

Date: 12/07/2017
Referenced Sources: Board of Registration of Chiropractors

Table of Contents

Policy Guideline on Dietary and Nutritional Advice

From:   Massachusetts Board of Registration of Chiropractors

Re:       Policy Guideline on dietary and nutritional advice

Date:    January 6, 2012 (as revised October 4, 2012)

The Massachusetts Board of Registration of Chiropractors (Board) has voted to adopt the following Policy Guideline. This policy guideline is intended as a recommended protocol for the profession to follow. The guideline set forth below does not have the force or effect of law, as would Massachusetts General Law or a Board rule or regulation. However, the Board utilizes this and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.

Purpose

On numerous occasions, the Board has been asked if a licensed Massachusetts chiropractor may properly give dietary and nutritional advice to an individual without also providing a chiropractic adjustment.  The purpose of this guideline is to clarify for licensees and members of the public that chiropractors may provide dietary and nutritional advice as an independent service without any other accompanying primary chiropractic procedure, provided the chiropractor complies with all applicable laws and Board regulations.

Discussion:

General Law Chapter 112, Section 89 defines the practice of chiropractic in Massachusetts to include “the science of locating, and removing interference with the transmission or expression of nerve force in the human body, by the correction of misalignments or subluxations of the bony articulation and adjacent structures, more especially those of the vertebra column and pelvis, for the purpose of restoring and maintaining health.”  The science of chiropractic includes assessment of the three components of health, often described as:  structural, nutritional/biochemical and mental.  Evaluation of a patient’s nutritional health is recognized as both a primary and a supplemental chiropractic procedure.  For this reason, in defining the chiropractic scope of practice in Massachusetts, Board regulations refer to dietary and nutritional advice in two places: 233 CMR 4.01(1) (c) 2 as a supportive service and 233 CMR 4.01(1)(d) as an independent therapy. 

Furthermore, licensed chiropractors are primary health care providers. As such, it would be inconsistent to say that a licensed chiropractor may not answer questions or give advice regarding diet, nutrition and other health matters, unless they also provided a chiropractic adjustment.

Thus, “[c]ounseling and instructing patients of all ages regarding health matters, including but not limited to the following: nutrition, supplementation, diet, exercise, activities of daily living, ergonomics, and good health habits,” as described in 233 CMR 4.01(1)(d), may properly be provided by a chiropractor as a stand-alone service.

Policy Guideline on Fee Discounts and Discount Payment Plans

Date: February 3, 2010

The Massachusetts Board of Registration of Chiropractors (Board) has today voted to adopt the following Policy Guideline. This policy guideline is intended as a recommended protocol for the profession to follow. The guideline set forth below does not have the force or effect of law, as would a Massachusetts General Law or a Board rule or regulation. However, the Board utilizes this and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.

Purpose:

Over several years, the Board has received numerous requests for clarification regarding payment options for chiropractic services. As the Board is responsible for licensing Doctors of Chiropractic and ensuring that our licensees follow appropriate standards and protocols in all aspects of the delivery of chiropractic services to the citizens of the Commonwealth, the Board wanted to make the following information available to all interested parties. This guideline focuses on avoiding potential conflict with the Board's rules and regulations.

It is important to remember that nothing in this guideline requires a licensed chiropractor to offer fee discounts to patients or insurance organizations. Also, nothing in this guideline supersedes Massachusetts or federal statutes or regulations. Various external references have been included for additional information, but do not represent a policy of the Board.

Policy:

I. Definitions and Limitations

1) Discount plans do not relieve a licensed chiropractor from his or her duty to provide competent, necessary care in a timely and affordable manner.

2) A discount plan allows the public a cost saving on some of the services from a chiropractor. Discount plans do not pay anything toward chiropractic services. Instead, they allow the patient to get a discount off of some of your chiropractic charges.

3) A discount plan is not health insurance and does not meet the Massachusetts "individual mandate" requirement for health insurance coverage. The Massachusetts Attorney General's office has promulgated regulations pertaining to Discount Health Plans and licensed chiropractors should consult these regulations. (940 CMR 26.00: Discount Health Plans and Discount Health Plan Organizations)

4) A patient has the right to forgo available insurance benefits for chiropractor services in favor of a self-pay process. Documentation of the patient's decision, if known, should be maintained in the patient record. Such documentation should include:

a) Patient's name and date of birth;

b) Insurance company name and card (identification) number;

c) The licensee's name and practice address;

d) The patient's decision to forgo available third party pay benefits in favor of a self-pay process;

e) The patient's signature; and

f) The date it was signed.

5) This guideline does not release a licensed chiropractor from any contractual obligation that he or she has with an insurer or other entity. (233 CMR 4.11: False Health Care Claims Prohibited)

6) All care recommended and rendered must be clinically justified and appropriately documented. (233 CMR 4.08: Overutilization of Practice)

7) Discounts and payment plans should not include any improper solicitations or inducements for any good, service or item for which payment is or may be made in whole or in part by a health care insurer. (MGL c.175H §3: False Health Care Claims, and 233 CMR 4.12: Improper Solicitations, Inducements or Referrals)

8) Fee discounts and discount payment plans fall into four general categories:

a) Time of Service Discounts

b) Membership Discounts

c) Hardship Discounts

d) Pre-payments (pre-payment discounts and concierge plans)

II. Financial arrangements between a licensed chiropractor and his or her patient must be in compliance with 233 CMR 4.00: Standards of Practice and Professional Conduct.

1) The Board is concerned with protecting the public from misrepresentation, deceit, fraud, improper solicitation, overutilization and unprofessional conduct, as it applies to fee discounts and discount payment plans.

2) Licensees should use clarity in describing financial responsibilities, payment choices and discount plan options, and should be particularly mindful of the following:

a) A licensee who is contracted with an insurance carrier should adhere to the terms of their provider contract in regards to the collection of co-pays, co-insurance, and applied deductibles. The contractual obligation of an "in-network" provider will typically differ from that of an "out-of-network" provider;

b) Many insurance plans do not cover maintenance or wellness/preventative care;

c) Any co-payment, co-insurance or applied deductable collected in advance should be promptly refunded if the patient recovers before those fees would apply;

d) Some insurance carriers may specifically prohibit the collecting of co-payments, co-insurance and applied deductibles in advance;

e) A poorly worded pre-pay plan could inadvertently result in 'Balance Billing' which is a violation of Board policy. (233 CMR 4.09: Improper Charges) Balance Billing is the practice of charging full fees in excess of covered amounts and billing the patient for the balance that the insurance carrier does not pay when the provider has a contractual obligation to write-off this balance. On the other hand, collecting co-payments, deductibles or fees for non-covered services is not Balance Billing;

f) Discounting co-payments, co-insurance, and/or applied deductible s amounts without first determining in good faith that the individual is in financial need or that reasonable collection efforts have failed, could be considered an improper solicitation or inducement. (OIG Advisory Opinion: Hospital Discounts Offered To Patients Who Cannot Afford To Pay Their Hospital Bills, appendix 2 and 3); and

g) While types of prepayment and concierge plans share some similarities, they can vary widely in their structure, payment requirements, and form of operation. In addition to this policy guideline the Board recommends that licensees consult with a knowledgeable health care attorney to ensure that any plan they offer does not violate Massachusetts or federal statutes or regulations; or any insurance or contractual obligation by which the licensee may be bound.

III. Time of Service Discounts

1) A Time of Service (TOS) discount is a discount offered to patients who pay in full at the time of service to reduce the costs of collection.

2) The TOS discount, if utilized, should be offered to all patients on a non-discriminatory basis. The TOS discount is most often not publicly advertised, but may be offered to patients during the course of discussions about payments and fees.

3) The discount price must be clearly noted on all bills, receipts and account statements. Thus, patients wishing to submit an insurance claim should be given a receipt that reflects the discounted price that was actually paid.

4) The amount of the discount should bear a reasonable relationship to the amount of avoided collection costs.

5) Time of Service Discounts should comply with all applicable laws and regulations.

(OIG Advisory Opinion: 08-03, regarding prompt payment discount, appendix 1)

IV. Hardship Discounts

1) Discounts based on financial hardship (waivers) are acceptable provided:

a) The waiver is not offered as part of any advertisement or solicitation;

b) The licensee offering the waiver does not routinely waive coinsurance or deductible amounts;

c) The licensee waives the coinsurance and deductible amount after determining in good faith that the individual is in financial need; and

d) Documentation of financial need is created concurrent with or prior to the discount being given and maintained. (233 CMR 4.05: Chiropractic Record-keeping)

2) The Board recognizes that what constitutes good faith determination of "financial need" may vary depending on the individual patient's circumstances and that a licensee should have flexibility to take into account relevant variables. These factors may include for example:

a) The regional cost of living;

b) A patient's income, assets, and expenses;

c) A patient's family size;

d) The scope and extent of a patient's chiropractic/medical bills; and

e) Whether the patient has already been approved by a government agency as qualifying for state or federal financial support.

3) A licensee should use a reasonable set of financial need guidelines that are based on objective criteria and appropriate for the applicable locality. The guidelines should be applied uniformly in all cases.

4) Hardship discount plans should comply with all applicable laws and regulations.

(OIG Advisory Opinion: Hospital Discounts Offered To Patients Who Cannot Afford To Pay Their Hospital Bills, appendix 2 and 3.)

V. Membership Discounts

1) Membership discount plans offer members a discount off some of the incurred charges from a participating chiropractic provider.

2) Membership plans are typically created and maintained by an organization with statewide or national scope. A membership plan comprised of just a small or limited number of chiropractors could be considered simply a change in these chiropractors' usual and customary fee rather than a true membership discount plan.

3) In addition to the disclosures required under 940 CMR 26.04 where applicable, membership discount plans should describe in writing:

a) A description of eligible services, and the time frame that the plan covers;

b) How the patient will pay for the eligible chiropractic services;

c) The handling of any insurance related matter arising within the membership period, including the understanding that any alternative insurance benefit would fall outside of the membership discount arrangement; and

d) A clear exit provision.

4) Membership discount plans should comply with all applicable laws and regulations.

VI. Pre-payments (prepayment discounts and concierge plans)

1) In a pre-payment discount plan the subscriber purchases a package of services that cost less than if the services were purchased individually.

2) The business model, known as Concierge Care is a relationship between a patient and a licensee in which the patient pays an annual or monthly fee out of pocket. This may or may not be in addition to other charges. In exchange for this retainer the licensee provides a defined set of services and amenities during the coverage period.

3) In addition to the disclosures required under 940 CMR 26.04 where applicable, pre-payment discount plans and concierge plans should describe in writing:

a) The total cost to the patient as well as the method and timing of payment;

b) A description of what chiropractic services are included and excluded;

c) A description of the time frame which the plan covers;

d) How special circumstances, such as extended absence, new injury or new illness will be handled;

e) The handling of any insurance related matter arising within the prepayment/concierge period;

f) A statement to the effect that the chiropractor makes no claim or representation that a particular treatment, procedure or service, or any combination of treatments, procedures or services, is guaranteed to result in a particular clinical outcome. (233 CMR 4.10: Misrepresentation or Deceit); and

g) A clear exit provision describing under which conditions the agreement can be terminated and how the remaining balance will be accounted including the method and timing of reimbursement if necessary.

4) Early termination

a) The patient should have the right to terminate the pre-payment or concierge plan at any time;

b) The licensee may terminate the prepayment or concierge plan at any time, for good and sufficient cause, except the licensee must ensure that patient abandonment does not occur;

c) It is expected that a licensee will maintain sufficient funds to cover potential refunds of unused repayments. An escrow or similar accounting system should be considered on plans that exceed $600;

d) In event of early termination of a prepayment discount plan by the patient, the maximum fee charged cannot exceed the chiropractor's usual and customary fee for the services rendered;

e) In event of early termination of a prepayment discount plan by the licensee, the discount should be prorated when determining the amount of repayment; and

f) In event of early termination of a concierge plan, the fee for the unused portion should be returned with no penalty.

5) Prepayment plans should comply with all applicable laws and regulations.

References

a) 233 CMR 4.00: Standards of Practice and Professional Conduct

b) 233 CMR 4.08: Overutilization of Practice

c) 233 CMR 4.09: Improper Charges

d) 233 CMR 4.10: Misrepresentation or Deceit

e) 233 CMR 4.11: False Health Care Claims Prohibited

f) 233 CMR 4.12: Improper Solicitations, Inducements or Referrals

g) 940 CMR 26.00: Discount Health Plans and Discount Health Plan Organizations

h) MGL c.175H §3: False Health Care Claims

i) OIG Advisory Opinion: 08-03 regarding prompt pay discounts (Appendix 1)

j) OIG Advisory Opinion: Hospital Discounts Offered To Patients Who Cannot Afford To Pay Their Hospital Bills(Appendix 2)

k) OIG Advisory Opinion: Addendum to Hospital Discounts Offered To Patients Who Cannot Afford To Pay Their Hospital Bills (Appendix 3)

Practice Advisory: Chiropractic Marketing Practices

Date Issued: November 4, 2010

The Massachusetts Board of Registration of Chiropractors (Board) is charged with regulating the practice of chiropractic, including marketing practices by chiropractors, to protect the public from improper solicitations, inducements or referrals. The Board issues this practice advisory to caution licensed chiropractors to ensure that their marketing practices comply with Board regulations.

The Board received a flier from a marketing company that advertised an arrangement where a participating chiropractor would be required to remunerate the marketing company for each patient who is referred, and then presents, to the chiropractor's office. From the flier, it appeared that a participating chiropractor would pay the marketing company only for patients who actually came into the office and opted to receive chiropractic treatment. The flier suggests that the participating chiropractor would not pay the marketing company for prospective patients who opted not to receive chiropractic treatment. The Board is concerned that such a marketing strategy requires a participating chiropractor to pay remuneration for the purpose of inducing a person to purchase or arrange for a service related directly to chiropractic care or services in violation of 233 CMR 4.12(3).

The Board recommends that all Massachusetts chiropractors be knowledgeable of Board regulation 233 CMR 4.12 Improper Solicitations, Inducements or Referrals. Failure to comply with Board regulations may subject the licensed chiropractor to disciplinary action.

This posting serves as a practice advisory only. It does not represent an administrative disciplinary finding by this Board.

 

June 3, 2010
Supercedes: similarly named guideline (dated 8-2-01)

The Massachusetts Board of Registration of Chiropractors (Board) has today voted to adopt the following Policy Guideline. This policy guideline is intended as a recommended protocol for the profession to follow. The guideline set forth below does not have the force or effect of law, as would a Massachusetts General Law or a Board rule or regulation. However, the Board utilizes this and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.

I. Purpose

The Massachusetts Board of Registration of Chiropractors, (the Board) is responsible for licensing Doctors of Chiropractic and ensuring that our licensees follow appropriate standards and protocols in all aspects of the delivery of chiropractic services to the citizens of the Commonwealth. Ensuring that patients receive appropriate information before undergoing chiropractic care is an important part of the Board's responsibility to protect the public.

Patients have the right to control their body and what happens to it. This autonomy relies on the patient being informed about care being proposed and the risks associated with receiving this care. The Board recognizes that nearly all medical treatment has some potential for causing injury to a patient. Performance of a particular treatment or procedure without the consent of a properly informed patient deprives that patient of what they may reasonably expect from such care. It also does not allow the patient to fully understand the inherent risks that may be associated with the treatment or procedure. Finally, it impairs a patient's fundamental right to make decisions about what kinds of care, if any, they wish to undertake. This is the doctrine of Informed Consent.

The Board recognizes that some chiropractors use the terminology "terms of acceptance" rather than "informed consent". It is the Board's view that the standards to be followed are the same even though the nomenclature is different.

II. When Should Consent be Obtained from a Patient?

A licensed chiropractor should obtain the informed consent of his or her patient before carrying out any diagnostic or therapeutic procedure on that patient.

It is impossible for a patient to give his or her consent to undergo a particular treatment or procedure if the treatment or procedure is performed without the patient's knowledge or before the patient fully understands his or her right to either accept or decline the care being proposed.

III. Who Can Give Informed Consent?

(A) Where the patient is an adult, the licensed chiropractor should obtain consent for care from the patient himself or herself.

The adult patient is presumed to be able to give legally effective consent for care unless there are other known factors that the patient is not adequately competent to understand what is being proposed along with the potential risks/benefits. If it is reasonably believed that the adult patient is somehow unable to understand the information being provided, the doctor should inquire whether the patient has a legal guardian or health care proxy with the legal authority to make decisions on their behalf. This concept extends to a language barrier, handicap or disability which may impede the communication and understanding of the patient.

B) Where the patient is a minor, the licensed chiropractor should generally obtain the necessary informed consent from the parent or legal guardian of that minor patient.

The authority to give legally effective consent for care of a minor child typically belongs to the parents or legal guardian of that child. It should be noted that the consent of only one parent is generally necessary to permit treatment, but the doctor should be mindful that child custody disputes often complicate this issue. When consent must be obtained from a party other than the parent of a minor child, it is advisable to ensure that the individual giving the consent is the legally-appointed guardian and has the authority to give such consent. There are certain circumstances in which a minor child may be considered "emancipated" and can give legally effective consent himself or herself. This is generally the case only where the minor child is (1) married, widowed or divorced; (2) the parent of a child himself or herself; (3) a member of the armed forces; or (4) living apart from his or her parents and managing his or her own financial affairs. Practitioners are encouraged to seek the legal advice of private counsel if they have any questions about these issues.

IV. What Information Should Be Disclosed to the Patient?

A) A licensed chiropractor should disclose to the patient all significant clinical information which the chiropractor possesses, or reasonably should possess, which would be material to an intelligent decision by that patient about whether or not to undergo the proposed diagnostic or therapeutic procedure.

For the consent of the patient to be legally effective, the patient must receive sufficient information, in layman's terms, about the proposed procedure, the potential benefits and risks of that procedure, and common alternatives to that procedure including not performing the procedure, to be able to make an intelligent decision about whether or not he or she should undergo the proposed procedure or treatment.

B) In determining what information a licensed chiropractor is expected to possess about the potential benefits and risks of a particular diagnostic or therapeutic procedure, the benchmark is the quantum of information about that procedure typically possessed by the average Doctor of Chiropractor within the Commonwealth of Massachusetts (a state-wide standard).

However, a chiropractor who possesses specialized certification in a particular subject area (e.g., board certification in chiropractic orthopedics, neurology or pediatrics) could be expected to possess a higher amount of information about the potential benefits and risks of treatments or procedures in that specialty area.

(C) In determining what information to convey to a patient about a proposed diagnostic or therapeutic procedure, the licensed chiropractor should include information he or she knows, or has reason to know, that the patient would consider important in making his or her decision about whether to undergo the proposed procedure or not.

Where some jurisdictions apply a "reasonable doctor" standard and others use a "reasonable patient" standard, the comprehensive approach is to disclose risks which are inherent to the proposed procedure if either a reasonable doctor would disclose those risks as being material or a reasonable patient would think those risks are material and therefore important to the patient's decision-making process to accept or reject what is being proposed.

(D) In determining what information to convey to a patient about the risks involved in a particular proposed diagnostic or therapeutic procedure, the licensed chiropractor should take into consideration both the potential severity of the injury or adverse consequences which may result and the likelihood that the injury or consequence will occur.

The question of a particular risk and whether it may be material or not depends on both the severity of the adverse outcome which might occur and the probability that it will happen. A doctor is not required to disclose every single conceivable risk of a proposed procedure, regardless of how remote that risk of injury might be. However, for risks that involve the most serious adverse consequences, as for example paralysis or even death, the more material that risk becomes relative to informing the patient, in spite of the (presumably low) probability.

(E) If a chiropractor has reason to believe that a patient would consider information about a potential risk important in making his or her decision, the licensed chiropractor should not remain silent about that risk; he or she should disclose that information even if that information might prompt the patient to reject the proposed procedure.

The Chiropractic Oath, similar to the Hippocratic Oath, places the needs of the patient as paramount and in deference from any self- preference, curiosity or pecuniary interest of the doctor.

(F) What information a licensed chiropractor should disclose to his or her patient about the potential benefits and risks of a particular diagnostic or therapeutic procedure is not controlled by whether that information is customarily disclosed in similar circumstances.

It is not the customs of a particular health discipline which are decisive; rather it is whether the doctor has reason to know that his or her patient would consider the information important in making a decision about whether or not to accept care. Inherent risks are relative to a designated procedure and become more material relative to the patient's particular circumstance. The relative significance of any risk can not be viewed from any particular profession or society that as a profession or society arbitrarily chooses not to disclose those risks.

G) A licensed chiropractor is not required to disclose information about the potential benefits or risks of a particular procedure or treatment if he or she has reason to believe that the patient already has that information.

A doctor should not be expected to disclose information about particular benefits or risks of a diagnostic or therapeutic procedure if those benefits or risks would be obvious to any reasonable person or if the doctor has a specific, factual basis for believing that the patient in question already knows about those benefits or risks.

(H) Where the option of not doing anything is a reasonable, clinically acceptable option, a licensed chiropractor should disclose information about the likely results of undergoing no care at all in order to fulfill his or her obligation to obtain informed consent.

It is important to explain to a patient that the "no care" option is a viable option.

V. Documentation of Patient Consent

(A) Board regulations 233 CMR 4.05(1)(f) require a licensed chiropractor to include written documentation of "informed consent" in every patient's treatment record.

Documenting the patient's informed consent for chiropractic care is a minimal standard, but aside from that it is the practitioner's best protection against malpractice litigation or patient claims that they have been provided a service which they did not want or ask for.

B) A licensed chiropractor should document patient consent in a manner which acknowledges that:

  • the patient has been part of an informed consent process;
  • the patient received sufficient information about the diagnostic or therapeutic procedures which the chiropractor proposes to use;
  • the material risks have been disclosed to the patient, including a description of those risks; and
  • the patient, after assessment, has accepted (or rejected) the procedure or care understanding the material risks to that procedure.

Informed consent is more of a process than it is a procedure. The Board understands that the use of broad generalized consent forms in which a patient essentially authorizes the chiropractor to use any and all diagnostic or therapeutic procedures, but is not adequately informed about the procedures prior to their use, runs counter to the basic concept of "informed consent".

The process of informed consent should involve a meaningful discussion between the doctor and patient about the care that is being proposed. It should include a frank discussion about the material risks to any recommended procedure which are unique to that patient. It also necessitates that the patient adequately understand and accepts these risks, and agrees to receive the proposed diagnostic or therapeutic procedure.

This process of informed consent could also involve the patient participating in an educational presentation about chiropractic care that includes a description of the procedures that are commonly used in patient care. However, where these presentations are not individualized, they must also include information about the most serious adverse risks that are associated with these procedures. The chiropractor would still need to have a discussion with the patient about the presentation and the procedures the chiropractor is proposing to use. The chiropractor would then assess the patient's understanding of what is being proposed and lastly, elicit the patient's consent to receive the proposed diagnostic or therapeutic procedure.

Finally, whereas it is necessary that a chiropractor have notations in a patient's clinical record reflecting that the patient was advised of the material risks and consented to care, there is no substitute for having the patient's own signed confirmation of those facts.

 

Advisory Opinion on Solo Practice Inspections

The Board of Registration of Chiropractors received a request for an advisory opinion concerning the inspections of solo practices. In addition to responding to that specific inquiry by letter, the Board wanted to make the following information available to all interested parties.

The Board appreciates the importance of balancing the needs of consumer protection with the rights of licensees to practice their professions without undue interference. To that end, the average solo practice verification inspection is typically completed within 10 minutes, and often even less than that. The investigator waits to be acknowledged by staff or the licensee and provides a business card to that person. Typically, the investigator then immediately informs that staff person or licensee of the following:

  • The investigator will wait for the chiropractor to finish with any patient because patient care is not to be interrupted.
  • The chiropractor may dedicate a staff person to assist the investigator in lieu of the doctor.
  • The inspection is general in nature and there has not been a complaint filed against the chiropractor (unless the investigator is in fact on site in response to a complaint).

Below please find questions about solo practice inspections received by the Board and the Board's responses:

  1. Does the Board believe that 233 CMR 4.16 requires a chiropractor to speak to investigators, although that is not listed in the regulation? If so, how is a chiropractor to know that is a requirement?
    Chiropractors are expected to know and comply with all regulations and laws governing the practice of chiropractic in Massachusetts. Section 4.06(18) of the Board's regulations authorizes the Board to take disciplinary action against any chiropractor who fails to "cooperate with the Board or its agent with regard to inspections or investigations." Refusing to allow an investigator to complete the inspection described in 233 CMR 4.16, either by insisting that the investigator come back later or by refusing to speak to the investigator, is a failure to cooperate, and thus constitutes grounds for disciplinary action under 233 CMR 4.06(18). In such a scenario, both 233 CMR 4.16 and 233 CMR 4.06(18) are relevant to allegations against an uncooperative licensee, but the paramount regulation becomes 233 CMR 4.06(18).
  2. Has the Board taken any steps to ensure that site inspections conducted by investigators pursuant to 233 CMR 4.16, do not unreasonably interfere with a chiropractor's patient care and business?
    Yes, both the Board and the Division of Professional Licensure emphasize to investigators the importance of not disrupting patient treatment. Although the unexpected arrival of a board representative can be disconcerting, Board investigators make every effort to make the process as unobtrusive and cordial as possible. When approving the solo practice verification form, the Board ensured that the form was brief and capable of being completed expeditiously. The Division has not received any allegations of unreasonable interference by investigators during an unannounced inspection.
  3. Does the Board expect that a chiropractor will interrupt direct patient care and meet with an inspector as soon as the inspector arrives, thus to the detriment of the patient? If not, is there a reasonable time that the chiropractor can ask the inspector to wait or return e.g., the next available free time in their schedule?
    The Board does not expect a chiropractor to interrupt the care of the patient being treated when an investigator arrives. However, once the treatment of that patient has been completed, the Board expects a chiropractor to take a few minutes between patients to assist the investigator or to identify an available staff person to assist the investigator. It is not appropriate for a chiropractor to request that an investigator wait through multiple patient appointments or return at another time in order to complete his or her investigation. The Board recognizes that unannounced inspections are the most effective means of assessing the true nature of activity at a particular location and the optimal manner of fulfilling the Board's consumer protection mission. Requiring an investigator to wait for a prolonged period or make two trips to the same practice would defeat the unannounced purpose of these verification inspections and constitute an inefficient use of public resources.
  4. How does the Board determine whether a licensed Chiropractor has "cooperated" with an inspection within the meaning of 233 CMR 4.06(18), if there is no requirement that they speak with the investigator under the 233 CMR 4.16? For example, is it acceptable for a chiropractor to make his office space available to the inspector for an office inspection and ask the inspector to return at another time to conduct the interview portion of the inspection? If so, is there a reasonable time that the chiropractor can ask the inspector to wait?
    The Board looks at the totality of circumstances surrounding an inspection to determine if a chiropractor has failed to cooperate with a Board investigator in violation of 233 CMR 4.06(18). The Board considers communication to be an essential component to cooperation. As to the remaining issues raised in this question, please refer to the Board's responses to questions 1 and 3 above.
  5. What safeguards can a chiropractor reasonably expect from the investigators who are performing the inspections to protect any patients from undue anxiety or concern due to the presence of an inspector from "the Board"?
    The Board has never received any report of a patient having "undue anxiety or concern" because of the presence of a Board representative. All site visits are handled as swiftly and unobtrusively as possible. The Board further believes that most consumers expect active oversight of individuals licensed by state or federal government. It would be impossible for the Board to prevent unique individuals from having undue reactions, as by definition undue means unwarranted, unjustifiable, or excessive.

Policy Guideline on the Performance of Chiropractic Supportive Procedures and Therapies by Unlicensed Assistants

The Massachusetts Board of Registration of Chiropractors has voted to adopt the following policy guideline. This guideline is intended as a recommended protocol for the profession to follow. A policy guideline does not have the force or effect of law, as would a Massachusetts General Law or board rule or regulation. The Board utilizes this and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.


Date: April 2, 2009

Policy # 09-002

Purpose:

The Massachusetts Board of Registration of Chiropractors ("the Board") issues this policy to provide guidance to licensees regarding the delegation of supportive procedures to unlicensed assistants.

A licensed chiropractor may permit an unlicensed assistant to perform certain services which do not require licensure, registration or certification, including but not limited to supportive procedures, in a manner consistent with accepted chiropractic standards appropriate to the assistant's skill. In delegating procedures to staff, chiropractors must adhere to all applicable Board regulations, including but not limited to, 233 CMR 4.02 and 233 CMR 4.03. Those regulations prohibit chiropractors from delegating any clinical function for which licensure, registration or certification is required by state law or regulations to any person who does not possess the required license, registration or certification. When delegating permissible procedures, the Board recommends that chiropractors adhere to the following guidelines.

  1. The patient must be properly evaluated by the licensed chiropractor and a determination made that a supportive procedure or therapy is clinically indicated before any supportive procedure or therapy may be applied to the patient by an unlicensed assistant during the same patient visit.
  2. The licensed chiropractor must make all clinical decisions regarding the type of supportive procedure or therapy to be applied, the location to which such supportive procedure or therapy will be applied, and the duration and intensity of the supportive procedure or therapy where applicable.
  3. The licensed chiropractor must generally supervise the unlicensed assistant in the application of any supportive procedure or therapy by being present on the premises and readily available to provide direction and guidance to the unlicensed assistant throughout the performance of the supportive procedure or therapy.
  4. The licensed chiropractor must ensure that the assistant possesses a sufficient level of education and training in the application and use of the supportive procedure or therapy. The licensed chiropractor must maintain written documentation of the education and training possessed by each office assistant regarding the proper application and use of supportive procedures and therapies.
  5. The licensed chiropractor must properly report and code any supportive procedure or therapy in a manner consistent with appropriate reporting and coding requirements.

Policy Guideline on Applicants for Chiropractor of Record

The Massachusetts Board of Registration of Chiropractors ("Board") has voted to adopt the following Policy Guidelines. These policy guidelines are intended as a recommended protocol for the profession to follow. The guidelines set forth below do not have the force or effect of law, as would a Massachusetts General Law or a Board rule or regulation. However, the Board utilizes these and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.

DATE: March 5, 2009

Policy #09-001

This policy guideline revises policy guideline No. 08-001, dated March 8, 2008, with the same title.

Purpose

To provide guidance to licensed chiropractors and owners of chiropractic facilities concerning qualifications to serve as a Chiropractor of Record.

Policy

Chiropractors of Record (CHoRs) are responsible for a Chiropractic Facility's compliance with the laws of the Commonwealth and Board rules and regulations. A licensee on probation or stayed suspension may not be qualified to serve as a CHoR until the probation or stayed suspension has been concluded. The determination of whether a licensee on probation or stayed suspension is disqualified from serving as a CHoR will be made on a case by case basis. In making this determination, the Board will evaluate factors, including but not limited to, the nature of the misconduct underlying the discipline, whether the licensee is the sole owner of the Facility, the number of health care professionals working within the Facility, and whether the Facility will be monitored by a Board-approved monitor during the disciplinary period. If the Board finds that a licensee on disciplinary status is not qualified to serve as CHoR, the licensee may apply to serve as a CHoR at the conclusion of the disciplinary period,. The Board will then review the licensee's disciplinary history, compliance with probationary terms, and evidence of rehabilitation to evaluate the licensee's current qualifications for serving as CHoR at a particular facility.

A licensee with a case that is awaiting a formal adjudicatory hearing (and the case is with the Office of Prosecution of the Division of Professional Licensure) may be denied the opportunity to serve as a CHoR until the case is resolved. The determination of whether to deny will be made on a case-by-case basis. In order to make this determination, the Board will assess factors such as: the nature of the allegations; the evidence against the licensee; and the licensure history of the applicant including but not limited to past disciplinary history.

Board Policy Guidelines on Manipulation Under Anesthesia (MUA)

November 4, 2004

The Massachusetts Board of Registration of Chiropractors ("Board") has today voted to adopt the following Policy Guidelines. These policy guidelines are intended as a recommended protocol for the profession to follow. The guidelines set forth below do not have the force or effect of law, as would a Massachusetts General Law or a Board rule or regulation. However, the Board utilizes these and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.

Manipulation under anesthesia or MUA is within the scope of chiropractic practice in the Commonwealth of Massachusetts as defined by MGL Chapter 112, Sections 89 to 97.

Any chiropractic physician wishing to perform MUA must have completed appropriate coursework in this procedure and be certified in the performance of said procedure.

MUA as a procedure shall only be performed in an appropriate healthcare facility under the direction of a licensed anesthesiologist.

Follow up care shall then be according to established protocols and shall be properly documented.

Board Policy Guidelines Regarding the Use of Advanced Technology in a Chiropractic Office

July 12, 2001

Supercedes: The use of High Tech Equipment in a chiropractic office (dated 5-22-91)

The Massachusetts Board of Registration of Chiropractors ("Board") has today voted to adopt the following Policy Guidelines. These policy guidelines are intended as a recommended protocol for the profession to follow. The guidelines set forth below do not have the force or effect of law, as would a Massachusetts General Law or a Board rule or regulation. However, the Board utilizes these and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.

The Massachusetts Board of Registration of Chiropractors, after reviewing the most recent scientific evidence, including but not limited to information supplied by equipment manufacturers and independent researchers, has adopted the following guidelines regarding the use of advanced technology in the practice of chiropractic.

  1. For purposes of these policy guidelines, the term "advanced technology" includes, but is not necessarily limited to, the following equipment and/or procedures: Paraspinal Electromyography (Paraspinal EMG), Electronic Muscle Testing, Sonography, Thermography, Videofluoroscopy, Plethesmography, and Electronic X-Ray Analysis.
  2. All advanced technology used in a chiropractic office should be certified as meeting the currently applicable federal standards for such equipment. The appropriate federal safety certificates for each such piece of equipment should be conspicuously displayed on the equipment itself or elsewhere in the office.
  3. The protocols for the proper use of any type of advanced technology should be based upon appropriate, generally-accepted professional standards concerning the purpose and intended use of such technology, and the manufacturer's instructions concerning its operation. In determining the appropriate, generally-accepted professional standards concerning the purpose and/or intended use of a particular type of advanced technology, the Board recognizes chiropractic colleges accredited by the Council on Chiropractic Education (CCE), and independent research organization(s) recognized or approved by the Foundation for Chiropractic Education and Research (FCER) or a similar organization, as acceptable sources for such standards. The Board would not consider the manufacturer or any entity that serves within the manufacturer's distribution network as an acceptable source for such protocols.
  4. A physical examination of the patient, utilizing standard diagnostic and testing procedures, should always be performed before ordering the use of any advanced technology. Standard testing procedures may include, but are not necessarily limited to, palpation; neurological, orthopedic, vascular, and/or musculoskeletal studies or tests; radiographic imaging; and inspection of all available diagnostic studies that the patient had previously undertaken. In all circumstances, appropriate standard examination procedures should be exhausted before advanced technology is used, and the results of the standard examination procedures should indicate that the use of additional advanced technology is both appropriate and clinically necessary for proper diagnosis and/or treatment of the patient.
  5. If the clinical information that could be ultimately obtained from the use of advanced technology would be the same as what could be typically determined from a standard testing procedure(s), then the use of the advanced technology would be considered clinically unnecessary by the Board. Advanced technology should be used only if it will contribute significant clinical information which is both reasonably necessary for proper diagnosis and/or treatment of the patient and not reasonably available through use of standard diagnostic or testing procedures.
  6. If advanced technology is used as the exclusive means of documenting a particular diagnosis or evaluation, the chiropractor's treatment records should demonstrate that the same advanced technology was used for all patients with an identical diagnosis or evaluation, regardless of payment source, and that all such patients were charged a similar fee for it. If this cannot be demonstrated, then the chiropractic physician may, at his or her option, utilize the advanced technology, but should not charge for it.
  7. The use of advanced technology for the purpose of performing uniform patient screenings, pursuing or defending against an impending legal action or insurance claim, or simply for the doctor's own edification would be considered clinically unnecessary by the Board. Nevertheless, in such instances, advanced technology may be used and the patient may be charged for the cost of this service if utilization of that advanced technology does not pose a material risk to the patient and there is documentation in the patient's treatment record that the patient has specifically requested the service.
  8. The use of a computer drawing or analysis of x-ray films does not typically give a diagnostic or pathological finding which would not already be observable to the viewing doctor. Therefore, the clinical information that would be obtained from such computer drawings or analyses are presumed by the Board to be of questionable value in the diagnosis or treatment of the patient. Since the doctor can readily obtain the same information by carefully viewing and analyzing the x-ray film directly, any advantage afforded by computer drawings or analyses would be considered by the Board to have been performed solely for the doctor's own benefit and therefore would be regarded as not clinically necessary to the patient. The doctor may use such drawings or analyses, but the patient should not be made liable for the cost of this additional service unless there is documentation in the treatment record that this service has been specifically requested by the patient.
  9. The use of advanced technologies, such as Paraspinal Electromyography (paraspinal EMG), Electronic Muscle Testing, Thermography, Sonography, Videofluoroscopy, Plethesmography and others not specified, would generally be presumed to be clinically unnecessary if: (a) such procedures are being used during the initial trial phase of a condition, and (b) the relevant information available from these tests could typically be determined through standard testing procedure(s). Furthermore, the use of advanced technology of any type would be considered clinically unnecessary if the ultimate potential benefit of using the advanced technology would have no significant effect on the overall outcome for the patient when compared to the outcome obtained without utilization of the advanced technology. This is not meant to imply that these procedures are always invalid in a chiropractic setting, but rather that the Board believes that use of these procedures is of limited potential benefit to many patients in many situations.

The Board reserves the right to modify this policy and/or promulgate a regulation(s) as new scientific evidence is made available. This policy guideline is not exclusively limited to the particular advanced technologies that have been specifically named in this guideline.

Chiropractic Practice Protocol for the Treatment of Non-human Vertebrates

January 18, 2001

Supercedes: Policy Decision (dated May 22, 1991)

The Massachusetts Board of Registration of Chiropractors has today voted to implement the following Policy Guideline. This Guideline is intended as a recommended protocol for the profession to follow. This Guideline is not a Board rule or regulation and therefore does not carry with it the force or effect of law.

A Massachusetts licensed chiropractor may not provide a therapeutic intervention, which may include a vertebral or extra-spinal manipulation and/or supportive procedure(s), on a non-human vertebrate unless:

  1. The location of such intervention takes place within the Commonwealth of Massachusetts but outside of a chiropractor's office or clinic which caters to human patients; and
  2. The chiropractor has obtained a written referral and/or direct authorization from the animal's licensed Veterinarian to do so.

Timely Release of Patient Records

Date: April 5, 2001

Supercedes: General guideline (dated 2-24-00)

The Massachusetts Board of Registration of Chiropractors (Board) has today voted to implement the following Policy Guideline. This guideline is intended as a recommended protocol for the profession to follow. This policy guideline does not carry with it the force or effect of law as would Massachusetts General Law or a Board rule or regulation. However, the Board utilizes this and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.

In accordance with regulation 233CMR 4.05 (Chiropractic Record-keeping) and to ensure the public safety through the proper continuity of patient care and/or right of disclosure, the Board has recommended the following minimal intervals for a timely execution following the receipt of a proper request for patient records.

Document Timeframe
1. Case History * 1-10 days
2. Examination/ Re-examination findings * 1-10 days
3. Special studies/ Radiographic report *
(if reviewed)
1-10 days
4. Radiographic copies *
(if performed)
1-20 days
5. Clinical Impression * 1-10 days
6. Informed Consent * 1-10 days
7. Daily progress notes * 1-10 days
8. Billing Records 1-20 days
9. Discharge summary
(if performed)
1-20 days
10. Narrative report/ Impairment rating
(if performed)
1-30 days

* mandatory patient records required under 233CMR 4.05

Protocol for Investigational Interventions

December 2, 2004

Supercedes: May 3, 2001

The Massachusetts Board of Registration of Chiropractors (Board) has today voted to implement the following Policy Guideline. This Guideline is intended as a recommended protocol for the profession to follow. This Guideline does not carry with it the force or effect of law as would Massachusetts General Law or a Board rule or regulation. However, the Board utilizes this and other guidelines as an internal management tool in formulating decisions that relate to issues of chiropractic practice.

  1. A chiropractic procedure, service, or treatment shall be considered an "investigational intervention" if:
    1. The procedure, service, or treatment is based on existing and generally accepted chiropractic theory or methodology;
    2. The procedure, service, or treatment is not generally taught at any chiropractic college which is accredited by the Council on Chiropractic Education (CCE) or by a university accredited by the U.S. Department of Education in either the undergraduate, predoctoral, or postdoctoral programs;
    3. There is presently insufficient evidence to permit a determination about the appropriateness and/or effectiveness of the use of the procedure, service or treatment because it has not yet been subject to sufficient testing or clinical trials; and
    4. The procedure, service, or treatment warrants further clinical study because it may have sufficient potential clinical benefit for one or more specified patient populations.
  2. A chiropractor shall not perform or provide, or offer to perform or provide, any investigational intervention unless:
    1. Each patient upon whom the investigational intervention is performed has:
      1. been informed that the investigational intervention to be performed or provided is not considered part of the established curriculum of any chiropractic college accredited by the CCE;
      2. been informed that the procedure, service, or treatment is considered an investigational intervention by the Board;
      3. been informed of all of the material risks and benefits of undergoing the proposed investigational intervention; and
      4. consented, in writing, to the performance of the investigational intervention; and
    2. The chiropractor has otherwise complied with all applicable state and federal laws and regulations governing the use of human subjects in health care research activities.
  3. A chiropractor who performs, provides, or offers to perform or provide any procedure, service, or treatment which is not properly within the scope of chiropractic, as defined in M.G.L. c. 112, s. 89, or which does not qualify as an investigational intervention because it does not meet all of the above requirements, may be in violation of 233 CMR 4.06(e), 233 CMR 4.06(p) and 233 CMR 4.10(4), and may be subject to possible disciplinary action by the Board pursuant to 233 CMR 4.06.

Disposal of Patient Treatment Records

January 18, 2001

Supercedes: None. Clarification of 233CMR 4.05

The Massachusetts Board of Registration of Chiropractors (Board) has today voted to implement the following Policy Guideline. This Guideline is intended as a recommended protocol for the profession to follow. This Guideline is not a Board rule or regulation and therefore does not carry with it the force or effect of law.

A licensed chiropractor should maintain a patient's treatment records for a minimum of seven years from the date of the last patient encounter, or until the patient reaches the age of nine (if longer than seven years).

Physical Therapy or Physiotherapy

April 18, 1984

The Massachusetts Board of Registration of Chiropractors (Board) has today voted to implement the following Policy Guideline. This Guideline is intended as a recommended protocol for the profession to follow. This Guideline is not a Board rule or regulation and therefore does not carry with it the force or effect of law.

Advertising in public media shall not include the use of the terms Physical Therapy or Physiotherapy.

Board Policy Guidance To Applicants Of Chiropractic Facilities

August 7, 2008

The Massachusetts Board of Registration of Chiropractors ("Board") has voted to adopt the following Policy Guidelines. These policy guidelines are intended as a recommended protocol for the profession to follow. The guidelines set forth below do not have the force or effect of law, as would a Massachusetts General Law or a Board rule or regulation. However, the Board utilizes these and other guidelines to educate members of the Chiropractic profession and the general public.

Purpose:

To provide guidance to applicants of chiropractic facilities.

Policy:

Effective January 3, 2005, all chiropractic facilities in the Commonwealth were subject to mandatory facility licensure. All facilities that were operational at the time the facility licensure requirement became effective should have applied for or been granted licensure. Consequently, as of the date of this policy, the Board will no longer allow applicants for facility licensure to operate the facility while licensure issues are being resolved. Applicants for a chiropractic facility must wait until a facility license has been issued by the Board prior to operating the proposed facility.

Referenced Sources:
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