They may be viewed and/or copied.
The documents that are posted include:
- Invitation Letter From Joint Commission to
Discuss My Proposals
- Letter from ACA to Fred Beck, D.C.
Demonstrating a Lack of Interest
- Letter From Paul Watson Lambert in Regards
To Meeting With Social Security In Which
I Was Not Invited Or Given Prior Notice Of.
OVERVIEW
Chiropractors are not listed as acceptable medical sources within the Social Security Administration to perform Disability Examinations. The ACA had tried changing that 11 years earlier but their strategy was flawed. Find out how the ACA (The American Chiropractic Association) managed to make lemons from lemonade.
THE CHIROPRACTIC CRUSADER
A ROADMAP TO BECOMING A MAJOR PLAYER IN HEALTHCARE
BY FRED BECK, D.C.
Fighting For the Right to Perform Social Security Disability Examinations
Part 1 of 4
Back in the year 1998, a friend recommended that I contact the Social Security Administration so that I could get listed for performing disability examinations with them. To my dismay, I received information that Chiropractors were not listed as an “acceptable medical source” to perform disability examinations for the Social Security Administration. In Case Development Procedures (DI 22505 003b.2) Chiropractors are listed as “other sources of information”, but evidence from an “acceptable medical source” is required to establish the existence of a medically determinable impairment(s). Chiropractors may be utilized to provide insight into how an impairment(s) affects the claimant’s ability to function. According to the sources I spoke to, Chiropractors are rarely used since they are not considered an “acceptable medical source”.
In a memo titled, “Why We Don’t Select Treating Chiropractors To Do CE’s (consultative examination)” , the memo states “20 CFR 404.1519g provides, among other things, that we will purchase a CE only from a qualified medical source and that the medical source may be the claimant’s own physician or psychologist, or another source. By “qualified”, we mean that the medical source must be currently licensed in the State and have the training and experience to perform the type of examination or test, we will request. Chiropractors do not have the degree of medical training and education needed to provide the full range of evidence that we require to evaluate disability.”
The memo goes on to state, “20 CFR 404.1519h provides that, when in our judgment the claimant’s treating physician or psychologist is qualified, equipped, and willing to perform the additional examination or tests for the fee schedule payment, and generally furnishes complete and timely reports, the treating physician or psychologist will be the preferred source to do the CE. This regulation does not apply to a chiropractor because a chiropractor is not a physician. Under our regulations, therefore, it is solely our decision on who is selected to do a CR. We have no obligation to select a claimant’s treating chiropractor.”
In correspondence from Alan Zatz at the Social Security Administration (SSA) Office of Disability in Baltimore, Maryland to the Atlanta office, he writes, “We do not intend to change our policy that chiropractors are not acceptable medical sources whose evidence can be used to establish the existence of a medically determinable impairment. Additionally, even if SSA were to recognize chiropractors as acceptable medical sources, under the regulations that govern our policies on the consultative examination (CE) process, the State disability determination services would not be obligated to use chiropractors as CE sources.”
Now lets go back in time a little to 1987 to review some correspondence between the American Chiropractic Association and the Social Security Administration. In a October 29, 1987 letter from the American Chiropractic Association to Dorcas Hardy, Commissioner of Social Security, W.Randall Rawson, ACA’s director of governmental relations writes, “Earlier this year, Administrative Law Judge Herbert Rosenstein, in a Decision pertaining to a Claim For Period of Disability and Disability Insurance Benefits, said the following, “The only medical evidence from a treating source is from Dr. Sherman, the claimants’ chiropractor. The administrative law judge places little weight on this report since he is not considered an “acceptable source” according to section 404.1513.” W. Randall Rawson goes on to write, “Inasmuch as the claimant in this case was seeking determination of a Period of Disability and Disability Insurance Benefits as a disabled individual due primarily to musculoskeletal-related impairments makes the “unacceptablility”of the doctor of chiropractic as an “acceptable” treating source particularly outrageous and obnoxious.”
In a November 18, 1987 letter from Dorcas R. Hardy, Commissioner of Social Security, in response to a letter from the American Chiropractic Association (ACA), Hardy writes, “While chiropractors may be licensed by the State, they do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability. Thus since the law requires that a disabled person have a “medically determinable” impairment, evidence from a physician or osteopath licensed to practice medicine and surgery is given greater weight than evidence from other health care professionals.” In reality, the Social Security procedures manual does not at all state that the medical physician or osteopath that they utilize practice surgery. The ACA’s response to Commissioner Hardy’s letter on December 3, 1987 included the following, “with respect to disability claims pertaining primarily to musculoskeletal related impairments, a doctor of chiropractic – by virtue of his specialty training in that area – should be accorded the same “acceptable source” status as that accorded to psychologists and optometrists for impairments within their specialty field. Your regulations (again, 20 CFR404.1513) currently give information from psychologists and optometrists (to a more limited degree) the same weight as that submitted by physicians and osteopaths.”
In a letter to the Office of Public Inquiries, in response from an inquiry from the American Chiropractic Association, from the Office of Disability dated May 6, 1992, the following statement occurs again, “Chiropractors do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability.”
Lets get back to 1998 when I began my own quest to obtain authorization to perform Social Security Disability Examinations. I began by contacting the local office of the Social Security Administration that was quite sympathetic to the unfairness that existed in regards to Chiropractors performing disability examinations. I was of course given the standard policy explanation that all branches of the Social Security Administration have been directed to give, “Chiropractors do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability.” Of course no one can provide specifics as to explaining what part of a chiropractors education is deficient to perform such an examination. This story continues in my next column.
THE CHIROPRACTIC CRUSADER
A ROADMAP TO BECOMING A MAJOR
PLAYER IN HEALTHCARE
BY FRED BECK, D.C.
Fighting For the Right to Perform Social Security Disability Examinations
Part 2 of 4
As I reported in my last column, records from 1987 demonstrate the frustration that the American Chiropractic Association endured when dealing with the Social Security Administration. I reported that the ACA would continually be told that, “Chiropractors do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability.” The local branch of the Social Security Administration told me the same thing. Unfortunately, the Social Security Administration could not provide an explanation as to how a Chiropractors education is deficient.
After first contacting the local chapter of the Social Security Administration, I was next referred to a Senior Management Analyst II at the Florida Department of Labor and Employment Security, Office of Disability Determinations, in Tallahassee, Florida. I was told once again, “Chiropractors do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability”. When asked for specifics, he could not provide me with any.
My next step was to contact the Regional Commissioner of the Social Security Administration located in Atlanta, Georgia. I wrote him that I was tired of hearing the same pat answer from everyone I spoke to from the Social Security Administration, “Chiropractors do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability” I made it clear that I was upset that no one seemed to know exactly how a Chiropractors education was deficient to perform such an examination. How could the Chiropractic profession remedy this deficiency in education and training at its’ institutions of higher learning if no one from the Social Security Administration could tell us what the deficiency actually was? My letter continued to discuss topics such as the comprehensive education that Chiropractic students receive and the AMA antitrust suit. In addition I wrote, “I was born in the U.S. My parents were born in the U.S. I think as an American Citizen, I deserve the right to know, why the Social Security Administration considers Chiropractors unqualified to perform disability examinations.” I went on to demand, “I am demanding a fair and equitable number of Chiropractors to be added to panels across the U.S. Doctors of Chiropractic are fully trained to perform such testing, and failure to utilize such doctors to do such disability examinations is clearly unfair, and should be considered a deliberate attempt to restrain trade and competition in the market place. I look forward to performing consultant examinations for the Social Security Administration in the very near future.” The Regional Commissioner in Atlanta, Georgia was also quite sympathetic to the unfairness of the system in regards to how Chiropractors were treated in the system. In a letter to the SSA in Baltimore, Maryland, dated May 18, 1998 he asks, “Dr. Beck is a Chiropractor in the state of Florida. He has expressed interest in performing consultative examinations for the local DDS. Our regulation in CFR 20, 404 1513 (April 1, 1997) lists Chiropractors as other sources of medical evidence, which may help us understand a claimant’s impairment, whereas physicians, osteopaths and psychologist are listed as acceptable sources. In the present climate of wide ranging health care, I was wondering if we are now permitted to purchase Chiropractic consultative examinations. Your comments on this will be appreciated.”
In a letter dated September 28, 1998 to me from the Regional Commissioner in Atlanta, Georgia, he writes, “As you may know, the regional office here is involved in policy, although our role is to help interpret and implement policy rather than to make it.” He goes on to say, “In order to research this fully, central office has written to the national chiropractic association for background information on the training their members receive.” Since it was not clear which chiropractic organization the SSA intended to contact, if any, I was not taking any chances, so I gave the SSA a list of contacts in a October 5, 1998 correspondence from me. I supplied two contacts with phone numbers; Tom Dailey, General Counsel of the ACA and Paul Lambert, legal counsel to the Florida Chiropractic Association.
In my next column, I will continue telling you about my quest to obtain status with the Social Security Commission allowing Chiropractors to perform disability examinations within the Social Security system.
THE CHIROPRACTIC CRUSADER
A ROADMAP TO BECOMING A MAJOR PLAYER IN
HEALTHCARE
BY FRED BECK, D.C.
Fighting For the Right to Perform Social Security Disability Examinations
Part 3 of 4
In my last two columns I told you about my quest to obtain status within the Social Security Administration allowing Chiropractors to perform disability examinations within the Social Security system I wrote that the Social Security Administration would always give the same response, no matter which office or whom you had spoken to. The pat answer that they would give would be, “Chiropractors do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability” The Social Security Administration could or would not explain to me exactly in what way a Chiropractors education was deficient, that they could not provide a competent disability evaluation. I also reported that the American Chiropractic Association also came across the same problem when trying to deal with the Social Security Administration in 1987.
In a letter from Myrtle S. Habersham at Social Security, dated July 2, 1999, Ms. Habersham wrote to tell me that Central office had contacted the following sources for materials on the extent of training and education chiropractors receive: Horace C. Elliott, Executive Director for the National Board of Chiropractic Examiners; Dr. Preston Fitzgerald, Executive Director for the National Board of Forensic Chiropractors; Tom Daily, general counsel of the American Chiropractic Association; and Paul Lambert, Legal Counsel of the Florida Chiropractic Association. Her letter states, “Central Office’s review and analysis of the materials from those sources led to the conclusion that our current policy should not be changed. They found that there are differences in the training and experience of physicians and chiropractors, particularly in the area of treatment modalities.”
In a letter to Paul Lambert, legal counsel to the Florida Chiropractic Association, dated July 7, 1999, I write, “Trust me; no one in the Social Security Administration actually knows exactly what training chiropractors are deficient in to provide such services. The correct approach to take has appeared from the start to be one of backing them into a corner. We are qualified and that is that. They should be obligated to show cause why we are not being allowed to perform such examinations. How exactly are we not qualified? At this point it is not our burden of proof, or of any clear benefit, to prove that we are qualified to perform such examinations. It is the Social Security Administrations burden of proof to justify their present position that we are not qualified.”
In a letter from me dated July 7, 1999 to Myrtle S. Habersham, at the SSA Atlanta, Georgia office, I write, “Once again the real issue has not been addressed. My question remains, “How am I not qualified?” My letter is in response to her July 2, 1999 letter stating that current policy should not be changed. I also in my letter once again demand that Chiropractors be added to SSA panels across the country. I also bring up the subject of the apparent attempt to restrain trade and competition in the market place. My letter also demands a copy of this review and an accounting as to whom in the SSA central office actually performed the review.
In a July 29, 1999 response to my July 7, 1999 letter, Ms. Habersham writes, “We regret that our earlier response was taken to be a statement about qualification, because we are duly respectful of your credentials as a Chiropractic Physician. As we indicated earlier, our national regulations, i.e., Title 20 of the Code of Federal Regulations, Sections 404.1513/416.913, have been found to restrict the purchase of medical evidence from chiropractors. We have referred your recent letter to our central office in Baltimore, Maryland. We will provide you with a further response when it is received.”
On December 13, 1999, Paul Watson Lambert, the FCA general counsel wrote an excellent letter to Clifford Lawrence at the Social Security Administration, Office of Disabilities, in Baltimore, Maryland. The letter outlined our qualifications; and legal and statutory examples of our diagnostic authority.
On December 20, 1999 a meeting occurred between representatives of the American Chiropractic Association and the Social Security Administration (See letter by Paul Lambert dated December 20, 1999). The meeting went quite bad for Chiropractic. A follow-up meeting was proposed for February of 2000. Because of the failure to achieve any positive changes at the first meeting, representatives of the Chiropractic profession decided to scrap the follow-up meeting that would have been held in February 2000.
Whether the December 20, 1999 meeting could have had a better outcome, we will never know. I do know that I had made many excellent personal contacts at the local, state, and regional level. Many of these contacts felt strongly that Chiropractors should be allowed to perform Social Security Disability Examinations. I believe that a number of my SSA contacts would have testified on our behalf at the central Baltimore, Maryland office. In fact my timing would have been great. One of our staunchest supporters from the Atlanta regional office, the Regional Commissioner had retired prior to the December 20, 1999 meeting, and had nothing to lose by testifying on our behalf.
Alright doctors, if you have made it this far through my column, please sit down. I have some more disturbing news. I never received advance notice that there would be a meeting on December 20, 1999. I had not been invited to the meeting. We should have taken the stance at the meeting that it was the Social Security Administrations burden of proof to justify their present position that we are not qualified. The Social Security Administration was not prepared to justify their position. Instead we chose to try to prove to the SSA that we were qualified. The SSA really did not care if we were qualified or not. They really had no intention of making changes if they did not have to. Their weakness was that they could not justify their patent statement that, “Chiropractors do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability”. The opposition had a weakness and we failed to take advantage of that weakness.
Why the ACA never invited me to the December meeting, I will never know. Why they did not utilize the help of supporters of Chiropractic within the ranks of the Social Security Administration, I will never know. I was never looking out for personal self- interests but for the interests of the entire chiropractic profession. Just like the hospital fiasco I described in earlier columns, the powers to be in our profession let me down, and let the entire profession down.
I have not been a member of the American Chiropractic Association for many years. I am not a member of any of the national chiropractic associations. I have not been a member of any national chiropractic association for approximately twenty years. As a member of a national organization, my thoughts were that I would be professionally obligated to utilize my organization to speak on my behalf. Not being a member of a national chiropractic organization, I believed gave me the flexibility to directly contact organizations such as the Social Security Administration and the Joint Commission of Accreditation of Hospitals, to voice my concerns. I did learn from my experience that either the ACA does not have a clue as to what they are doing in terms of expanding practice rights for Chiropractors or they just plain don’t care. Can one chiropractor make a difference? Of course……..not!
In my next column we will be assessing the damage created by the American Chiropractic Associations mishandling of the Social Security Disability Examination issue. I will refresh your memory as to the ACA’s total lack of interest in expanding practice opportunities for Chiropractors into U.S. hospitals. I will tell you about my last ditch effort to try to make lemonade out of the lemons.
THE CHIROPRACTIC CRUSADE
A ROADMAP TO BECOMING A MAJOR PLAYER IN
HEALTHCARE
BY FRED BECK, D.C.
Fighting For the Right to Perform Social Security Disability Examinations
Part 4 of 4
As I discussed in my last column, a meeting that was held between representatives of the American Chiropractic Association (ACA) and the Social Security Administration (SSA) in December of 1999, pertaining to the performance of disability examinations by chiropractors, had a terrible outcome. The meeting was so bad and frustrating for the ACA, that they decided not to follow-up with a February 2000 meeting that had been agreed upon by both sides. The ACA appeared to utilize the same exact strategy as they had used in their 1987 correspondence with the SSA. This strategy did not work in 1987 and to ACA’s surprise; it did not work at the 1999 meeting with the SSA. The ACA was confused. They had used this strategy before with negative results, but who would ever guess that utilizing this same exact strategy would result in exactly the same negative outcome?
It is bad enough that the ACA did not invite me or my pro-chiropractic SSA contacts to the December 1999 meeting, but now our profession had taken a few steps backward instead of the intended leap forward. The SSA now knew that they had the upper hand since we could be easily intimidated. I wrote another letter to the Atlanta regional office on January 21, 2000. I demanded once again as I had before that I wanted a clarification as to exactly why, “Chiropractors do not have the degree of medical training and education needed to provide the full range of information that we require to evaluate disability.” I once again demanded that Chiropractors be allowed to immediately begin performing disability examinations for the SSA. I wrote, “From feedback that I have received regarding the December 20, 1999 meeting between Chiropractic officials and Social Security administrators; it appears that although Social Security administrators are well aware that their stance against Chiropractors performing examinations for them is arbitrary, indefensible, anticompetitive, and without merit; they are unwilling to admit to this and move forward.” In addition, I wrote, “Restraining trade and competition in the marketplace should not be the purpose of the SSA. A Federal Government agency should not be party to violation of antitrust laws.”
A response to my letter dated February 1, 2000 from the Regional Commissioner of the SSA in Atlanta, Georgia states, “Central office informed us about a meeting that was held last month in Baltimore between representatives of the American Chiropractic Association (ACA) and members of Social Security. The purpose was to discuss the request from ACA to reconsider using chiropractors to perform CE’s, which included the issue that you have raised. We understand that there was agreement about the possibility of a further discussion of this matter.”
On April 26, 2000, I had a telephone conversation with Bill Anderson, the SSA Division Director for Medical & Vocational Policy at SSA central headquarters in Baltimore, Maryland. After talking to Mr. Anderson, I really was not a very happy camper. My five-page reply to Mr. Anderson on April 27, 2000 wasn’t the most diplomatic letter ever written. Actually, it wasn’t really the time for diplomacy. At times it is best to keep a cool head, but at the same time fight arrogance with arrogance. That is, as long as you also sprinkle in a little sarcasm. In my letter to Mr. Anderson, I wrote, “Thank you once again for talking to me on the phone on April 26, 2000. I’m sure you had much more important things to attend to at the time. I was very impressed with your lack of concern in answering my complaints regarding the failure to allow qualified physicians, that graduate from Federally and Regionally accredited Chiropractic Colleges from performing Social Security Examinations. At a time when public officials and government agencies are being scrutinized to make sure that they are accountable to the public they serve; it is refreshing to see a public official such as yourself buck the trend.” I also write, “Social Securities response for the past two years to my complaints has been the same line over and over again: “Chiropractors are not qualified to perform Disability Examinations.” My question that I continue to ask the Social Security Administration, “Why are we not qualified?” …And what is Social Securities response to this question? “Because Chiropractors are not qualified to perform Disability Examinations.” I love circular reasoning, but it is beginning to get quite old.” In my letter I go on to discuss a comment by Mr. Anderson, that regionally, local Social Security offices can decide on their own to utilize Chiropractors. In my letter, I write, “When I asked if you would be willing to clarify to the local Social Security offices that Chiropractors can be utilized by the Social Security Administration; you made it clear that you do not have to do that. The fact is that Chiropractors throughout the country are being prevented from performing testing that they are qualified to perform. How the rules are written, local Social Security offices do not see themselves as having authority to enroll Chiropractors to do such examinations. In fact the Central Office has gone out of their way to ensure that local and regional Social Security offices interpret the rules to deny Chiropractors access into the system. How else would you explain the fact that the Central Social Security Office refused to answer an inquiry by Gordon M. Sherman (now retired), the regional commissioner for the Social Security Administration in Atlanta, Georgia. In Mr. Sherman’s May 18, 1998 memorandum (refer to S2D4 / PJ2-1419) to the Associate Commissioner for Disability, and the Deputy Commissioner for Operations he wrote, “In the present climate of wide ranging health care, I was wondering if we are now permitted to purchase Chiropractic consultative examinations. Your comments on this will be appreciated.” “
Well, my April 27, 2000 letter resulted in a reply from Bill Anderson on May 23, 2000. Finally after two years, Bill Anderson, on behalf of the central Social Security Office, provided an explanation as to why he thought Chiropractors should not be utilized for Social Security Disability Examinations. A copy of that letter appears with this article. Reasons he gave for denying Chiropractors the opportunity to perform SSA disability examinations included: limited scopes of practice in many states; Chiropractors do not perform surgery or prescribe medication; lack of experience with non-neuromusculoskeletal conditions; length of education and training; that the American Academy of Disability Evaluating Physicians does not allow D.C.’s to be certified by their organization; the military does not reimburse for chiropractic services; Medicare’s limited reimbursement to Chiropractors; limited ordering of blood tests and special studies by Chiropractors; and the limited use of specialized imaging studies.
I replied with a five-page rebuttal letter on June 11, 2000 that challenged most of the so-called facts in Mr. Andersons previous letter. My reply included accurate information on typical classroom hours at Chiropractic colleges; clinical internship programs; specialty programs; vast variety of courses taken; National Boards; our competency in differential diagnosis and all recognized and appropriate diagnostic procedures; our utilization of specialized procedures when indicated; and our diagnostic authority in the State of Florida. I even mentioned the popularity of the reference book, “Essentials of Skeletal Radiology” by Dr. Terry Yochum, a board certified Chiropractic radiologist.
What did I do next? Believe me, it was finally time to give up. Time to throw in the towel. I called it quits. Being a Chiropractic crusader can really take its toll. Especially when you put your heart into one of your crusades, look behind you, and realize that you don’t have any troops backing you up. After a while, you even wonder if anyone even cares about your crusade. Is my vision of the future of the Chiropractic profession the same as a majority of the profession? Maybe no one shares my same visions. These are the questions you ask yourself. I was to the point where it seemed no one else really cared. I spent countless hours attempting to achieve a goal; which then was sabotaged by the powers to be in my own profession. I figured that it was just time to give up on this crusade.
My next series of columns will focus on an opportunity to expand our practice opportunities in sports that we are not presently following through on.
PRINTER FRIENDLY SOCIAL SECURITY
ARTICLES IN FILE SHARING SECTION
