Don't Pay or Contract in Advance for
Chiropractic Visits at a "Discount" Price

Stephen Barrett, M.D.

Many chiropractors offer contracts under which patients pay in advance or agree to pay for many visits at a "discount" price. I have seen contracts for as many as 100 visits. Chiropractors who offer them typically tell all patients that long-term care is needed to prevent recurrence, spinal degeneration, or various serious viseases. Some chiropractors display a chart of "subluxation degeneration" or "spinal decay" that they say is inevitable without intensive and/or long-term care. All such advice represents overselling. Even if chiropractic treatment can legitimately help a problem, it is not possible to know in advance that a large specified number of visits will be needed.

In addition to excessive visits, contracts often contain provisions intended to discourage quitting. Some say that if treatment is stopped before all of the visits are used, the discount will be cancelled and visits used will be figured at their "full" price. Some contracts also call for an "administrative fee" for early stoppage.

Payment Arrangements

Three types of payment arrangements are common:

  1. Installment payments to the chiropractor
  2. Advance patient to the chiropractor
  3. Use of a "health care credit card" in which the chiropractor gets paid by a loan company and the patient is obliged to repay the loan company

Installment payments pose the least risk because patients who stop "early" are unlikely to be forced to pay for more services than they have received. The amount of money is usually too small to make a lawsuit practical, and failure to pay medical bills will not affect a person's credit rating. Full advance payment is more risky because if the chiropractor refuses to make an appropriate refund for unused services, it may be difficult to obtain one. Third-party financing through a credit agency is very dangerous because no matter what happens between the patient and the chiropractor, the patient remains legally bound to repay the loan and failure to repay can seriously damage a person's credit rating.

Many chiropractors encourage patients to finance the contracted amount through CareCredit, a company that pays the chiropractor (minus a small fee) upfront and then collects from the patients. The process is typically described as an interest-free loan or interest-free credit plan. However, if payments are late, the interest and other fees can be very high. Some patients are led to believe that the chiropractor was simply extending credit with a payment plan. However, the CareCredit plan is a "non-recourse" loan from what the law would regard as an independent loan company [1].

The worst contract I have seen included a provision that the patient is responsible for any legal fees incurred by chiropractor for collection of any unpaid balances. That means they wind up in court and the patient loses, the patient could be faced with a large legal bill.

Contract-Related Legal and Regulatory Actions

In 2008, in response to complaints from patients, the Maryland Board of Chiropractic and Massage Therapy Examiners advised chiropractors not to use "extended treatment contracts":

A licensee is free to use whatever patient contract he/she desires provided that the contract is clear, fair, and may be terminated at any time for any reason, without penalty by the patient. If a contract unduly restricts a patient to commit for extended periods of treatment requiring penalties for termination, the contract is unconscionable and considered as unprofessional conduct by the Board. Licensees must carefully assess binding a patient to an extended care contract since parameters of care, patient health and patient desires change as time goes by. For example, a patient may simply not like the personality or treatment methods of the licensee. In such cases, the patient must have the free, unfettered and unobstructed right to terminate the patient care contract for any reason and at any time without penalty. The Board has received numerous complaints from patients regarding the unfair use of such contracts. For these reasons, the Board strongly advises licensees to refrain from the use of long-term, extended treatment contracts.

During the same year, the Maryland Board issued a consent order that placed Andrew Joyce, D.C. on probation for three years, fined him $9,000, and required that his practice be monitored. The order described how Joyce had contracted to provide long courses of treatment but failed to adequately document the need for the treatment, what took place during many of the visits, the patient's status at each visit, and what treatments were administered during each visit. The board also found many improprieties in Joyce's insurance billings [2].

In 2007, the Kansas State Board of Healing Arts charged Bradley Eck, D.C., of Wichita, Kansas, with unprofessional conduct. The complaint stated that he engaged in deceptive advertising and used improper contracts under which patients paid "discount" prices in advance for multiple visits but would receive no refund for visits that were not used [3]. In February 2009, the case was settled with a consent order under which Eck must pay investigative costs plus a $5,000 fine; serve probation for two years; and provide full refunds to patients listed in the complaint who did not receive all of the treatments for which they contracted [4].

That same month, a small claims court judge voided the contracts between chiropractor Donald Harte and two former patients who sued Harte in Marin County, California. Gertrude West, a retired attorney, had sought help for knee pain but was advised to have intensive care for “subluxation degeneration” of her spine. She contracted for 100 visits with a discount for advance payment but severe penalties for discontinuing. After 49 visits over a 4-month period, she concluded that she was not being helped and asked that payment for the unused visits be refunded. When Harte refused, she filed suit. The judge concluded that (a) West had been misled, (b) the penalty clause was "unconscionable," and (c) West was entitled to a $6,401 refund, plus the cost of the suit [5]. The other former patient, Victoria Pollock-Grasso of Tiburon, objected to Harte charging a $559 "administrative fee" when she decided to stop seeing him. Grasso said she stopped because an orthopedist she consulted for a second opinion said she had degenerative disc disease in her cervical spine and that Harte's manipulation of her neck could cause her to have a stroke [6]. Harte appealed the West ruling, asserting that the contract was enforceable and that he was entitled to reasonable compensation for services rendered. The small claims appeal judge reduced the award to $4,589.00 plus costs of $75.00. The judge did not explain how he decided what was "reasonable," but he clearly agreed that the contract was not.

Documents from the case show how Harte used scare tactics. His "report of findings" is a pre-printed form with fill-in sections such as:

The bottom of the form contains "recommendations for initial intensive care," with blanks to fill in the number of visits per week, and a statement that the speed and degree of eventual recovery are influenced by consistency in following the recommendations. The contract called for 92 regular visits at $97 each ($55 Medicare discount price) and 8 "progressive examination visits" @ $250 each—said to be a total value of $7,080 for a discount price of $6,354 if paid in advance. It goes on to say, however, that if care is stopped before completion, services will be charged at regular prices and a 10% "administrative fee" would be added.

In 2009, the Minnesota Attorney General and Minnesota Board of Chiropractic Examiners filed a lawsuit accusing Express Health of Lakeville, Minnesota and its owner Cory Couillard, D.C. of engaging in predatory lending practices [7,8]. The suit alleged:

The Attorney General's office also published a Consumer Alert cautioning patients to be wary of high-pressure sales pitches using health care credit cards [9]. After the lawsuit was settled, the Minnesota licensing board suspended Couillard's license [10].

In 2011, the Minnesota Board suspended the license of Jeffrey Styba, D.C. for improperly enrolling patients into credit card plans, overbilling them, ordering unnecessary services, and failing to keep adequate records. The board noted that when enrolling patients in a CareCredit plan, Styba or a staff member would complete the application form online and routinely claim an annual income at or above $120,000. Rather than inquiring about the patient's income, he or his staff would just "plug in a number." Styba was ordered to pay a $30,000 administrative fine and pass an examination in ethics and boundaries. When he did neither, the board extended his suspension and in 2014 canceled his license [11].

The South Dakota Board of Chiropractic Examiners has banned the use of prepayment contracts and taken disciplinary action against at least three chiropractors who used them:

In 2013, the Texas Board of Chiropractic Examiners fined Randall Johns, D.C. $1,000 and ordered $590 restituition to a former patient who had paid $2,675 in advance but stopped before having all of the treatments, and was not reimbursed for the treatments not received [16].

A Florida law enacted in 2012 limits the amount that a chiropractor can hold in trust to $1,500. That should prevent Florida chiropractors from collecting full contract amounts in advance from patients who pay directly. However, contracts with installment plans can still be used [17]. That same year, David Yachter and the Florida Board of Chiropractic Medicine signed a settlement agreement under which he was reprimanded, ordered to pay a $6,000 fine plus $5233.31 for costs, placed on probation for 2 years, and required to take continuing education courses in risk management, record-keeping, and coding [18]. The agreement settled charges that (a) he had improperly recomended that an 87-year-old patient undergo treatment that included 80 spinal adjustments, (b) the patient paid $3,034.50 in advance to get a discounted price and (c) Yachter had failed to follow proper trust accounting procedures for the payment [19].

Michael McClain, D.C., who operates Vital Energy Chiropractic in Helena, Montana has been disciplined by the Montana Board of Chiropractors for marketing treatment plans with 72 or 80 prepaid visits. In 2013 and 2014, he settled complaints by revising his procedures to separate recommendations for "medically necessary/corrective care" from those for "wellness/maintenance care." He is also required to administer an informed consent form that specifies that his wellness/maintenance plan "makes no representation that any treatment it offers will cure or prevent any condition, disease, or event, other than vertebral subluxation." [20] In 2014, the Montana board also reprimanded his wife, Terah McClain, D.C., for her involvement with one of the patients [21].

Government Actions Involving CareCredit

In 2013, the Financial Protection Bureau ordered GE Capital Retail Bank and its subsidiary, CareCredit to refund up to $34.1 million to potentially more than 1 million consumers who had been victims of deceptive credit card enrollment tactics [22]. The agency's press release noted that at professional offices around the country, consumers were signed up for CareCredit credit cards they thought were interest free, but were actually accruing interest that would kick in if the full balance were not paid at the end of a "promotional" period. The settlement also called for better disclosures [23]. Earlier that year, GE Capital Retail Bank and CareCredit settled a lawsuit by the New York Attorney General by agreeing to similar safeguards (plus a few others) and payment of $125,000 to cover the costs incurred during the investigation and monitoring of the matter [24]. The documents in these cases did not mention whether chiropractic offices were involved, but I assume they were.

My Advice to Consumers

The best way to avoid being tricked is to stay away from tricksters. In line with this, I have published a list of warning signs that are associated with overselling [25]. The most important are "free examinations" and recommendations to treat "subluxations." If you have signed a chiropractic contract of the type described above and later conclude that keep the following mind:

References

  1. Frequently asked questions. CareCredit Web site, accessed Nov 13, 2009.
  2. Final consent order. In the matter of Andrew Joyce, D.C. Maryland State Board of Chiropractic Examiners Case No. 05-32C, June 12, 2008.
  3. First amended complaint. In the matter of Bradley Eck, D.C., Kansas State Board of the Healing Arts, KSBHA Docket No. 0-HA00095, filed Aug 24, 2007.
  4. Consent order. In the matter of Bradley Eck, D.C., Kansas State Board of the Healing Arts, KSBHA Docket No. 0-HA00095, filed Feb 25, 2009.
  5. Decision. West v. Harte, Feb 19, 2009.
  6. Halstead R. Corte Madera chiropractor ordered to pay 2 patients more than $7,000. Contra Costa Times, Feb 28, 2000.
  7. Swanson, board sue chiropractic clinic for predatory lending involving health care credit cards. Press release, Minnesota Attorney General, Aug 12, 2009.
  8. Summons. State of Minnesota v. Express Health, P.A. and Cory D. Couillard. First Judicial District Court, Aug 12, 2009.
  9. Be wary of health care credit cards. Minnesota Attorney General's Office. Consumer Alert, Aug 12, 2009.
  10. Stipulation and order. In the matter of Cory Dean Couillard, D.C. Before the Minnesota Board of Chiropractic Examiners, April 8, 2010.
  11. Barrett S. Jeffrey M. Styba, D.C., loses chiropractic license. Casewatch, Feb 8, 2016.
  12. Order and consent agreement. In the matter of the license application of Josh G. Biberdorf, DC. South Dakota Board of Chiropractic Examiners, Sept 30, 2011.
  13. Order and consent agreement. In the matter of the license of Jayson D. Snyder, DC. South Dakota Board of Chiropractic Examiners, March 9, 2013.
  14. Order and consent agreement. In the matter of the license of Bryan Williams, DC. South Dakota Board of Chiropractic Examiners, Jan 23, 2014.
  15. Garrigan M. State board reprimands chiropractor for billing practice. Rapid City Journal, Dec 26, 2011.
  16. Agreed final order. In the matter of Randall Johns, D.C. Texas Board of Chiropracfric Examiners, Aug 15, 2013.
  17. Florida CB/HB B 413. Effective July 1, 2012.
  18. Settlement agreement. Department of Health v. David Evan Yachter, D.C. Case No. 2011-10582, Aug 20, 2012.
  19. Administrative complaint. Department of Health v. David Evan Yachter, D.C. Case No. 2011-10582, March 29, 2012.
  20. Barrett S. Disciplinary actions against Michael McClain, D.C. Casewatch, Aug 18, 2015.
  21. Stipulation and final order. In the matter of Terah McClain, D.C. Before the Montana State Board of Chiropractic Examiners Case No. 2011-CHI-LIC-11, April 4, 2014.
  22. Consent order. In the matter of GE Capital Retail Bank, CareCredit LLC. Administrative proceeding file No. 2013-CFPB-0009, Dec 10, 2013.
  23. CFPB orders GE CareCredit to refund $34.1 million for deceptive health-care credit card enrollment. Consumer Financial Protection Bureau news release, Dec 10, 2013.
  24. Assurance of discontinuance under New York Executive Law Section 63, Subdivision 15. In the matter if GE Capital Bank and Care Credit LLC. Assurance No. 12-103, June 2013.
  25. Barrett S. Tips on choosing a chiropractor. Quackwatch, Oct 13, 2000.
  26. Carter Cl. Consumer Protection in the States: A 50 State Report on Unfair and Deceptive Acts and Practices Statutes. National Consumer Law Center, Feb, 2009.
  27. Carter CL. Appendix B: State-by-State Summaries of State UDAP Statutes. National Consumer Law Center, Jan 10, 2009.

This article was revised on March 2, 2016.

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