Coronavirus (COVID-19) in the Chiropractic Physician office Updated June 5, 2020, 4:00 pm
Editor’s Note: This article is being constantly updated as new information is made available. Please continue checking this article for updates.
The Illinois Chiropractic Society continues to work diligently to support our members, both individually and as a profession, during the Coronavirus pandemic. In providing accurate and current guidance on issues affecting chiropractic physicians during this time, the ICS serves as a bridge to strengthen the chiropractic community and lessen the potential isolation felt by some small practice owners.
As essential workers in the health care system, chiropractic physicians are integral players whose continued functioning is critical to treat acute pain and other conditions, while decreasing the burden on hospitals. In this article, we have provided information and resources to enable physician offices to continue to provide their important services during this challenging period.
The ICS is constantly monitoring and updating this information as it becomes available. Of course, given the fluidity of this situation, these recommendations are for the current time and are subject to change; please review recommendations of the CDC, Illinois Department of Public Health, and this document frequently for revisions. Please see the important disclaimer information in the footnote.[i]
In this article:
Table of Contents
The following section is a listing of the many topics covered in this article. Each listing is a link that will take you to that section when clicked. Find the section that pertains to the information you need and click the link to jump to your information directly.
Frequently Asked Questions (FAQ)
These are the questions we currently receive most often at the ICS regarding COVID-19. They are included in the full Table of Contents and also included here to help users quickly find the information requested most often.
Action Alerts and Court Cases
Call YOUR Member of Congress TODAY! [Updated 4/2/2020]
Please contact your U.S. Senator and U.S. House Representative, using the links below, and ask them to support the Immediate Relief for Rural Families and Providers Act. Legislation has been introduced in both the U.S. Senate and the U.S. House of Representatives that would allow relief specifically for healthcare providers. The Immediate Relief for Rural Families and Providers Act (H.R. 6365 and S. 3559) would allow a grant and low-interest loan for rural health care hospitals and providers which includes chiropractic physicians. Please contact your U.S. Senator and U.S. House Representative, using the links below, and ask them to support these very important pieces of legislation.
Financial and Business Aid
Medicare 2% Reduction Suspended (Sequestration) – [Updated 5/26/2020]
According to a CMS release, “Section 3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily suspends the 2% payment adjustment currently applied to all Medicare Fee-For-Service (FFS) claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through December 31, 2020.”
In short, this means that you will not see a 2% reduction in the amounts you receive from Medicare for services after May 1 and through the rest of 2020.
Unemployment for Self-Employed, Sole Proprietors, or Independent Contractors – [Updated 5/5/2020]
The pandemic put chiropractic physicians in positions of closing their practices for a period of time or substantially reducing hours. However, those who are self-employed, sole proprietors, or independent contractors did not have access to unemployment claims. Illinois Department of Employment Security announced today that the system will be available on May 11, 2020, for those who are self-employed, sole proprietors, or independent contractors.
They also announced that these claims can be backdated to the first week of unemployment, but not earlier than February 2, 2020.
“PUA provides 100% federally-funded unemployment benefits for individuals who are unemployed for specified COVID-19-related reasons and are not eligible for the state’s regular unemployment insurance program, the extended benefit (EB) program under Illinois law, or the Pandemic Emergency Unemployment Compensation program (PEUC), including independent contractors and sole-proprietors. Up to 39 weeks’ worth of benefits are potentially available under the program for COVID-19-related unemployment claims.”
In order to receive these benefits, you MUST “must first apply for regular unemployment insurance before applying for benefits under PUA [Pandemic Unemployment Assistance].” Due to your self-employed status, your benefits will be denied. Once denied, however, you can apply for PUA when the portal opens on May 11.
The ICS is recommending that
- If you are self-employed, a sole proprietor, or an independent contractor, AND
- If you closed your office or saw a significant reduction in hours worked
- File for unemployment today,
- Wait for the initial denial (due to your self-employed status), and
- Apply for PUA on May 11.
Hereis the announcement from IDES.
$20 Billion More Under Provider Relief Fund – [Updated 5/26/2020]
[Updated 5/26/2020] Important Note: You must apply for these funds by June 3, 2020. Here is the announcement by CMS that sets this deadline.
HHS announced and began the next round of payments under the Provider Relief Fund. The first $30 billion was distributed according to Medicare payments (see the next section). This round is $20 billion and is based on your net revenue in 2018 against the entire estimated healthcare net revenue amounts from 2018 (some estimating $2.5 trillion total). Additionally, most providers are required to submit information via a portal to receive their portion of the $20 billion.
HHS stated, “Any provider who has already received a payment from the Provider Relief Fund as of 5:00 pm EST Friday, April 24th can and should apply for additional funding via the Provider Relief Fund Application Portal.” Additionally, before submitting your information to receive the additional payment, you must have already attested to the terms and conditions for the first disbursement.
To receive your funds, you must submit your application through the portal. You can find the link for the general distribution application portal on the Provider Relief Fund page or by direct link here.
According to the General Distribution portal FAQ, HHS is collecting four pieces of information for use in allocating these remaining General Distribution funds:
1) a provider’s “Gross Receipts or Sales” or “Program Service Revenue” as submitted on its federal income tax return;
2) the provider’s estimated revenue losses in March 2020 and April 2020 due to COVID;
3) a copy of the provider’s most recently filed federal income tax return; and
4) a listing of the TINs any of the provider’s subsidiary organizations that have received relief funds but that DO NOT file separate tax returns.
Like the first $30 billion, these funds can be used to cover additional COVID-19 expenses OR lost revenues. Thus, if you had lower revenue in March and April that are greater than the funds received from HHS from the initial disbursement and this disbursement combined, that will satisfy the usage portion of the requirement.
Provider Relief Fund Providing $30 Billion and Includes Chiropractic Physicians Under CARES Act – [Updated 5/11/2020]
Yet another provision of the “Coronavirus Aid, Relief, and Economic Security Act” (CARES Act) will directly impact doctors who billed Medicare in 2019. Although initial indications were this provision would focus on hospitals, the federal government has allocated $30 billion in “relief funds” that will include individual providers including chiropractic physicians. This is NOT a loan. Instead, it is an automatic grant.
To determine your portion of the funds, you would take your Medicare reimbursable billings (i.e. Medicare allowed charges for 98940, 98941, 98942) divided by $484 billion (total Medicare billings in 2019) and multiply by $30 billion. A doctor who had $32,250 in Medicare allowed charges billings in 2019 would receive approximately $2,000 (32,250 / 484,000,000,000 x 30,000,000,000 = 1,999).
Beginning Friday, April 10, the funds will be automatically deposited into your bank account via Optum Bank (CMS partner in this project) with “HHSPAYMENT” as the payment description. If you are typically paid by Medicare via check, then your funds will arrive in the next 2 weeks.
[Updated 5/11/2020] HHS has placed “terms and conditions” on the funds that must be accepted within 45 days (was 30 days) of receipt through the HHS portal starting sometime in the week of April 13 which will be located on the provider relief fund page. Included in those conditions:
- “Providers must agree not to seek collection of out-of-pocket payments from a COVID-19 patient that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider;”
- “The Recipient certifies that it will not use the Payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.” This would include funds for PPP loans or EIDL loans;
- “shall reimburse the Recipient only for health care related expenses or lost revenues that are attributable to coronavirus.” Thus, lost revenues are a component of these funds that would NOT be included in the PPP or EIDL funds.
- Recipient must also keep documentation regarding the use of the funds.
[Updated 5/11/2020] Additionally, HHS has indicated that if the terms and conditions are not accepted within the 45-day timeframe and the funds are not returned, they will automatically assume the provider agrees to the terms and conditions.
HHS gives further clarification of intent on the main relief page:
- “This quick dispersal of funds will provide relief to both providers in areas heavily impacted by the COVID-19 pandemic and those providers who are struggling to keep their doors open due to healthy patients delaying care and cancelled elective services.
- If you ceased operation as a result of the COVID-19 pandemic, you are still eligible to receive funds so long as you provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19. Care does not have to be specific to treating COVID-19. HHS broadly views every patient as a possible case of COVID-19.” [emphasis added]
More information is available on the HHS provider relief site.
Paycheck Protection Program Forgivable Loans – [Updated 6/4/2020 1:00 pm]
[Updated 6/4/2020] If you have questions about the overall program, please read the information that follows this short update. On 06/03/2020, the US Senate passed the Paycheck Protection Plan Flexibility Act and is sending it to the President for his signature. We expect the President will sign this bill that will assist chiropractic physicians who have obtained or will be obtaining a PPP loan (see information below for details). The legislation makes the following changes:
- Extends the 8-week forgiveness period to 24 weeks. This will allow employers more time to offset the loan amount with payroll expenses. In other words, employers can now use payroll expenses for the entire 24-week period and increase their forgiveness amount.
- Reduce the payroll expense requirement from 75% to 60%. However, if employers do not use at least 60% for payroll expenses, then none of the loan will be forgiven. This is unlikely with the changes mentioned above.
- Employers can now use the entire 24-week period to restore their workforce to the pre-COVID-19 era (February 20, 2020) levels.
- It allows for additional forgiveness exceptions. It specifically codifies the “good faith offer to return to work” exception. Then it adds other exceptions for those businesses that cannot find qualified candidates or those that can never return to pre-COVID-19 levels as a result of the pandemic operating restrictions.
- It extends the term of the loan from 2 years to 5 years. For those loans already in place, the term can be extended if both the borrower and lender agree.
- It also allows for PPP recipients to delay payment of payroll taxes that were previously restricted in the CARES Act.
[Updated 5/19/2020] SBA released the PPP forgiveness form. You can find that form here. PPP recipients can use this form to see how SBA will handle forgiveness. As always, we continue to encourage doctors to work with your issuing bank through the forgiveness process.
[Updated 5/15/2020] Some doctors have had concerns about the requirement to satisfy the certification indicating that the “[c]urrent economic uncertainty makes this loan request necessary to support the ongoing operations of the Applicant.” As a result, some doctors have been concerned about future audits and even consider returning the funds. However, the Treasury Department released new information regarding audits, good-faith certifications, and safe harbors on 5/13/2020 that should give our PPP recipients relief.
SBA has now clarified that anyone receiving PPP “loans” less than $2 million would have less access to adequate liquidity in the current economic environment. Thus, they are considering all PPP loans of less than $2 million automatically meet the required certification of necessity. Additionally, they cited that this will also allow them to focus their limited resources to larger loans.
This should give all of our doctors who received PPP loans (assuming they are less than $2 million) comfort that there will be no necessity audits for PPP loans and do not have to be concerned with the return of funds.
Note: Some details have changed in the final ruling: the interest has increased to 1% (instead of 0.5%), references to employees appear to be consideration of full-time equivalent employees, and some more confusion regarding those who are attempting to obtain both the PPP and the EIDL loans. Please see the information below for more explanation. Additionally, note the information at the end of this section regarding banks.
There was an important section in the “Coronavirus Aid, Relief, and Economic Security Act” (CARES Act) passed by Congress last Friday (3/27/2020) that provides for SBA loans that ultimately can be forgivable. Most people refer to this section as the “Paycheck Protection Program.” At this point, the Small Business Administration (SBA) has until April 11 to establish the regulations or rules for this act, which will be necessary to answer some additional questions and to begin the loan application process.
These loans will have different requirements than those found in most SBA rules. Some requirements are more restrictive, and some s are significantly loosened. The information below is based on our understanding of the law now and may be adjusted based on new information and the release of regulations by SBA.
How the CARES loan different than typical SBA loans and the basic CARES loan requirements:
- Do NOT have to prove that you cannot receive credit from other sources. This is a typical SBA requirement, but it appears this has been removed for these loans.
- NO personal guarantee will be required.
- 100% guaranteed by the federal government.
- No federal government guarantee fees or prepayment fees.
- The borrower MUST make good faith certifications that they have been impacted by COVID-19 AND will use the funds to maintain payroll and other debt obligations. This language includes, i) “that the uncertainty of current economic conditions makes necessary the loan request to support the ongoing operations of the eligible recipient; (ii) acknowledging that funds will be used to retain workers and maintain payroll or make mortgage payments, lease payment, and utility payments”; and no other SBA loans applications are pending.
- Must have fewer than 500 employees.
- Funds must be used to cover payroll costs, benefits and leave, mortgage interest, rent, and utilities.
- Interest is capped at 4%, although SBA has indicated that the interest will be only 1.0%. (they previously indicated only .5%, but increased it in the final rule)
- The borrower can defer payments (including the low interest) between 6-12 months. However, SBA has fixed the deferral timeframe to 6 months.
- The loans will be for 2 years.
- The amount of the loan can be up to the average monthly payroll from 2019 times 2.5 (i.e. 2019 total payroll expenses are $240,000, then 240,000/12 = 20,000 x 2.5 = $50,000 maximum). However, the loan amount is reduced by any amounts paid to individuals greater than $100,000.
- $1 million loan amount maximum.
- Section 1106 of the Act, titled “Loan Forgiveness,” provides that the Government will forgive up to the original principal amount of a loan under the Act that a recipient can document was used to pay: (1) payroll costs; (2) mortgage interest; (3) rent and (4) utilities—in each case for up to eight weeks following the issuance of the loan. Additional details:
- Like the loan amount, the forgiveness will be proportionately reduced for salaries greater than $100,000.
- Each of these documented expenditures for utilities, lease payments, mortgage interest must have been in place prior to 2/15/2020 (i.e. no mortgage interest can be included if the mortgage began on 2/25/2020).
- Employees must remain employed through the end of June.
- Employee pay cuts greater than 25% will reduce the forgiveness proportionately.
- [Updated 5/5/2020] The SBA recently changed their information sheet and removed the specific information regarding full-time equivalent hours. See the next bullet for that information. According to the SBA, forgiveness requires the following:
- “Number of Staff: Your loan forgiveness will be reduced if you decrease your full-time employee headcount.
- Level of Payroll: Your loan forgiveness will also be reduced if you decrease salaries and wages by more than 25% for any employee that made less than $100,000 annualized in 2019.
- Re-Hiring: You have until June 30, 2020 to restore your full-time employment and salary levels for any changes made between February 15, 2020 and April 26, 2020. “
- The CARES Act provision regarding full-time employees references previous IRS code (26 U.S. Code § 4980H(c)(4)(a)) that states “The term ‘full-time employee’ means, with respect to any month, an employee who is employed on average at least 30 hours of service per week.”
[Updated 5/4/2020] SBA and the Treasury Department released more information on the PPP loan forgiveness on 5/3/2020 and they answered questions that many of our doctors have. The clarification came in the form of a FAQ:
“Question: Will a borrower’s PPP loan forgiveness amount (pursuant to section 1106 of the CARES Act and SBA’s implementing rules and guidance) be reduced if the borrower laid off an employee, offered to rehire the same employee, but the employee declined the offer?
Answer: No. As an exercise of the Administrator’s and the Secretary’s authority under Section 1106(d)(6) of the CARES Act to prescribe regulations granting de minimis exemptions from the Act’s limits on loan forgiveness, SBA and Treasury intend to issue an interim final rule excluding laid-off employees whom the borrower offered to rehire (for the same salary/wages and same number of hours) from the CARES Act’s loan forgiveness reduction calculation. The interim final rule will specify that, to qualify for this exception, the borrower must have made a good faith, written offer of rehire, and the employee’s rejection of that offer must be documented by the borrower. Employees and employers should be aware that employees who reject offers of re-employment may forfeit eligibility for continued unemployment compensation.”
Based on this information, it appears that employees that refuse to return to work will not count against an employer for PPP loan forgiveness if the offer to return to work was:
- Made in good faith,
- In writing, and
- Employee’s rejection is documented by the employer (does not indicate signature required from employee, just documented).
- If you have already laid off employees, you can re-hire them once the loan is disbursed and count them toward the calculation.
- The loan forgiveness is not taxable income.
- SBA has indicated they would have a process in place by Friday April 3, 2020.
PPP + EIDL:
- It appears that you can apply NOW for an Economic Injury Disaster Loan Assistance (EIDLA) and then later apply for the Payroll Protection Program loan. If you choose this option, it appears you have two options:
- Re-finance the EIDLA loan into the PPP loan, or
- Use the EIDL loan (including $10,000 “advance”) for expenses NOT used to account for the forgiveness of the PPP loan.
- It is unclear if both will be available after April 3, 2020 or if only the borrower would have to choose between the two programs. We anticipate this will be addressed soon by SBA and the Treasury Department.
- The ICS has not been able to determine how raises and hazard pay will be directly addressed. We anticipate more information coming and the regulations may address this, as well.
What can you do now while waiting for the process to be finalized (i.e., for applications to be made available)?
- Start gathering documentation for application while waiting for the process to finalize. This would include payroll information for 2019. This includes ALL payroll expenses, such as health benefits, retirement benefits, etc. Include everything, and you can negotiate with the bank as to what, if any, they will exclude. In addition to payroll information, gather documents showing mortgage interest, rent, and utilities in place prior to 2/15/2020. See the information and links below.
SBA released more information on this program on their dedicated site. Additionally, they released the application that could be used to get ready for the actual release and start date which they have indicated will be Friday, April 3, 2020:
If you are considering this loan, please speak with your local bank NOW to determine your next steps and proper timing for your situation and practice. Remember, this program begins on April 3, 2020, and has limited funds. Some local banks are ONLY assisting current banking customers. Please check with your local bank soon to determine their policies and allow for time to find another potential lender to work with on the PPP.
Economic Injury Disaster Loans (EIDL) and Loan Advances [Updated 4/16/2020]
The Small Business Association Economic Injury Disaster Loans (EIDL) and Loan Advance are available to businesses (including Doctors of Chiropractic) that have been impacted by COVID-19.
This program includes an emergency advance of up to $10,000 to small businesses affected by COVID-19. To access the advance, you must first apply for an EIDL and then request the advance. The advance does not need to be repaid under any circumstance. The funds may be used to keep employees on the payroll, to pay for sick leave, meet increased production costs due to supply chain disruptions, or pay business obligations, including debts, rent, and mortgage payments. You may also qualify for funds above the emergency advance to help your practice.
[Updated April 16, 2020] On April 10, 2020, SBA announced that the advance funds will be limited to $1,000 per employee which is a question on the application. Thus, take the number of total employees (it appears to include part-time and full-time the same) times $1,000 to a maximum of $10,000 to determine the maximum advance portion of these funds.
There is a lot of confusion about the types of loans available, and some think they must maintain their employees to be eligible. While this may be true for some other types of loans, this advance and loan do not require you to keep your employees. This loan is structured to give immediate assistance to businesses that have seen an economic impact due to COVID-19. You must qualify as one of the business types below and be able to certify the second list of criteria to be eligible.
Choose your business type:
- Applicant is a business with not more than 500 employees.
- Applicant is an individual who operates under a sole proprietorship, with or without employees, or as an independent contractor.
- Applicant is a cooperative with not more than 500 employees.
- Applicant is an Employee Stock Ownership Plan (ESOP), as defined in 15 U.S.C. 632, with not more than 500 employees.
- Applicant is a tribal small business concern, as described in 15 U.S.C. 657a(b)(2)(C), with not more than 500 employees.
- Applicant is a business, including an agricultural cooperative, aquaculture enterprise, nursery, or producer cooperative, that is small under SBA Size Standards
- Applicant is a business with more than 500 employees that is small under SBA Size Standards
- Applicant is a private non-profit organization that is a non-governmental agency or entity that currently has an effective ruling letter from the IRS granting tax exemption under sections 501(c),(d), or (e) of the Internal Revenue Code of 1954, or satisfactory evidence from the State that the non-revenue producing organization or entity is a non-profit one organized or doing business under State law, or a faith-based organization.
Applicant must review and check all the following:
- Applicant is not engaged in any illegal activity (as defined by Federal guidelines).
- No principal of the Applicant with a 50 percent or greater ownership interest is more than sixty (60) days delinquent on child support obligations.
- Applicant is not an agricultural enterprise (e.g., farm), other than an aquaculture enterprise, agricultural cooperative, or nursery.
- Applicant does not present live performances of a prurient sexual nature or derive directly or indirectly more than de minimis gross revenue through the sale of products or services, or the presentation of any depictions or displays, of a prurient sexual nature.
- Applicant does not derive more than one-third of gross annual revenue from legal gambling activities.
- Applicant is not in the business of lobbying.
- Applicant cannot be a state, local, or municipal government entity and cannot be a member of Congress.
Contact your accountant to see if an SBA EIDL is right for you, or you can visit the SBA website for more information to start the application process.
Additionally, please see the PPP section above to assist you in your decision-making process.
Employee Retention Credit – Another Potential Avenue for Assistance [Updated 5/7/2020]
The IRS announced there is an additional employer tax credit that is available to SOME employers. The credit is equal to 50% of qualified wages, up to $5,000 per employee ($10,000 in wages at 50%), and will be applied against the employer portion of FICA (employers share of Social Security taxes).
To qualify, employers will have to meet several requirements:
- Employers that received Paycheck Protection Program (PPP) funds are not eligible and cannot take the credit.
- The business must have been affected by COVID-19
in one of the following ways:
- The business must have been fully OR partially suspended as a result of governmental orders, OR
- A significant decline in gross receipts and must demonstrate that decline is greater than 50% for the same calendar quarter in 2019.
The IRS has released the following information to assist understanding the program.
If you believe that you may qualify for this credit, the ICS urges you to contact your accountant or payroll processing company to determine your eligibility.
Federal Stimulus Package – CARES and CARES 2 [Updated 4/24/2020]
Both the House and the Senate have passed a $2 trillion federal stimulus package (CARES Act). The text is approximately 880 pages long and we are working to determine inclusions. There are many provisions in the act including Federal Student Loan Relief, HPOG Funding, Small Business Administration (SBA), Employee Retention, Recovery Rebates, and more. We will continue to expand this section over the coming days and as the bill progresses.
The language for which we were advocating (call to action on 3/21/2020) did not make it into the final bill passed by the Senate. The ACA is continuing its efforts to find other avenues. Watch for future calls to action.
[Updated 4/24/2020] CARES 2 (or COVID-3.5) was passed by the Senate on 4/21/2020 and subsequently by the House on 4/23/2020 that will infuse another $484 billion into the economy. The President signed the bill on 4/24/2020, and thus it becomes law.
Notably, CARES 2 adds $310 billion into the PPP program (see Paycheck Protection Program section) in addition to the original $349 billion. We would strongly encourage doctors who have not yet applied for the PPP but meet the qualifications to apply now even though the additional funding has not yet passed the House. Also, the bill adds $60 billion to the EIDL loan/grant program with $10 billion allocated for the advance grant portion. As more information becomes available, we will update doctors in Illinois.
Student Loan Assistance (Federal and Private) – [Updated 4/22/2020]
The CARES Act addressed federal government student debt and gives an automatic deferral of payments through September 30, 2020. During this payment “pause” interest does NOT accrue and the 6 months counts toward the time for forgiveness programs.
[Updated 4/22/2020] Governor Pritzker announced a program to assist with private student loan payments during COVID-19. This program is different than the federal program that was passed for federal loans. Governor Pritzker’s program applies to private student loans only. The Governor’s release announced the following relief options for private student loan borrowers:
- Providing a minimum of 90 days of forbearance
- Waiving late payment fees
- Ensuring that no borrower is subject to negative credit reporting
- Ceasing debt collection lawsuits for 90 days
- Working with borrower to enroll them in other borrower assistance programs, such as income-based repayment.
Borrowers interested in accessing these relief options need to contact their student loan lender. For more information, the Governor’s release can be found here.
Business Interruption Insurance Coverage – [Updated 4/14/2020]
Some general liability insurance policies have provisions that assist businesses that lose revenues after a devastating loss (typically an act of God such as tornados or fires). These clauses are typically called “Business Interruption Coverage.” The intent is to cover lost revenues as a result of a physical disaster, and the policy is designed to make you whole (up to the coverage amount).
After the SARs virus and H1N1 impacted a number of businesses, many insurers began to put in policy provisions that excluded viruses as a reason for business interruption coverage. The main complicating factor in the case of COVID-19 is that the negative business impact is also significantly related to the steps required to flatten the curve (i.e. stay at home orders, etc.).
Although many insurers are now denying business interruption claims based on virus exclusions, you may want to file a claim anyway. If you receive a blanket denial without explanation, you should request the provisions of the policy that led to the decision. In other words, ask them to explain why the denial is justified. In this way, you can evaluate the strength or weakness of the denial and document your attempt to make a claim. We are seeing a legislative trend across the country that may impact how some states interpret and enforce business interruption coverage. As of 4/14/2020, it does not appear that any state has fully implemented or passed legislation like this.
However, regardless of what the legislative future holds, chiropractic physicians in Illinois may want to review their coverage, file a claim for business interruption, and (if necessary) request a full explanation if a denial is received.
Medicare Advance Payment (Loan) – [Updated 4/27/2020]
HHS announced the following on 4/27/2020 – “Beginning today, CMS will not be accepting any new applications for the Advance Payment Program, and CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund.”
State Loans for Small Businesses [Updated 3/31/2020]
During Governor Pritzker’s daily presser today, he announced new financial assistance options for small businesses. The applications for these programs will not be available until the end of the day on Friday, March 27, 2019, at the DCEO website. The two options are as follows:
Illinois Small Business Emergency Loan Fund
The Illinois Small Business Emergency Loan Fund was established as a partnership between the Illinois Department of Financial and Professional Regulations (IDFPR) and the Illinois Department of Commerce and Economic Opportunity (DCEO).
- Low-Interests loan for up to $50,000
- No payments for the first 6 months
- Fixed payments at 3% interest rate
- 5-year term loan
- Loans must be used for working capital with at least 50% of the loan going towards payroll or other eligible compensation. This could include salaries, wages, tips, paid leave, and group healthcare benefits.
- Any compensation over $100,000 will not qualify.
- Borrowers are required to commit to hire or retain at least 50% of their workforce for six months
- Small business must be outside of Chicago
- Fewer than 50 employees AND
- Less than $3 million in revenue in 2019
- Must have a loss of 25% from COVID-19
- Located in Illinois and have a valid business license
- Previous bank statements and tax returns will be required
For more information, please visit the DCEO website here.
Downstate Small Business Stabilization Program
- Grants of up to $25,000 for working capital to small businesses that are served by DCEO’s Office of Community Development
- Partnership between business and local governments
- Local governments have to apply for the business
- Fewer than 50 employees
- Focuses on downstate and rural counties
- Local government will need to check with the Department of Commerce and Economic Opportunity to ensure they are located in an eligible area
For more information, please visit the DCEO website here.
Chicago Small Business Resiliency Fund
If a business is located in the City of Chicago, they can apply for a small business grant through the City entitled the Chicago Small Business Resiliency Fund. This loan comes from the City of Chicago and was NOT part of the Governor’s announcement today.
- Loan Amount of up to $50,000
- Required to be used for working capital
- At least 50% of the proceeds are required to be used for payroll
- Low-interest loan with a 5-year repayment period
- Employs fewer than 50 employees
- Less than $3 million of revenue in 2019
- Had a revenue loss of more than 25% revenue strictly due to COVID-19
- City address or City business license
- Cannot have any pre-existing tax liens
For more information and application for this loan please click here.
Federal and State Tax Deadline Extended – [Updated 3/25/2020]
Both the Internal Revenue Service and the State of Illinois have extended the deadlines for filing and paying federal and state taxes from 4/15/2020 to 7/15/2020.
SBA Loans and Other Information for Small Businesses Affected by Coronavirus [Updated 3/23/2020]
All Illinois small businesses (according to SBA’s size standards) and private non-profits can now apply for loans of up to $2 million through the U.S. Small Business Administration’s Economic Injury Disaster Loan Program. If your businesses have been affected by the coronavirus pandemic, this program offers working capital to meet needs including payroll, accounts payable, and fixed debt payments until the situation improves. Interest rates are 3.75% for small businesses and 2.75% for non-profits. Your businesses may apply now at https://disasterloan.sba.gov/ela/
- Economic Injury Disaster Loan Program FAQ
- Daily Webinars will be available at www.sba.gov/il
- Disaster loan information at https://disasterloan.sba.gov/ela/Information/Index
- Information for small businesses affected by coronavirus at www.sba.gov/coronavirus
- All coronavirus-related federal government resources: www.usa.gov/coronavirus
Find more information for small businesses affected by coronavirus at www.sba.gov/coronavirus. Go to www.sba.gov/local-assistance to find a counselor or mentor. You can also email Illinois.firstname.lastname@example.org or call (312) 353-4528 (Chicago office) or (217) 747-8249 (Springfield office) to talk to a Small Business Administration team member directly.
Treatment Recommendations and Potential Alternatives
Maintenance Visits [Updated 5/26/2020]
[Updated 5/26/2020] Through May 28, please refer to the information for Phase 2 and Before. Phase 3 ONLY (Are you in Chicago? Please see City of Chicago section for different guidelines) – Beginning May 29, 2020, it appears all areas of the state will be in Phase 3 of the Restore Illinois Plan. As a result of several changes (i.e. massage therapy and other personal care service changes), the Illinois Chiropractic Society believes that maintenance care could resume in Phase 3. However, all of the requirements and guidelines in the office would remain in place (i.e. social distancing, maximum 50% occupancy, face masks, patient screening, cleaning protocols, etc.). Please see the massage therapy section for more information about the changes in Phase 3.
Phase 2 and Before (May 28, 2020 and prior):
To be clear, the following section is NOT for patients who are in pain. As we have contended from the beginning, in the absence of chiropractic physicians’ care, these patients would need to turn to emergency rooms, which would tax and already-overly burdened system who may not even be able to serve them, or they would turn to treatment such as opioids and other addictive medications, resulting in increased opioid use disorder cases.
Based on all of the above, including the Governor’s Executive Order 2020-10 issued March 20, 2020 (and each subsequent extension), the ICS strongly recommends that our doctors postpone or cancel any appointments for in-office maintenance care or care for patients who are close to or have reached maximum medical improvement (MMI). The ICS also urges doctors to postpone or cancel non-medically necessary or ancillary in-office services (such as non-therapeutic massage and other services – see Massage Therapy section below). Our doctors should continue the process of moving to telehealth for any services that may be provided as an alternative to in-person care, including functional medicine, rehab services (e.g. range of motion and therapies), and some primary care services. We believe that, for all physicians, limiting in-person patient encounters to the extent practicable is an ethical and medically responsible way to comply with the Executive Order while helping patients in need and facilitating the levelling off of the Coronavirus in the coming weeks.
Additionally, we are receiving questions regarding the May 1, 2020 stay-at-home order update that addressed elective surgeries beginning on May 11, 2020. Although there will be relaxed rules surrounding elective surgeries, these new rules are 1) focused on surgeries only and 2) require that all elective surgery patients must test negative for COVID-19 and self quarantine until the surgery. This, of course, is not a prerequisite that could be met for maintenance chiropractic care visits. As a result, these changes will not impact the ICS’ current recommendation that Illinois chiropractic physicians see only pain patients in person. Here is a link to the IDPH information and requirements for elective surgeries.
Again, the ICS believes that chiropractic care is extremely important to the health care of patients, and in the current COVID-19 environment, chiropractic care is essential for musculoskeletal pain patients. In the absence of our doctors’ care, these patients would need to turn to emergency rooms, which would tax and already-overly burdened system or may not even be able to serve them, or they would turn to non-contact treatment such as opioids and other addictive medications, resulting in increased opioid use disorder cases.
The basis of our recommendation:
- The Illinois Department of Public Health issued an alert on March 18, 2020, stating that all health care workers are at some risk of exposure to Coronavirus and asking that they self-monitor and isolate themselves at the first sign of any symptom: “Additionally, in the setting of a pandemic with widespread community transmission in Illinois, all healthcare workers are at some risk for exposure to COVID-19, whether in the workplace or in the community. Therefore, IDPH is asking ALL healthcare workers, regardless of whether they have had a known SARS-CoV-2 exposure, to self-monitor by taking their temperature twice daily and assessing for COVID-19-like illness. If healthcare workers develop any signs or symptoms of a COVID-19-like illness (for healthcare workers, fever cutoff is 100.0oF), they should NOT report to work. If any signs or symptoms occur while working, healthcare workers should immediately leave the patient care area, inform their supervisor per facility protocol, and isolate themselves from other people.” Additionally, the IDPH alert states: “Healthcare facilities are also encouraged to implement plans now for canceling elective admissions and procedures.”
- CMS announced through the Task Force, “All elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak.”
- Lastly, on March 20, 2020, the Governor issued Executive Order 2020-10 – the “Stay at Home” Order – that orders that non-essential operations must cease activities and essential operations must keep activities within “minimum basic operations.” (See pars. 2 and 13.) Link to Executive Order here.
- [Updated 5/5/2020] The CDC continues to state, “to ensure safety for patients and HCP, facilities should delay elective ambulatory provider visits and implement service delivery models such as telemedicine.” You can find the guidance here.
Offices that continue to provide in-person services must comply with the Governor’s Executive Order regarding social distancing, including by maintaining social distancing for employees as possible and six-foot requirements for members of the public in waiting rooms, in addition to other infection prevention protocols.
Please see the massage therapy section below.
Massage Therapy, the Pandemic, and the Open Chiropractic Office [Updated 6/5/2020 4:00pm]
[Updated 6/5/2020] The ICS has now confirmed with DCEO that they have removed the 30-minute time-limit on massages. Although the limit was in the document as of the beginning of Phase 3, they have since removed that limit. That means that one-hour relaxation massages may now be scheduled.
[Updated 5/26/2020] Through May 28, please refer to the information for Phase 2 and Before. Phase 3 ONLY (Are you in Chicago? Please see City of Chicago section) – Beginning May 29, 2020, it appears all areas of the state will be in Phase 3 of the Restore Illinois Plan. There are no changes to massage therapy rules when ordered by a physician for medically necessary care. However, “relaxation” massage therapy (not delegated by a physician) will be allowed in this phase with these restrictions:
- Reservations only. No walk-ins,
- Massage therapist must wear a mask,
- Customer must wear a mask,
Massages must be 30 minutes or less,[Editor’s Note: This provision was removed by DCEO after Phase 3 began]
- Reusable customer articles (e.g. towels, blankets, capes, robes) must be fully cleaned and sanitized after each customer,
- Maximum of 50% of capacity OR 5 customers allowed per 1000 sq. ft. of usable space applied within each suite,
- Because these massages will be performed in a healthcare setting, we believe screenings should be required as if the customers were presenting as a patient. Please see screening section. Additionally, this will give practices greater liability protection.
You can find these guidelines here.
Phase 2 and Before (May 28, 2020 and prior):
The ICS has received several questions regarding whether it is appropriate to provide massage therapy during the pandemic and stay at home order, i.e., whether it is considered an essential service. The ICS has and continues to use federal guidelines and state Executive Orders since the beginning of the pandemic to inform our recommendations concerning massage in the chiropractic office. As we have stated: Therapeutic massage procedures provided by massage therapists and as directly delegated by a physician as part of the patient’s treatment plan would be considered essential. However, if the massage therapist is taking appointments independently for relaxation (non-therapeutic, non-delegated) massages (even if the appointments are set by your front desk), that is non-essential. This is a very important distinction and medical necessity matters. Here is the excerpt from Illinois’ DCEO, “Are massage therapists considered essential? No, unless the massage treatment is being performed pursuant to a physician’s order.”
City of Chicago Phased Reopening Guidelines – Entered Phase 3 on June 3 [updated 6/4/2020 1:00 pm]
For businesses, including chiropractic offices, located in the City of Chicago, on May 26, 2020, Mayor Lori Lightfoot announced separate guidelines for the Chicago Phase 3. As of yesterday, the City of Chicago is in Phase 3 but some guidelines are different.
It is important to understand that you must follow the most stringent guidelines and orders from all governmental entities (local, county, state, federal). This means for any individual provision that if the state guidelines are stricter than the city, then you must follow the state. Additionally, if the city is stricter, then you must follow the city.
We have found only one notable difference in the City of Chicago’s Phase 3 vs. the state Phase 3 related to chiropractic physician practices: the city has a 25% occupancy limitation (instead of 50% as for all other areas of Illinois).
Here is the guidance issued for Chicago Phase 3 healthcare organizations here is the guidance issued for Chicago Phase 3 personal service organizations (i.e. relaxation massage therapy).
Telemedicine/ Telehealth Options [Updated 4/7/2020]
Our members should consider using telehealth for appropriate services, such as functional health services or rehabilitation services that could be performed by video (such as consultations, examinations, range of motion assessments, recommended exercise therapies, therapeutic exercises, etc.). The ICS recommends that physicians make a careful assessment of the types of services they can render via electronic technology, making certain to meet the usual standard of care and not to abuse the telemedicine delivery format. See the links here for telehealth and insurance issues:
- Telemedicine Services in Illinois (Article)
- Nutritional Services via Telemedicine (Article)
- Requirements of Telemedicine; Helping Patients Outside of Illinois (Video)
- Telemedicine-Methodologies for Communications (Video)
- Telehealth and Insurance Coverage (Video)
On 3/19/2020, Governor Pritzker issued an executive order regarding telehealth coverage that makes broad sweeping changes and requires an increase in insurance coverage for services provided via telehealth. You can see the full order here. The order includes provisions that make the following statements or changes that are in place during the Gubernatorial Disaster Proclamation:
- Telehealth services can be delivered by physicians (Illinois law includes chiropractic physicians as physicians);
- Methods include “video technology commonly available on smartphones and other devices” such as FaceTime, Facebook Messenger, Hangouts, and videoconferencing (i.e. Zoom, LogMeIn, etc.);
- “health insurance issuers regulated by the Department of Insurance are hereby required to cover the costs of all Telehealth Services rendered by in-network providers to deliver any clinically appropriate, medically necessary covered services and treatments to insureds.” Thus, it does appear this applies to in-network providers only;
- Documentation and recordkeeping required (insurers may establish reasonable requirements here);
- No ADDITIONAL utilization review requirements or treatment limitations can be added for telehealth than is required for in-person services;
- IMPORTANT: Providers should, “to the extent feasible, notify patients that third-party applications potentially introduce privacy risks.” Additionally, providers should take all precautions and turn on available encryption and privacy modes.
- This would NOT apply to public communication (i.e. Facebook pages, Facebook groups, etc.). Public communication for these services would still violate HIPAA; and
- Effective as of 3/19/2020.
On-demand education available – “Telehealth 101: Strategies for Treating Patients When In-office Care is Not an Option.” The course was co-presented by Dr. Tim Bertelsman, FACO, and Marc Abla, CAE, ICS Executive Director on how chiropractic physicians can continue to deliver services to homebound patients via telehealth. This is an important avenue of care during these uncertain times. Click here to take the course.
[Updated 4/7/2020] – Zoom Bombing – There have been reports of hackers are maliciously obtains access to random meetings and screen shares undesirable content. Increased usage of web-based environments has created greater opportunity for these “hacks.” Here are strategies to protect your telehealth sessions:
- Use the latest software version.
- Generate a unique meeting link, rather than your universal meeting code.
- Email your meeting link directly to your patient.
- Enable your virtual “waiting room” that allows you to screen attendees before granting access to the meeting.
- Follow the current federal guidance.
[Updated 4/7/2020] – Always communicate clearly expectations regarding billing and insurance coverage before a telehealth session. If you are providing services that you believe will not be covered by insurance, the ICS is providing members with an electronic version of the patient notification of non-covered services. This document can be transmitted, signed, and returned electronically. The ICS has also developed a consent to treat via telehealth. That is available here.
Business and Practice Considerations
Employees Refusing to Return to Work – Unemployment Considerations [Updated 5/19/2020]
We are hearing more and more from employer members that some employees are refusing to return to work during this time. Some are refusing due to fears, some are refusing because of unemployment compensation, some are simply not returning messages or calls. Although we have provided information for those that are navigating PPP forgiveness, we now want to provide information regarding the unemployment compensation status of these employees.
First, if you are not following proper protocols in your office during the pandemic, the employee is more likely to win unemployment appeals and possibly create compliance problems for your office. Please follow CDC, IDPH, and OSHA guidelines during this time.
However, assuming you are following guidelines, to protect your future unemployment insurance payroll charges, you should report employees that refuse to return to work to IDES. First, you should provide a bonafide written return to work offer to the employee and document that offer. Then you simply fill out this IDES form and upload it according to the information on the form.IDES Refusal of Work Reporting Form
Required and Important Signs to Post in Your Office [Updated 5/29/2020 12:00 pm]
We have previously informed you that there are required signs in places of business. Now that the state, except the City of Chicago, has entered Phase 3, Illinois now requires more signs at your office location.
First, all businesses that have employees reporting to a workplace (i.e., healthcare practice location including all chiropractic physician offices) are required to post a COVID-19 poster at the employee entrance and in a conspicuous place. Here is a link to the poster.
Although not explicitly required for healthcare only locations (i.e., chiropractic physician offices), those chiropractic physician offices that offer relaxation massage therapy are required to post signs for the following:
- Face Covering Requirements
- Social Distancing Guidelines
- Cleaning Protocols
- Visual Markers to maintain a 6-foot distance
- Symptoms of COVID-19 (Please refer to the ICS STOP Sign)
These required signs can be found at the link for Floor, Directional, and Misc. Signs.
Personal Service (i.e., massage therapy) Guidelines Signs for employee locations.
If you would like the full toolkit, please click here.
Additionally, for our multi-lingual offices, DCEO has indicated the signs must be posted in multiple languages, if necessary. Lastly, previously, the ICS made a “Stop Coronavirus” sign for physician offices available for our members.
Face Coverings for Patients, Staff, and Doctors – [Updated 5/26/2020]
According to the extended stay-at-home order that was issued and began on May 1, 2020, face coverings are now required in “public indoor spaces” which does include chiropractic physician offices. These face coverings can be N95 masks or simply cloth masks (including bandanas, etc.).
As a result, the ICS recommends that all chiropractic physicians and staff wear face coverings AND require patients to wear face coverings. Remember, this requirement is for face coverings and not N95 or surgical masks. In fact, cloth masks, bandanas, etc. are acceptable.
[Updated 5/26/2020] Illinois lays out specific requirements for all businesses, including personal care services, which gives important requirements that chiropractic physicians must follow. These requirements include face coverings when within 6 feet of others. This is again clear that the state does require doctors and patients to wear face coverings (unless there is a medical reason). Staff should wear masks when around patients or around each other within 6 feet. For additional clarification on guidance from the state, the massage therapy allowances in Phase 3 require both the therapist and customer to wear a mask during the massage.
If you or your patients need more information on face coverings, here are some resources:
IDPH After Work and at Home Guidance for ALL Healthcare Providers [Updated 4/27/2020]
On 4/26/2020, IDPH released guidelines for all healthcare providers (including chiropractic physicians) working in ALL healthcare settings with protocols when going home and preparing for work to protect your family and your home.
The guidance covers various topics including:
- Monitoring your health,
- Preparing for work,
- Before leaving for work,
- When you arrive home, and
- Disinfecting your home.
Please read the full guidance here.
Recommendations for Defense of COVID-Related Liability Claims and License Discipline[i] [Updated 4/27/2020]
The emergence of COVID-19 has raised some new questions about virus-related liability in the chiropractic office. Liability may exist in the form of civil malpractice claims (i.e., claims or lawsuits for money damages) or as a license disciplinary case (i.e., a complaint filed with and adjudicated by the Illinois Department of Financial and Professional Regulation). Issues that have been raised include how to mitigate liability for claims that a patient or employee contracted COVID-9 in a physician office, how to avoid patient abandonment during shutdown; and record-keeping requirements during the pandemic. Physicians who have continued to practice as essential workers should be aware of the unique liability issues that can occur during the current situation.
Civil Malpractice Claims
“Malpractice” is a conclusion that a doctor has been negligent, and a party is claiming financial damages as a result. To prove negligence and recover the money, the injured party must show:
- The doctor owed a duty to the injured party to act reasonably (i.e., to act as a reasonable doctor would have done in similar circumstances), also called “standard of care”;
- The doctor breached the duty or standard of care;
- The doctor’s breach (failure to act reasonably) caused the injury; and
- The injured party suffered financial damages as a result.
Doctors are always obligated to use the appropriate standard of care when treating a patient. However, standard of care is a variable concept that requires an expert to give an opinion that the doctor did or did not do what a “reasonably prudent’ chiropractic physician would have done in the same or similar circumstances. The Standard of care varies, depending on the nature, geographical location, and other circumstances of the practice; however, for offices remaining open during the pandemic, it is reasonable to assume that CDC protocols for screening, disinfecting, and social distancing are indisputably essential elements of the standard of care. See the Patient and Staff Screening Tools section for more details.
A common question is whether essential practices can be held to pay malpractice damages to patients who contract COVID-19 within 14 days of an office visit and claim they contracted the disease at the physician’s office. Applying the 4-step test above, the physician has a duty to conform to the standard of care, which includes CDC protocols. If the physician can prove that he/she has followed those protocols consistently, it would probably be difficult for the patient to prove that the doctor breached the standard of care (#2) or that the doctor’s behavior caused the illness (#3). Therefore, in addition to simply being good practice, strict adherence to these protocols is an excellent mitigation tool for malpractice cases in which patients claim they caught COVID-19 in the office.
Common pitfalls that could result in COVID-related license investigation include:
- Advertising of exaggerated, unproven claims for treatments and “cures” of COVID-19 (see advertising section in this document)
- Documentation and record-keeping
- It is especially tempting in telehealth visits to neglect documenting the encounter; however, the rules fully apply to electronic encounters. For example, if you schedule a FaceTime or other telehealth visit with a patient, you must record a compliant SOAP note. Phone calls and text messages should also be documented in the record.
- In addition to following the usual standards for record-keeping, physicians should consider including additional information unique to current circumstances. For example, a physician who develops a treatment plan of home exercise for an elderly, immunocompromised patient may want to include a statement that, due to the patient’s condition, it is less risky for the patient to follow home exercise than to make repeat visits to the office; that the patient can benefit from a home exercise plan; that the options have been discussed with the patient and the patient concurs; that the doctor will follow the patient’s progress, etc. It may be helpful to provide the pandemic context in the event of a future review of the records for any reason.
Patient Abandonment Issues
The Illinois Medical Practice Act does not define “patient abandonment,” but it is listed as a clear license violation. It is generally understood to be the termination of the doctor-patient relationship without reasonable notice or excuse, and without giving the patient an opportunity to find qualified replacement care.
Faced with fears about the ability to practice safely or profitably, many chiropractic offices shut down at the beginning of the pandemic. Under these circumstances, these offices certainly had a “reasonable excuse” sufficient to overcome that portion of the abandonment definition. However, even during the pandemic, and even for those offices who plan temporary shutdowns, physicians are obligated to identify and make arrangements for patients who are under care. During any closure, whether temporary or permanent, doctors must take reasonable steps to notify current patients, suggest and facilitate other care, and provide information about how to obtain or transfer their medical records. These steps are especially crucial to avoid abandonment charges for patients who are under urgent care. Some physicians who are in the midst of treating accident cases have asked whether they can be charged with patient abandonment for closing their offices due to the pandemic. It has been reported that a patient’s attorney claimed that the doctor was obligated to continue to treat the patient, even though the doctor had closed the office. Both the ICS and NCMIC disagree, as long as the doctor takes the necessary steps to facilitate record transfers and make alternative arrangements for urgent patients. For example, the doctor could write to the attorney to say that the doctor will remain available for phone or telehealth consultations, but must close the office for patient safety reasons, which is of utmost importance.
COVID-19 Antibody Assays, Scope, and Warnings [Updated 5/14/2020]
There is a wide variety of research surrounding antibody testing including a high number of inaccurate tests. Illinois officials are warning against giving false hope with inaccurate tests and the effectiveness of antibody positive results.
Governor Pritzker addressed antibody testing in his press conference on 4/24/2020. He stated, “we’ve seen many of these tests promoted in a way that errs on the side of irresponsible.” The concerns center around:
- Continued question surrounding whether having antibodies is equivalent to having immunity, and
- Questions surrounding explicit COVID-19 antibodies vs. other corona viruses.
With the specific warning from the governor about antibody testing, we give strong cautions to our members about providing these services. If you decide to provide these tests, please contact your malpractice carrier to determine coverage, verify that all advertising is in no way misleading (see 1-3 above), and provide a very clear verbal and written informed consent.
[Updated 5/5/2020] The FDA issued new guidance on 5/4/2020 specific to approval submission requirements and performance thresholds for antibody test developers. This new guideline is considerably more restrictive than the previous guidance issued in March. The FDA statement indicates, “the FDA has become aware that a concerning number of commercial serology tests are being promoted inappropriately, including for diagnostic use, or are performing poorly based on an independent evaluation by the NIH.” Additionally, the FDA added a statement regarding marketing and fraudulent tests – “We unfortunately see unscrupulous actors marketing fraudulent test kits and using the pandemic as an opportunity to take advantage of Americans’ anxiety. Some test developers have falsely claimed their serological tests are FDA approved or authorized.”
Lastly, in the 5/4/2020 guidance announcement, the FDA added an additional warning to those administering the test, “those who use an antibody test need to understand its limitations and use test results as just one piece of data to inform decision making. All tests can provide at least some false results. Even a high-performing antibody test when used on individuals in a population that does not have many cases of COVID-19 infection – a population with low prevalence – may produce as many or more false results as true results because the likelihood of finding someone who has been infected is very small.” [emphasis added]
[Updated 5/14/2020] Lastly, malpractice carriers may indicate additional potential liability for doctors who perform the test. They are looking to the FDA approved tests and specific language used with patients when performing the test when considering liability. Please check with your malpractice carrier for coverage information for antibody testing.
Do You Need/Want to be Tested for COVID-19? [Updated 4/27/2020]
IDPH has new testing guidelines available and a list of individuals that can be tested for COVID-19. The testing guidance by IDPH provides the following information:
- Have COVID-19 symptoms (cough, shortness of breath, fever) OR
- Have a risk factor such as
- Contact with someone confirmed to have COVID-19
- A compromised immune system or serious medical condition
The release also has now made testing available for individuals with or without symptoms who:
- Work in a healthcare facility
- Work in correctional facilities such as jails or prisons
- Serve as first responders, such as paramedics, emergency medical technicians, law enforcement officers, or firefighters
- Support critical infrastructure, such as workers in grocery stores, pharmacies, restaurants, gas stations, public utilities, factories, childcare and sanitation.
For more information and a list of testing sites please click here.
Resources for Reopening the Chiropractic Physician Office [Updated 5/7/2020]
From the time of recognition of COVID-19 as a pandemic, chiropractic physicians have been designated as essential providers who could remain open to render medically necessary services in acute pain cases. In some cases, practice owners chose to temporarily close for reasons of economics, staffing problems, vulnerability of patient populations, or liability. As some of those practices consider reopening, they are seeking guidance as to how to do so in a safe and compliant manner. Of course, this is uncharted territory that is completely different from the initial opening of the physician office pre-COVID-19.
The ICS recommends that practice owners consult the following information sources specific to physician practices. They address topics such as governmental guidance, planning and opening in phases, safety measures for patients and staff, screening and scheduling procedures, use of telehealth, staffing, sanitation, equipment, business and liability considerations, and others:
Both sources provide detailed steps for a safe, smooth, and successful office reopening.
OSHA and Illinois Outline Risk and Reporting for Employees and Employers [Updated 4/20/2020]
In addition to CDC and other guidelines related to the care and treatment of patients, physician offices must comply with OSHA standards for safe workplaces. Illinois physicians are impacted by these standards as both employers and employees.
The State of Illinois recently issued a release advising that both the Attorney General and the federal OSHA are investigating complaints about workplace safety violations related to COVID-19. These agencies encourage voluntary compliance with CDC guidelines for social distancing, limitations on number of persons, and sanitation recommendations. However, they consider failure to provide adequate personal protective equipment (PPE) as a high-risk violation to be referred for enforcement: https://www.osha.gov/SLTC/covid-19/standards.html#directives.
The State release explains the steps taken to evaluate OSHA complaints and includes links for the online filing of OSHA complaints. Private sector employees may file complaints with OSHA www.osha.gov/pls/osha7/eComplaintForm.html and/or with the Illinois Attorney General https://illinoisattorneygeneral.gov/rights/labor_employ.html.
Workers’ Compensation – Amendment Makes Essential Workers and COVID-19 Claims Presumed Compensable with Employer Right to Rebut [Updated 6/2/2020 11:00 am]
As the ICS reported, on April 13, 2020, the Illinois Workers’ Compensation Commission adopted an emergency rule that applied to first responders and front line (essential) workers, making it easier for them to collect workers’ compensation if they missed work due to COVID-19 exposure. Essentially the rule granted automatic compensation to essential workers who claimed they experienced a period of incapacity due to COVID-19, unless the employer could prove the employee’s exposure was not work-related. However, the rule did not specify how an employer could negate an employee’s claim in these cases. In response to a successful legal challenge filed by the Illinois Retail Merchants’ Association and the Illinois Manufacturers’ the IWCC withdrew the rule, and the legislature passed a compromise bill to clarify how an employer can challenge this type of claim. The bill is now on the Governor’s desk awaiting his signature.
Ordinarily, to qualify for workers’ compensation, an employee must prove that an injury occurred during the scope of employment and that his/her assigned tasks caused the harm. In legal terms, the worker has the burden to prove these elements of the claim. Under the new bill, when an essential worker files a workers’ compensation claim for lost time due to COVID-19, the burden shifts to the employer to prove the claim did not arise from, and was not caused by, the employee’s job. The employer may provide evidence to attempt to refute the claim, which may include (without limitation) any or all of the following:
- The employee was working from home for 14 or more consecutive days prior to becoming ill;
- The employer was applying to the best extent possible all industry-specific guidelines for health and safety practices to reduce the transmission of COVID-19;
- The employee was exposed to COVID-19 by an alternate source.
For the presumption to apply, for COVID-19 diagnoses occurring on or before June 15, 2020, an employee must provide a confirmed medical diagnosis by a licensed medical practitioner or a positive laboratory test for the virus or antibodies. For diagnoses occurring after June 15, 2020, an employee must provide a positive laboratory test for the virus or antibodies. Because physician office staff are essential employees, this provision will apply in cases where a staff member files a claim for COVID-19 exposure. Therefore, benefits will be automatic unless the employer rebuts the claim by presenting evidence that the staff member did not contract the virus as part of his/her employment. The ICS anticipates that the Governor will sign this bipartisan into law in the near future.
Editor’s Note: The ICS has recently added a new ICS member benefit for workers’ compensation insurance. The policies are handled by Ameriprotect, underwritten by Hartford, and require ICS membership. Find out more about how to access these potential significant savings here.
Does Malpractice Insurance Cover Claims of Coronavirus Exposure in a Chiropractic Physician Office? [Updated 4/28/2020]
A professional liability (malpractice) policy is a legally binding contract. As a contract, the terms of each policy will determine what is covered and what is excluded, so it is important to review your individual policy for these items. Sometimes exclusions are added in riders (attachments) to the document, so you should review the full policy.
However, there are some general provisions that usually apply in malpractice policies. One of the most important is that insurance covers “ordinary negligence” but does not cover more extreme forms of negligence, nor does it cover criminal acts. Ordinary negligence occurs when someone does something that a reasonably careful doctor would not do under similar circumstances, or fails to do something a reasonably careful doctor would do. Negligence law requires reasonable measures to protect oneself and others from harm.
The ICS has carefully reviewed information provided by two major chiropractic liability carriers. Both strongly urge that physicians who choose to keep their offices open must follow guidelines recommended by the CDC and other authorities to reduce possible transmission of the virus. Following these steps MAY comply with policy requirements for the company to cover claims that a patient or employee contracted COVID-19 in your office. However, once it is determined that the insurer will cover you for a claim, whether the claim is compensable (i.e., whether your office committed the type of negligence covered by the policy) is determined on a case-by-case basis that will include expert opinions on the standard of care for your office, your practice, and your geographical area. Remember that simply because an individual has an unwanted outcome (e.g., contracts the virus) does not mean the office failed to meet the standard of care, so meeting the recommended protocols may greatly mitigate or defeat damages in these cases.
For reference, the following steps are recommended by one malpractice insurer:
- Establish and follow a thorough cleaning process for all areas of your office, including the waiting room, reception area, exam rooms and restrooms.
- Do not allow staff members who are sick, have been sick or have sick family members to come to the office.
- Have a detailed conversation by phone with the patient on the day they’re scheduled to come in, and ask:
- If they or anyone in their family has a fever or has had one in the last two weeks. The incubation period can be as long as 24 days.
- Have they or family members had any symptoms of a cold or flu? Symptoms include fever, tiredness, and a cough that isn’t necessarily productive. They may also have or have had aches and pains, runny nose or nasal congestion, and vomiting or diarrhea.
- Have they traveled abroad in the last two weeks?
- Have they been near anyone who has potentially had the virus through their own family or work contact? People can be contagious without symptoms.
- Ask high-risk patients to delay if possible. High-risk patients are those who:
- Are undergoing chemotherapy.
- Are immunocompromised.
- Are diabetic.
- Have heart disease.
- Have high blood pressure.
- Have asthma or another respiratory issue.
- Are over 60 years of age.
- Stagger appointments to allow time for thorough cleaning between sessions.
- Ask patients to wait in their car (rather than the waiting room) until it’s time for their appointment.
- Ask anyone accompanying the patient to wait in the car during the appointment if possible.
- Remove magazines and other printed reading material.
- Remove toys or other diversions you may have in the office for children.
Another chiropractic liability insurer provides the following information regarding physician liability for COVID-19 transmission in the office:
In regard to patients:
Physicians ALWAYS have a duty to utilize “universal precautions” notwithstanding the current crisis. Universal precautions, standard precautions, and contact precautions should ALWAYS be utilized with all patients – those are the standards to prevent cross-contamination. To the extent a physician is not following current generally accepted guidelines, they may be held liable to a patient or staff member.
Offices should already have policies in place to aid in prevention of all respiratory diseases, but if not, the office should immediately put into effect strict respiratory hygiene/cough etiquette guidelines.
More on the CDC website:
In regard to staff:
OSHA’s General Duty Clause, Section 5(a)(1) of the Act, requires an employer to protect its employees against “recognized hazards” to safety or health which may cause serious injury or death. While there is no specific regulation dealing with COVID-19, it is the General Duty Clause which mandates that you must act to protect your employees.
You are obligated under OSHA to develop a written plan to protect your employees from this risk. The plan assessing the “hazard” should include, but is not limited to:
- Training employees with regard to the hazard
- Revisiting the procedures utilized with personal protective equipment (PPE)
- Recording (logging) any illness which are occupationally related
- Documenting all efforts and training on this hazard
More information from OSHA:
Important Note: You should document all procedures – cleaning, staff screening, patient screening, etc. Create a document that demonstrates the procedures and document regular screenings with checklists or other similar mechanisms.
Please see the patient and staff screening section below for screening tools.
Patient and Staff Screening Tools [Updated 5/26/2020]
The CDC updated the list of symptoms without fanfare on April 17 and those changes have been reflected in the new screening documents below. If you downloaded these screenings before 4/28/2020, please download the new versions below.
[Updated 5/26/2020] In Illinois’ new guidelines, DCEO is specifically requiring ALL businesses to screen employees at the beginning of their shift AND mid-shift. This means that chiropractic physicians must screen all employees (including themselves) at the beginning of the day and at least once later in their shift – No fewer than twice daily. You can use the download above to document compliance.
The patient screening documents can be included in their file, and staff screening documents can be kept in separate files for each employee. Current CDC information regarding symptoms.
Considerations for Expiring Certifications and/or Diplomates [Updated 5/11/2020]
In the middle of times like this, we tend to let some things move to the back burner, but chiropractic physicians may want to take a moment and review the expiration dates (or renewal dates) of your certifications and diplomates. Here is some examples:
- CPR Certification – Some health care certifications (i.e. CCSP) and some PPO agreements require that holders maintain an active CPR certification. You should check your expiration date on your CPR card to determine if you need to update it. If you hold a CPR certification from the American Heart Association, they have extendedthe expiration of all cards from March 1, 2020 forward by 120 days. The American Red Cross requires a very short online training (no actual training takes place, it only requires you to agree to simple terms and conditions) after which students are emailed a 120 day extension certificate. However, be aware that the American Heart Association told the ICS that although they are giving the extension, the entity that requires the certification has to accept that extension.
- CCSP (Certified Chiropractic Sports Physician) – The American Chiropractic Board of Sports Physicians has indicated that they are extending some CCSP expirations to September 30, 2020. However, they also indicated that they require hands-on CPR certification and recertification and thus a hands-on course will be required by September 30. Once we are closer to that date and you find problems updating your CPR certification (or other CCSP courses), we are recommending that you reach out directly to ACBSP.
Other Certifications and Diplomates – If you review your renewal dates and expirations of other certifications and find that you will not be able to meet the deadline as a direct result of governmental orders, CDC group guidelines, or other issues related to COVID-19, the ICS recommends reaching out directly to the governing body of the certification or diplomate to determine your best course of action.
Business Issues and Steps You Can Take to Protect Your Practice [Updated 3/27/2020]
The following links provide helpful, non-state-specific information about unemployment, family and medical leave, employer tax credits, business interruption insurance, and other topics of interest to businesses:
The “Families First” law is federal and applies to all employers of 500 or fewer, so the information pertaining to employee leave under Families First will apply to most, if not all, of our doctors. Here is information from Hinshaw Law regarding Families First (https://www.hinshawlaw.com/newsroom-updates-employer-faqs-for-covid-19-coronavirus.html).
Unemployment compensation is under state jurisdiction, so doctors should refer to the Illinois Department of Employment Security for specific guidance in Illinois:
General Information (https://www2.illinois.gov/ides/Pages/default.aspx), and
COVID-19 Specific Information (https://www2.illinois.gov/sites/coronavirus/FAQ/Pages/Unemployment-FAQ.aspx).
The ICS is continuing research to answer questions about the interplay of unemployment compensation and physician abandonment, treating patients while receiving unemployment compensation, and whether the business structure has an impact on eligibility unemployment compensation. We will update as soon as we have reliable information to share.
Additionally, the ICS is offering an on-demand course on “Protecting Your Chiropractic Business During the Covid-19 Pandemic.” Click here to take the course.
Temporary Closing of Offices [Updated 3/24/2020]
At this time, the ICS recommends that doctors use their best professional judgment, applying relevant guidelines, such as those of the CDC and the White House Coronavirus Task Force, to determine whether to close offices.
- The ICS recommends closing any office that does not have staff or resources to maintain strict CDC disinfecting protocols, social distancing, and other prevention tools. Here are the CDC Guidelines for healthcare settings.
- Any office that has more than 10 persons present at a time should close or schedule staff and patients to reduce the number of persons to 10 or fewer.
- Additionally, the ICS notes that the Illinois Dental Society has recommended closing offices. Chiropractic physicians may want to review their release to assist in deciding whether to remain open or temporarily close.
- Offices that close should make certain that patients have access to medical care during this period to avoid patient abandonment. The ICS recommends including a section in your closing letter to patients advising that you are available for phone calls for emergencies and providing a phone number. The letter should indicate your availability to triage patient issues by phone and make the best recommendation for their care, based on their symptoms and condition, as well as the status of the Coronavirus pandemic. Doctors should provide a health care alternative for their patients to contact, such as the County Health Department, for additional advice and/or necessary services.
- Physician offices should let patients know that they will make every effort to comply as quickly as possible with medical record requests during the closure period. Provide information about how patients may obtain records (such as providing phone and/or email contact information) and respond to requests promptly.
If you have unopened Personal Protection Equipment (PPE), the state is in dire need of these items. Please visit the Illinois COVID-19 PPE site to find out how your PPE can make a difference in the state and how to make it available.
Hereis a template letter for patients to notify of a temporary closure.
Offices Remaining Open – Screening and Protection [Updated 4/21/2020]
The Governor’s “Stay at Home” order (Executive Order 2020-10) classified healthcare services as essential services. The order permits individuals to visit health care professionals and for clinics to remain open to provide healthcare services, applying social distancing and strict disinfecting protocols. However, to minimize the possibility of transmission, many offices have chosen to limit in-office visits to urgent and/or medically necessary services, and to use telehealth whenever possible and appropriate. Additionally, physicians should check with their general, professional liability, and workers’ compensation carriers to determine coverage for possible claims by employees and patient visitors that they contracted COVID-19 in your office.
For offices that remain open for any services, the ICS recommends applying the most current CDC guidelines to the following steps:
- Screen patients who call with concerns that they may be infected with Coronavirus (see link below) and refer the patient to their county health department;
- Reschedule staff and patients so that no more than 10 persons are in the office at a time, and comply with the Governor’s Executive Order regarding social distancing, including by maintaining social distancing for employees as possible and six-foot requirements for members of the public in waiting rooms;
- Conduct “pre-screening” of staff at the beginning of the shift and prior to any patient contact, assessing the presence of symptoms and risk, and sending staff home or referring for testing where appropriate. Here is a documentation template;
- Consider using a “parking lot waiting room.” By calling patients into the office one at a time and taking the patient immediately back to a treatment room, this reduces potential exposure.
- Consider limiting visitors that come to the office with patients. Although this may not be possible with children and parents, those in need of direct assistance, or parents who have no other child care alternatives, consider visitor limitation whenever reasonable;
- Screen all patients who come to the office for services and any persons who accompany patients by taking temperatures and interviewing for other symptoms, including cough and shortness of breath, plus other risk factors (exposure to positive cases and travel). Segregate, mask and refer to the county health department or hospital any patient who is possibly infected. Here is a documentation template for patients;
- Conduct regular screening of all other individuals who are present in the office for more than a brief time. This includes screening of workers’ children who are brought to the office in lieu of daycare. If a child in the office is determined to be positive for COVID-19 risk factors, the child should be segregated, masked and send home with the parent worker with referral instructions to the county health department or hospital (see the Patient and Staff Screening Tools section for more);
- The ICS recommends the same protocol for cleaning staff, computer technicians, and other service providers who spend more than a brief time on the premises. Any person who is determined to have positive risk factors should be segregated, masked and referred to the county health department or hospital any patient who is possibly infected;
- Additionally, practice regular disinfection of patient surfaces and facilities while using appropriate gloves (see CDC guidelines for cleaning);
- Suspend restrictions on cancellations and do not apply penalties for cancellations and no-shows;
- If you have not done so already, set up remote employment for staff who perform administrative, non-patient care tasks, such as billing, to avoid unnecessary exposure to the office; and
- Begin to use telehealth for care that may be rendered in that format (see paragraph below and ICS webinar on using telehealth in a chiropractic practice).
[Updated 4/15/2020] Regarding physician and staff precautions, the ICS is making the following recommendations based on the current recommendations from IDPH, CDC, OSHA, and the governor’s office:
- All staff – Illinois Department of Public Health and the governor have both strongly suggested that all persons should wear masks when out in public. This includes either single-use surgical masks, homemade cloth masks, or scarves and bandanas. Because they have stated that the purpose of the mask is to protect against potential transmission to others of the virus (especially by non-symptomatic COVID-infected persons), the ICS believes that this recommendation applies to any physician who is treating patients. Therefore, in addition to following CDC and OSHA guidance (see links above), all staff should wear some kind of mask during office hours when others are present. An exception would apply if the staff has either NO contact with others in the office or the staff person is behind a plexiglass screen at the front desk;
- Any staff performing hands-on treatment – Hands-on treatment staff should be using additional personal protective equipment such as single-use only medical exam gloves that should be disposed of after EACH patient to avoid potential cross-contamination.
- Additionally, if the hands-on treatment staff makes body contact with the patient such that staff garment touches patient garment or skin (i.e. side-posture adjustment), staff should either use disposable gowns (disposed of after each patient) OR spray clothes between patients (see NCMIC’s recommendation concerning this contact);
The ICS has curated these recommendations from a variety of guidelines and recommendations from IDPH, CDC, OSHA, and the governor’s office. For example, OSHA has indicated that “Workers with medium exposure risk may need to wear some combination of gloves, a gown, a face mask, and/or a face shield or goggles. PPE ensembles for workers in the medium exposure risk category will vary by work task, the results of the employer’s hazard assessment, and the types of exposures workers have on the job.” Since they have used the word “combination,” we believe the intention is no fewer than two from the list. The two that make the most sense for chiropractic physician offices would be masks and gloves. However, we would encourage the use of as much reasonable protection equipment as you deem necessary for your office and your specific practice.
[Updated April 21, 2020] Additionally, on April 21, 2020, the Illinois State Attorney General announced a cooperative program with local and county Boards of Health to address businesses who are not exercising proper protocols for PPE and cleaning. This statement addressed the methods that have been and will continue to be used to ensure the protection of the public and employees and include inspection, instruction, and enforcement. These steps highlight the continued importance of proper protocols in all settings, including chiropractic physician offices.
Return to Work Guidelines for Healthcare Personnel and Staff with Confirmed or Suspected COVID-19 [Updated 5/14/2020]
The federal Centers for Disease Control and Prevention (CDC) and the Illinois Department of Public Health (IDPH) have issued guidelines for determining when and how healthcare personnel (HCP), including staff, may return to work after having confirmed or suspected COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html#confirmed-suspected
The State has adopted CDC guidance at this time, although it may be adapted by state and local health departments to respond to rapidly changing local circumstances. Therefore, the ICS recommends being aware of both the general CDC guidance, as well as any county or municipal recommendations in local areas (check with your local health department).
[Updated May 14, 2020] The CDC return-to-work standards were recently updated and apply to healthcare personnel (HCP) with confirmed COVID-19, or who have had suspected COVID-19 (e.g., developed symptoms of a respiratory infection [e.g., cough, sore throat, shortness of breath, fever] but did not get tested for COVID-19). Options include a test-based strategy (time since onset) where testing is available or a symptom-based strategy. Here is the CDC information available on May 14, 2020:
“Symptomatic HCP with suspected or confirmed COVID-19 (Either strategy is acceptable depending on local circumstances):
- Symptom-based strategy. Exclude from work until:
- At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
- At least 10 days have passed since symptoms first appeared
- Test-based strategy. Exclude from work until:
- Resolution of fever without the use of fever-reducing medications and
- Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
- Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for 2019 Novel Coronavirus (2019-nCoV). Of note, there have been reports of prolonged detection of RNA without direct correlation to viral culture.
HCP with laboratory-confirmed COVID-19 who have not had any symptoms (Either strategy is acceptable depending on local circumstances):
- Time-based strategy. Exclude from work until:
- 10 days have passed since the date of their first positive COVID-19 diagnostic test assuming they have not subsequently developed symptoms since their positive test. If they develop symptoms, then the symptom-based or test-based strategy should be used. Note, because symptoms cannot be used to gauge where these individuals are in the course of their illness, it is possible that the duration of viral shedding could be longer or shorter than 10 days after their first positive test.
- Test-based strategy. Exclude from work until:
- Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens). Note, because of the absence of symptoms, it is not possible to gauge where these individual [sic] are in the course of their illness. There have been reports of prolonged detection of RNA without direct correlation to viral culture.”
Return to Work Practices and Work Restrictions
[Updated 5/14/2020] The CDC has also provided guidance for protocols after returning to work. HCP should:
- Wear a facemask for source control at all times while in the healthcare facility until all symptoms are completely resolved or at baseline. A facemask instead of a cloth face covering should be used by these HCP for source control during this time period while in the facility.
Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen.
Advertising and marketing caveat [Updated 5/11/2020]
This information is increasingly important, as we are continuing to hear of marketing claims made around the country that would be unprovable and likely result in disciplinary action. These claims are being made in a number of different platforms, including Facebook, YouTube videos, Instagram, and other social media. To be clear, at this time there is no empirical evidence that care provided by a chiropractic physician prevents or cures COVID-19. Please do not make these claims either directly, indirectly, or even through inference (i.e. citing a study regarding the Spanish Flu).
This advertising caution includes references to procedures that are used in both musculoskeletal care and functional medicine, including, without limitation, adjustments and detoxification diets. The same would apply to the sharing or promotion of some of the home remedies currently circulating, such as gargling with bleach or saltwater.
The ICS strongly recommends that our members exercise extreme care in advertising at this time and refrain from making claims that are not substantiated by peer-reviewed, empirical evidence about COVID-19. Both the U.S. Department of Justice and state regulators are on high alert for the exploitation of the pandemic and may view as grounds for prosecution and/or license suspension any claim that certain treatments can prevent or cure COVID-19 until more is known about the virus.
On 3/17/2020, Illinois Attorney General Kwame Raoul announced that his office will strictly enforce the Illinois Consumer Fraud Act against any individual who claims to have any method for immunizing, protecting from, or treating Coronavirus because the CDC has not approved any such method. Attorney General Raoul has encouraged the public to report such instances to his office for investigation and prosecution. Penalties for violations of the Act can include criminal conviction, injunction order, financial damages, punitive damages, and attorneys’ fees. Additionally, Governor Pritzker issued an executive order that prohibits price gouging and gives the Attorney General’s office enforcement authority. The Attorney General’s office is prioritizing enforcement action. Physicians have an additional risk for license discipline (up to revocation) by the Illinois Department of Financial and Professional Regulation for any such conduct.
On 3/23/2020, a chiropractor in Bend, Oregon settled with the Department of Justice for her advertising claims around COVID-19. Please do NOT use social media, video, websites, print or on-air advertising to make claims that cannot be directly supported with evidence. This clearly shows that advertising and marketing whether implied or directly related to COVID-19 is being scrutinized by the public, by Illinois regulators, and by federal regulators.
On April 27, 2020, U.S. Attorney’s office out of Texas filed enforcement action against a chiropractor promoting fake covid-19 treatment. The full release from the US Attorney can be found here. This demonstrates the ongoing scrutiny of regulatory bodies during the pandemic. Please continue to be cautious to not use any marketing 1) that can be construed to mislead the public, 2) without published research, 3) that asserts claims regarding cures and prevention of COVID-19 (direct or implied).
[Updated May 11, 2020] The Federal Trade Commission is now sending warning letters to health care providers and health care suppliers across the country (including at least three in Illinois) regarding advertising and claims related to COVID-19 prevention and treatment. The letters warned “marketers nationwide to stop making unsubstantiated claims that their products and therapies can treat or prevent COVID-19.” Although the warning letters are specific to each of the nearly 100 targets, each warn that “It is unlawful under the FTC Act, 15 U.S.C. § 41 et seq., to advertise that a product or service can prevent, treat, or cure human disease unless you possess competent and reliable scientific evidence, including, when appropriate, well-controlled human clinical studies, substantiating that the claims are true at the time they are made.”
[Updated May 11, 2020] Please remember that these warnings are public and may be reviewed by IDFPR and may potentially result in license discipline. Please continue to be diligent in your advertising and marketing during this pandemic.
Lastly, based on the White House Coronavirus Task Force guideline to cancel events with more than 10 people, the ICS strongly suggests chiropractic offices should cancel all practice marketing events, such as health fairs or informational seminars, for the foreseeable future.
Physician License Expiration and Renewal Deadline Change – [Updated 3/18/2020]
The ICS office has been asked whether the Illinois Department of Financial and Professional Regulation (IDFPR) will extend the regular license expiration date of July 31, 2020, due to the Coronavirus pandemic. On March 18, 2020, at 6:30 pm, IDFPR announced several variances for many different licenses. Chiropractic physician license expirations have been extended to September 30. 2020.
In addition to the variance for license renewal, the department included the same extension for completing required continuing education (CME). As a result, all requirements for renewal (fees, CME, etc.) now have a deadline of September 30, 2020.
Guidance For Health Care Practitioners Who Have Tested Positive For Coronavirus And Notification To Patients [Updated 5/11/2020]
We are seeing more and more COVID-19 cases of health care workers not on the “COVID-19 treatment frontline.” As a result, the ICS has been asked what steps should be taken by a health care practitioner (HCP) who has tested positive for the virus. The CDC has published interim guidance to help with assessment of risk, monitoring, and work restriction decisions for HCP with potential exposure to COVID-19, applicable in healthcare settings. The full guidance document may be viewed here.
Based on guidelines taken from IDPH guidance for dental providers, the CDC guidance, and what we hear from various local health departments in Illinois, the ICS currently recommends the following steps to take if you are a chiropractic physician and have tested positive:
- Contact your local health department if they have not already contacted you. This is a critical first step.
- Please cancel all appointments and stop treating immediately.
- Self-quarantine according to the CDC guidelines and as directed by your local health department (most likely 14 days).
- Notify patients treated in the 48 hours prior to symptom onset.
- Notify staff with whom the provider had direct contact in the 48 hours prior to symptom onset.
- If the diagnosis would result in a closed office, please review the closed office section in this article.
As always, physicians should comply with all mandates and recommendations of their state and local health authorities.
CDC Guidance For Health Care Practitioners Who Have Been Exposed to COVID-19 [Updated 4/9/2020]
The CDC has taken a conservative approach to work restrictions in health care settings, because, by the nature of their work, health care professionals (HCP) often have extensive and close contact with vulnerable individuals in the office setting. The CDC must balance the need for essential health care with the risk of exposure to patients, staff, and others. The CDC’s approach is to quickly identify early symptoms and prevent transmission from potentially contagious HCP to patients, HCP, and visitors, and to err on the side of early evaluation and testing of symptomatic HCP, particularly those who fall into the high-and medium-risk categories described in theguidance. CDC does not include secondary exposure (i.e. spouse of a patient tests positive) in its risk assessment, because the tool focuses only on possible direct exposure of a HPC to an infected person.
The recommended action for monitoring and work restrictions will depend on whether the HCP’s exposure is considered low, medium, or high risk. CDC has provided a detailed chart for multiple scenarios, incorporating epidemiologic risk factors, exposure category, recommended monitoring for COVID-19 (until 14 days after last potential exposure), and work restrictions for asymptomatic HCP.
Additionally, on April 7, 2020, the CDC changed their recommendations for Critical Infrastructure Workers Who May Have Had Exposure to a Person with Suspected or Confirmed COVID-19 and now allows exposed workers to return to work sooner. Although this new guidance is primarily for non-healthcare related essential workers, it provides additional guidance for your office. The guidance indicates the following:
“Critical Infrastructure workers who have had an exposure but remain asymptomatic should adhere to the following practices prior to and during their work shift:
- Pre-Screen: Employers should measure the employee’s temperature and assess symptoms prior to them starting work. Ideally, temperature checks should happen before the individual enters the facility.
- Regular Monitoring: As long as the employee doesn’t have a temperature or symptoms, they should self-monitor under the supervision of their employer’s occupational health program.
- Wear a Mask: The employee should wear a face mask at all times while in the workplace for 14 days after last exposure. Employers can issue facemasks or can approve employees’ supplied cloth face coverings in the event of shortages.
- Social Distance: The employee should maintain 6 feet and practice social distancing as work duties permit in the workplace.
- Disinfect and Clean workspaces: Clean and disinfect all areas such as offices, bathrooms, common areas, shared electronic equipment routinely.”
Steps to Take Following Primary Exposure:
- Notify the local county health department of the exposure,
- Work through the CDC Risk Assessment tool,
- Review and follow the ADDITIONAL guidance from the CDC regarding Critical Infrastructure Workers,
Healthcare providers, in consultation with public health authorities, should use clinical judgment to assign risk and determine need for work restrictions.
Annual Reports Now Due on Original Filing Dates– Illinois Legislative Committee Suspends Extension of Annual Report Deadline For Corporations And LLCs [Updated 5/29/2020 12:00 pm]
Owners of corporations and limited liability companies must file with the Secretary of State an annual report that is due on each anniversary of the entity’s formation. This requirement applies to medical corporations, professional service corporations, and professional limited liability companies whose purpose is to provide health care services. See detailed article on annual reports here. These reports may be filed online or in hard copy format.
The ICS reported in April that the Illinois Secretary of State had filed an emergency rule that extended the filing deadlines for any report due to be filed on or after March 17, 2020.However, the legislative committee that reviews administrative rules suspended the extension, finding that statutory deadlines may only be extended by gubernatorial executive order and not by agency rule. Therefore, all filing deadlines have reverted back to their original due dates. In general, this is the anniversary date of the corporation or professional limited liability company.
Annual reports may be filed online or by regular mail (PLLCs, medical and professional service corporations). The ICS recommends saving a copy of the signed report, and for those who send hard copies, using a trackable form of mailing.
Addresses for hard copy annual report filings are as follows:
Secretary of State
Business Services Department
Howlett Building, Room 350
Springfield, IL, 62756
Secretary of State
Business Services Department
69 West Washington, Suite 1240 Chicago, IL, 60602
Collections During the Pandemic [Updated 5/27/2020]
Although the governor suspended a few post-judgment collection procedures (such as wage garnishments) under his pandemic disaster declarations, none of these orders changed the underlying debts or prevented creditors from using non-judicial methods to collect. Moreover, this order under the disaster declaration will expire after May 28. Therefore, physician creditors may continue to use usual collection methods to collect any valid bill for professional services. Beginning May 29, physician creditors who already have court judgments against non-paying patients may use judicial procedures (such as wage garnishments and citations to discover assets) beginning May 29.
Additionally, physicians who engage collection agencies to collect unpaid fees may note that the Illinois Department of Financial and Professional Regulation issued guidance on March 30, 2020, for licensed collection agencies during the pandemic. In the guidance, the Department encouraged debt collection agencies and debt buyers to work with consumers to modify payment schedules or suspend all collection activity for a period of no less than 60 days. However, because 60 days from the date of the guidance is about to expire, collection agencies who may have suspended activities or modified payment activities may well return to usual procedures.
The IDFPR also reminded collection agencies to adhere strictly to the requirements of federal debt collection law, which prohibit communications at times and places that should be known to be inconvenient to the debtor. In light of the economic stress caused by the COVID-19 crisis, the Department has said it will closely monitor adherence to these provisions. For physicians who contract with collection agencies, it is a best practice to work with an organization that is reputable and compliant. Moreover, it may be unethical conduct for a physician to knowingly and intentionally hire an agency to make harassing, illegal calls and engage in other illegal collection activities.
Lastly, there is nothing in the proclamations that prevents physicians from sending bills to patients or collecting amounts due from patients.
Donations and Volunteering
Volunteering to Assist in the COVID-19 Response – [Updated 3/30/2020]
The State of Illinois has developed Illinois HELPS, which is the healthcare professional emergency volunteer program. Illinois HELPS allows healthcare professionals to register to volunteer to assist in the state coronavirus effort. Volunteers may be placed at both hospital surge and alternative housing sites throughout the state. Currently, the state does have certain placements they are trying to fill but are also signing up volunteers for future opportunities.
Chiropractic physicians that would like to volunteer should do so at the website link below.
For more information and to sign up for Illinois HELPS visit: www.illinoishelps.net
Donation of Personal Protective Equipment (PPE) [Updated 3/26/2020]
The State of Illinois, as well as the Illinois Health and Hospital Association, have issued a call to action for all unused Personal Protective Equipment (PPE). They are asking anyone who has unused, unopened PPE to donate it to hospital personnel and first responders.
The type of equipment being requested includes masks, gowns, gloves, and many other PPE items. For a full listing of items being requested and requirements please visit the State donation website site by clicking here.
Please note, the state requires all donated PPE to be unopened and in the original packaging from the manufacturer. To donate, please email the state at PPE.email@example.com.
For more information, please visit the Illinois PPE Donation Page.
To see the full press release from the Illinois Health and Hospital Association click here.
Coronavirus Scams [Updated 4/15/2020]
Unfortunately, scammers are taking advantage of fear and anxiety to defraud the public, including health care practitioners, during the Coronavirus pandemic. These schemes may come in the form of phishing phone calls seeking personal and financial information, or as online sales of bogus testing and “treatments” for COVID-19. The FTC, FDA, IRS and other agencies have provided excellent information about the types of communication that should raise an immediate alert and to which you should not respond.
One form of scam is for the caller to steal economic impact payments intended for recipients as relief money ($1,200 individual/$2,400 couple/$500 per child). The FDA has clarified that recipients don’t need to do anything, as long as they have filed taxes for 2018 and/or 2019, and that recipients should not give anyone personal information to “sign up” for the check. For more details, see the FTC website hereand IRS information on economic impact payments.
Of course, scammers will no doubt attempt to obtain personal information from persons who are eligible for other forms of government relief, such as payment protection money and unemployment compensation, during the pandemic. As always, the ICS strongly recommends not giving any information during a phone call and not clicking on links contained in an email from unknown senders. There is more than sufficient information online to allow individuals to verify the steps necessary to obtain and process stimulus funds. Any required phone contact should be initiated by the eligible person after verifying the correct phone contact information online.
Unapproved Products and False Advertising
In March, the FTC and FDA sent warning letters to seven sellers of unapproved and misbranded products, claiming they can treat or prevent the Coronavirus. This month, the FTC sent warning letters to 10 more companies. The unapproved products include supplements called an “ANTI-VIRUS KIT” and intravenous (IV) “therapies” with high doses of Vitamin C. The FTC says the companies have no evidence to back up their claims, as required by law.
Some of the FTC’s letters challenge products sold online; others challenge treatments offered in clinics or for use at home. The U.S. Food and Drug Administration (FDA) continues to say there currently are no products proven to treat or prevent the virus. The Illinois Attorney General has taken the same position and has publicly committed to strict enforcement. The ICS recommends that doctors be vigilant in products they purchase and advertise for use during the pandemic. For more details, see the FTC release here.
Important Public Health Alert about KN95 Masks [Updated 4/17/2020]
On April 15, 2020, the Illinois Department of Public Health (IDPH) issued a Health Alert that recommended discontinuing the use of imported KN95 respirators. NOTE THAT IDPH UPDATED AND CLARIFIED ITS HEALTH ALERT ON APRIL 16, (here is a copy of the alert) as detailed below.
A KN95 mask is a filtering mask made to Chinese standards (intended to be similar to an N95 mask under U.S. standards). Regular surgical or procedural masks, rather than N95 respirators, are appropriate for most chiropractic physician procedures, as they are non-aerosolizing. However, those chiropractic physicians who may use an N95 respirator should be aware of updated IDPH standards for their use, due to questions about some counterfeit masks from China. CDC recommends that all healthcare providers prioritize the use of an N95 respirator mask or equivalent for any patient procedures that are suspected or confirmed to have COVID-19 and undergoing aerosolizing procedures. For details, including a list of aerosolizing and non-aerosolizing procedures appropriate to N95 or regular masks, see the IDPH Health Alert here:
When supplies are available, IDPH recommends using NIOSH-approved N95s or similar respirators for aerosol-generating procedures, such as intubations. When supplies of NIOSH-approved N95s are not available, authorized respirators listed on the FDA’s list of authorized respirators on Appendix A may be used. When used in this manner, employees should still be fit tested to confirm a proper fit. Appendix A provides a list of these respirators. This listing changes frequently so partner agencies should check it often.
IDPH recommends using KN95 respirators that are not included in Appendix A to FDA’s EUA as acceptable crisis alternatives to medical procedures or cloth masks. KN95s may provide equal or greater protection under these circumstances. IDPH is not recalling previously distributed KN95 respirators.
Employer and Employee Rights about Returning to Work during the Pandemic – Fear and Coronavirus [Updated 4/29/2020]
COVID-19 has raised questions from both employers and employees about whether and under what circumstances an employer may force an employee to return to the workplace, even when the employee has expressed fear about being exposed to the virus. In chiropractic physician offices, this could happen when an office has temporarily shut down but is ready to reopen, or when staff has been allowed to work remotely (for example, performing telehealth visits from home) but is now told to return to the office to perform essential services in person. May an employer terminate an employee who refuses to return due to fear of becoming infected? Does an employee who fears contracting the virus have a right to work off site during the pandemic? The answers are not always obvious and will require the parties to thoughtfully evaluate the facts of each situation.
Generally, employers are not required to permit staff to “telework,” especially employees who do not have written employment agreements and who may be terminated “at will” by the employer. Most chiropractic office staff fit into this category. There is no general rule that allows staff the right to work remotely, even for fear of becoming infected during a pandemic. An exception could occur in a state with a very stringent state quarantine order; however, because Illinois’ order permits chiropractic offices to remain open as essential businesses, the exception would not apply in Illinois. For associate chiropractic physicians who have written employment or independent contractor agreements, the language of the agreement will be given great weight if it contains a provision for a natural disaster or pandemic (“force majeure”). However, most employment agreements contain ordinary termination provisions that do not contemplate disasters or pandemics; therefore, most associate or contractor physicians will be subject to the same rules as described for staff above.
Another consideration is whether the physician office is compliant with the Occupational Safety and Health Act, which requires that employers provide safe working conditions for their employees. In the physician office, this would include adherence to protocols for providing adequate personal protective equipment (PPE) disinfecting, social distancing, and limitations on the number of persons permitted in the office at the same time. Because regulators consider failure to provide adequate personal protective equipment (PPE) as a high-risk violation, an employee could probably cite this failure as valid reason to refuse to return to the workplace. However, the type of PPE will vary with each fact situation. Employers of chiropractic offices are not required to provide office staff with the same N95 masks, goggles, face shields, and other PPE that is used by hospital staff in the COVID-19 Intensive Care Unit. Each practice owner will need to determine the appropriate level of PPE for each employee, based on the employee’s job, the nature of the practice, and the patient population at the office.
Another exception to the “no right to telecommute” rule could occur when an employee qualifies for a reasonable accommodation under the Americans with Disabilities Act (ADA), i.e., when the employee has a disability protected by the ADA (especially one that makes the employee higher risk for COVID-10, such as asthma, for example) but is able to perform the essential functions of his/her job from home. This is a demonstration of how fact-dependent each case will be, because “essential functions” are variable within each office, and from practice to practice. For example, an employee who performs billing services for one practice may be able to perform the job remotely, but the same may not apply to a receptionist in one office. However, in another office, it is possible billing must be done on-site because the practice does not have adequate software to permit billing off premises, but the receptionist only schedules patients, which can be done remotely. The Coronavirus pandemic has presented new challenges in every aspect of modern life, including employment. Each practice owner should make certain he/she is in compliance with CDC and OSHA safety protocols and assess the needs of the individual practice to determine when to require employees to return to the workplace. Similarly, if the practice is compliant with standard safety protocols, each employee must evaluate his/her risk tolerance for the specific job position.
Paid Sick Leave and Tax Credits for Coronavirus-Related Employee Leave [Updated 4/3/2020]
The Families First Act provides relief for both employees and employers affected by Coronavirus. Affected employees can receive up to two weeks (80 hours) of paid sick leave, at either 100%, 80%, or 2/3 of their regular pay, depending on the reason they are unable to work. However, employers are to receive full reimbursement for amounts paid for this type of leave, in the form of an immediate dollar-for-dollar tax offset against payroll taxes. Where a refund is owed, the IRS will send the refund as quickly as possible. These provisions apply to employers of less than 500.
There are two potential exemptions: one for healthcare workers and one for small businesses under 50. The principal exemption for our doctors would be for healthcare workers. You can find the definition in the Department of Labor clarification document and it includes “For the purposes of employees who may be exempted from paid sick leave or expanded family and medical leave by their employer under the FFCRA, a health care provider is anyone employed at any doctor’s office…” The Department of Labor has also stated in rules that “…such individuals include not only medical professionals but also other workers who are needed to keep… health care facilities well supplied and operational” and that it intentionally broadened the definition to further that purpose. Therefore, physician employers may apply this exemption to their employees.
The second exemption indicates “An employer […] with fewer than 50 employees (small business) is exempt from providing (a) paid sick leave due to school or place of care closures or child care provider unavailability for COVID-19 related reasons and (b) expanded family and medical leave due to school or place of care closures or child care provider unavailability for COVID-19 related reasons when doing so would jeopardize the viability of the small business as a going concern.” Department of Labor gives specific requirements in the document. At this time, it appears this exemption is self-determined by the employer. The ICS suggests our physician employers who claim this exemption run some basic calculations as to the projected cost of providing additional COVID-19 sick leave to document that it would jeopardize the office’s financial viability.
Note that although employees may be exempt from paid leave for COVID-19, they are still entitled to take ordinary accrued sick and vacation leave (if any) in accordance with the physician office’s usual policies.
The IRS issued a release summarizing in easy-to-understand terms the law’s provisions about paid leave, employer credits, prompt payment, and small business exemptions, with links to detailed information. Click here for that information.
Employers must post the Families First poster at their places of business. Download the poster here. The ICS has also provided an optional noticethat physician employers may use to notify their staff that all employees of healthcare offices are exempt from receiving additional sick leave. Physician employers may post this noticeor print in the form of a letter to hand to staff. Although this notice is not required, providing it may be useful to advise employees of the reason they will not receive paid leave under the Families First Act and to remind them that they may still avail themselves of the office’s usual and customary policies for sick leave and vacation. Download the notice here.
Employee Layoffs as a Result of COVID-19 [Updated 3/20/2020]
Unfortunately, many businesses are suffering unsustainable losses due to the pandemic and must lay off staff. Although there are federal and state versions of “WARN” Acts requiring larger employers to give 60 days’ prior notice of mass layoffs, these laws will apply to very few chiropractic physicians. The Illinois WARN covers employers with at least 75 full-time employees; the federal version is 100; and both address mass layoffs. Thus, most chiropractic physicians will not have to comply with these notice provisions.
Individual employees who do not have written employment agreements are “at-will” employees, and either party may end the working relationship at any time without cause (i.e, without any required advance notice). In the absence of a written agreement to the contrary, the employee has no right to severance pay. However, the employee will qualify for unemployment benefits. Most unlicensed staff will fall into this category. On the other hand, employees who have contracts, as most associate physicians do, are not “at will,” and issues such as notice of layoff and severance pay will be governed by the terms of the contract. These employees are also entitled to unemployment benefits when they are laid off.
For all laid-off employees, employers must pay all earned salary, any bonuses, and any unused vacation time, on the next regularly scheduled pay date for the employee’s last check. Additionally, employers are required to provide exiting employees with a document from IDES titled “What every worker should know“.
You should indicate your intentions on bringing your workforce back to the office following the current public health crisis. This will help them navigate the unemployment compensation waters during the crisis. You can also reference the state unemployment benefit site for COVID-19 here, as the state has modified some of the program requirements during this time.
In addition to legal considerations, layoffs are difficult personally for both employer and employee, and particularly so during the current crisis. For some helpful suggestions about how to handle the process, see this article.
Mental Health Information and Resources
Mental Health Resources [Updated 4/13/2020]
We all know about the physical side effects of this pandemic, but sometimes the mental health side effect is put on the back burner. If you notice your patients are negatively impacted by the mental health challenges associated with virus fears, stay at home order, unemployment, or many other potential mental health challenges right now, please refer them to speak with a mental health professional. Click here to find a mental health professional near you.
Additionally, on April 11, 2020, the Illinois Department of Human Services established a new service for individuals who would like to speak with a mental health professional. The program, titled Call4Calm, allows individuals to text an emotional support line free of charge and callers will remain anonymous. For individuals, seeking mental health assistance they can text “TALK” to 552020 (5-5-2-0-2-0) or for Spanish text “HABLAR” to the same number.
Once an individual texts the number (552020), a mental health counselor will return the call within 24 hours.
The hotline can also be used to navigate services from the state as well. If you wish to use the system to ask about things like unemployment, just text “unemployment” to the same number and information will be provided on how to find services.
Mental Health Webinar for Chiropractic Physicians – April 13: NCMIC is sponsoring a webinar that will provide guidance to chiropractic physicians about managing stress during this difficult time. It will also cover tips for discussing the current pandemic with patients. The webinar will be taught by Kerry Doyle, LICSW RYT-200, a Clinical Associate Professor at the University of Southern California Suzanne Dworak-Peck School of Social Work. The webinar is scheduled for Monday, April 13, at 2:00 pm CST. To register for the webinar please click here.
Governor Pritzker Orders and Requests
Chiropractic Physician Services Are Essential Services Under Federal CISA Advisory and Illinois “Stay at Home Order [Updated 4/24/2020]
Governor Pritzker’s “Stay at Home Order” has now been extended to May 30, 2020, and applies to all Illinoisans but makes exceptions for persons who provide and use essential services. The text indicates “For purposes of this Executive Order, individuals may leave their residence to work for or obtain services through Healthcare and Public Health Operations. Healthcare and Public Operations includes, but is not limited to: hospitals; clinics […] Healthcare and Public Health Operations shall be construed broadly to avoid any impacts to the delivery of healthcare, broadly defined.”
It is clear that the intent of the order continues to broadly include all types of providers and that all physicians, including chiropractic physicians, are exempted for the delivery of healthcare. Therefore, chiropractic physicians can treat patients and patients can visit your office. However, review the Chiropractic Maintenance Visits section below for important considerations.
[Updated 4/24/2020] The Governor’s 5/1/2020 stay-at-home order will make several changes. Of those changes, the following impact chiropractic physicians as follows:
- Face Coverings will be required in “public indoor spaces” which we believe would include chiropractic physician offices. These face coverings can be N95 masks or simply cloth masks (including bandanas, etc.). As a result, the ICS recommends that all chiropractic physicians and staff wear face coverings AND require patients to wear face coverings. We will be including a Stop Sign download for your front door with that information in the coming days;
- Although there will be relaxed rules surrounding elective surgeries, these new rules will require that all elective surgery patients must test negative for COVID-19. As a result, these changes will not impact our current recommendation that Illinois chiropractic physicians see only pain patients in person (see the Maintenance Visits section above). Here is the press release for the 5/1/2020 stay at home extension.
Additionally, On March 28, 2020, the U.S. Department of Homeland Security Cybersecurity Infrastructure Security Agency (CISA) issued a “Memorandum On Identification of Essential Critical Infrastructure Workers During Covid-19 Response”.
The advisory list identifies various workers who conduct a range of operations and services that are typically essential to critical infrastructure. The healthcare section of the list specifically names chiropractors as essential healthcare providers.
Throughout this process, the ICS has advocated that chiropractic care is extremely important to the health care of patients and in the current COVID-19 environment, chiropractic care is essential for musculoskeletal pain patients. In the absence of our doctors’ care, these patients would need to turn to emergency rooms, which would tax and already-overly burdened system or may not even be able to serve them, or they would turn to non-contact treatment such as opioids and other addictive medications, resulting in increased opioid use disorder cases.
On March 22, 2020, the governor specifically addressed whether paperworkis required to prove that doctors or staff are open or traveling for essential services and said in his press conference that they would NOT require papers for people headed to deliver or who are delivering essential services. Doctors and staff should simply say that they are or work for a doctor and are headed to the clinic to assist in delivering healthcare services.
However, if the need arises, we have created a letter on Illinois Chiropractic Society letterhead that clearly demonstrates that chiropractic physicians are included as essential in Illinois. We are making that available to all chiropractic physicians (members and non-members) as a precaution if you are questioned or asked to close. You can access the letter here.
Illinois Department of Public Health – SIREN Sign Up [Updated 3/13/2020]
On March 13, 2020, the Illinois Department of Public Health (IDPH) requested we send Illinois chiropractic physicians the steps to sign up to receive COVID-19 situational awareness/guidance through the State of Illinois Rapid Electronic Notification System (SIREN). SIREN is a secure web-based messaging and alerting system that uses various formats to provide 24/7/365 notification, alerting, and flow of critical information. SIREN is used for targeted alerting based on members’ professional roles or functions. Chiropractic physicians have been selected to participate because of their role as physicians. The IDPH request can be found here. We encourage all of our doctors to sign up to receive the SIREN notifications.
Public Health Guidelines
Clinical and Public Health Guidance for Managing COVID-19 Interim Guidance [UPDATED 3/19/2020]
Illinois Department of Public Health issued a SIREN alert on 3/19/2020 titled “Clinical and Public Health Guidance for Managing COVID-19 Interim Guidance (subject to change); March 18, 2020.” We believe this is a very important document that providers should read. You can find the document here.
General Information from the Centers for Disease Control (CDC) and Illinois Department of Public Health (IDPH) [Updated 3/20/2020]
The ICS has been carefully monitoring the CDC and other information on the COVID-19 (coronavirus 2019). Although the ICS is not and cannot be a primary source on this subject, we want to make our members aware of relevant information that has been published by the CDC, the State of Illinois, and other reliable sources. The spread of this virus has particular implications for physician offices, as both health care providers and as employers. On March 11, 2020, the World Health Organization declared COVID-19 a pandemic, the first to be caused by coronavirus. The WHO director said hope remains that COVID-19 can be curtailed, and he urged countries to take action now to stop the disease.
The COVID-19 outbreak is rapidly evolving, and information is constantly changing. For that reason, the ICS strongly recommends that physicians stay up to date with guidance issued by the U.S. Centers for Disease Control and Prevention (CDC). The CDC has provided a number of links (end of the article below) to general information about the virus, as well as information for healthcare professionals and businesses. CDC updates these sites continually as information becomes available. The Illinois Department of Public Health (IDPH) has also created a webpage (end of the article below) with coronavirus updates, including statistics on persons under investigation and positive cases in Illinois. The IDPH page contains links to other recommendations, such as ways to reduce community spread and guidance for businesses, travel, and households.
For a list of current COVID-19 Illinois Public Health hotlines, please click here.
CDC Information for Clinicians [Updated 3/13/2020]
The CDC presented a one-hour live webinar for clinicians on March 5th. It is now available at no cost on-demand here. The presenters reported on important updates, including recommendations for office protocols for control of the spread of the virus. The experts recommend similar protocols for other infectious diseases, such as influenza. Aside from the obvious standards for the physical facility and staff (sanitizing surfaces, handwashing, etc.), if a patient presents to the office with symptoms, the patient should be separated from others in the waiting area and masked to prevent the spread of droplets.
The CDC also discussed how to determine which patients to refer for testing. CDC recommends using professional judgment to assess the presence of the following factors in presenting patients:
- Epidemiological factors such as being in close contact with a diagnosed patient or having been in an area of known community transmission
- Symptoms including:
- Acute respiratory illness – cough, shortness of breath, difficulty breathing
- Persons over 65 years of age
- Persons with underlying conditions and comorbidities
Physicians are to use their best judgment in assessing patients and refer those for testing as appropriate. Due to the general scarcity of testing kits, the CDC currently recommends that physicians should refer “persons under investigation” (PUI) to state and local public health laboratories in their areas. Additionally, the CDC states that “Healthcare providers should immediately notify their local or state health department in the event of a PUI for COVID-19.” Additionally, on March 9, 2020, Governor Pritzker announced that the Illinois Department of Public Health has a statewide COVID-19 hotline and website to answer any questions from the public or to report a suspected case: call 1-800-889-3931 or visit IDPH.illinois.gov. Thus, it appears that a call to the IDPH 800 line would be an appropriate way for a physician to report a suspected case.
Testing [Updated 3/16/2020]
The ICS is aware that there have been concerns about the limited supply of testing kits. On March 10, 2020, the Illinois Department of Public Health (IDPH) issued a helpful release about testing:
- To provide information on the availability of commercial lab testing for SARS-CoV-2 [the virus that causes the disease COVID-19];
- To clarify what testing will be prioritized through IDPH Public Health Laboratories;
- To clarify which persons under investigation should be reported to local health departments.
The IDPH reports that SARS-CoV-2 testing is now available through a limited number of commercial laboratories and availability through the hospital and reference labs will continue to grow. Expected turn-around time is longer at commercial laboratories (1 to 4 days) than at IDPH laboratories (1 to 2-days). Because IDPH has limited capacity/reagents to perform SARS-CoV-2 testing, it will target its testing to higher priority specimens (see IDPH Public Health Laboratory Testing section on page 2 of attachment). This will enable higher-risk patients to be identified sooner, assist with the care of patients with more severe illness, and inform response efforts, including critical infection control decisions. The full IDPH alert is attached below.
Of course, the availability or non-availability of testing kits should not change physician office protocols for identifying and handling of possibly exposed or infected persons. In any event, we encourage physician offices to review CDC information daily for updates to their recommendations for in-office procedures. In addition to evaluating symptomatic patients, many physicians are choosing to screen all patients by asking at each visit if patients fall into any of the above categories. It may be appropriate for some asymptomatic patients to be referred for testing if they have been in close contact with an infected person and/or are positive for some of the other factors (age and comorbidities).
CDC Environmental Cleaning and Disinfection Recommendations [4/6/2020]
The ICS is not aware of a specific CDC-issued cleaning and disinfection protocol for physician offices when COVID-19 cases are not present. However, the ICS provides chiropractic physicians with the best information currently available from experts, which, at this time, includes extensive directive information from the CDC and OSHA. Although some of the material below is voluminous, it is helpful to review.
Although we have not seen a general disinfection protocol for physician offices, the CDC has provided Cleaning and Disinfection for Community Facilities guidance which may be the most appropriate detailed information available for chiropractic physicians. This information is what was available in that guidance on April 6, 2020:
“Hard (Non-porous) Surfaces
- If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection.
- For disinfection, the most common EPA-registered household disinfectants should be effective.
- A list of products that are EPA-approved for use against the virus that causes COVID-19 is available here. Follow the manufacturer’s instructions for all cleaning and disinfection products for concentration, application method and contact time, etc.
- Additionally, diluted household bleach solutions (at least 1000ppm sodium hypochlorite) can be used if appropriate for the surface. Follow manufacturer’s instructions for application, ensuring a contact time of at least 1 minute, and allowing proper ventilation during and after application. Check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted.
- Prepare a bleach solution by mixing:
- 5 tablespoons (1/3 cup) bleach per gallon of water or
- 4 teaspoons bleach per quart of water
- Prepare a bleach solution by mixing:
Soft (Porous) Surfaces
- For soft (porous) surfaces such as carpeted
floor, rugs, and drapes, remove visible contamination if present and clean with
appropriate cleaners indicated for use on these surfaces. After cleaning:
- If the items can be laundered, launder items
in accordance with the manufacturer’s instructions using the warmest
appropriate water setting for the items and then dry items completely.
- Otherwise, use products that are EPA-approved for use against the virus that causes COVID-19 and that are suitable for porous surfaces
- If the items can be laundered, launder items in accordance with the manufacturer’s instructions using the warmest appropriate water setting for the items and then dry items completely.
- For electronics such as tablets, touch screens, keyboards, remote controls, and ATM machines, remove visible contamination if present.
- Follow the manufacturer’s instructions for all cleaning and disinfection products.
- Consider the use of wipeable covers for electronics.
- If no manufacturer guidance is available, consider the use of alcohol-based wipes or sprays containing at least 70% alcohol to disinfect touch screens. Dry surfaces thoroughly to avoid the pooling of liquids.
Linens, Clothing, and Other Items That Go in the Laundry
- In order to minimize the possibility of dispersing virus through the air, do not shake dirty laundry.
- Wash items as appropriate in accordance with the manufacturer’s instructions. If possible, launder items using the warmest appropriate water setting for the items and dry items completely. Dirty laundry that has been in contact with an ill person can be washed with other people’s items.
- Clean and disinfect hampers or other carts for transporting laundry according to guidance above for hard or soft surfaces.”
The CDC has also given extensive guidance by referencing a previously established guideline titled “Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.” For more extensive guidance than listed above, please reference this 163-page document.
Additionally, the CDC has provided standards for cleaning community facilities with suspected or confirmed Coronavirus Disease 2019 here. Additionally, the CDC has provided “Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings” here. The numbered recommendations may be useful to our members in their offices.
CDC Information for Employers [Updated 3/13/2020]
The CDC recommends the following strategies for employers to use now. The ICS has summarized the strategies here but strongly urges clinic owners to click on the link at the end of this article to review the details provided for businesses by the CDC:
- Actively encourage sick employees to stay home;
- Separate sick employees;
- Emphasize staying home when sick, respiratory etiquette and hand hygiene by all employees;
- Perform routine environmental cleaning:
- Advise employees before traveling to take certain steps as outlined in the employer link below
- Additional Measures in Response to Currently Occurring Sporadic Importations of the COVID-19:
- Employees who are well but who have a sick family member at home with COVID-19 should notify their supervisor and refer to CDC guidance for how to conduct a risk assessment of their potential exposure.
- If an employee is confirmed to have COVID-19, employers should inform fellow employees of their possible exposure to COVID-19 in the workplace but maintain confidentiality as required by the Americans with Disabilities Act (ADA). Employees exposed to a co-worker with confirmed COVID-19 should refer to CDC guidance for how to conduct a risk assessment of their potential exposure.
CMS Release for Providers [3/13/2020]
The Center for Medicaid and Medicare Services (CMS) has issued a number of releases containing information for disease mitigation in specific settings. The following link is a good, detailed strategy for community mitigation based on the level of community transmission: https://www.cdc.gov/coronavirus/2019-ncov/downloads/community-mitigation-strategy.pdf.
Resources and Webinars
Relevant On-Demand Courses [Updated 4/17/2020]
The ICS is working on a number of webinars for doctors during this time:
- “Telehealth 101: Strategies for Treating Patients When In-office Care is Not an Option.” On-demand. Click here to take the course.
- “Protecting Your Chiropractic Business During the Covid-19 Pandemic.” On-demand. Click here to take the course.
- “Mental Health Webinar for Chiropractic Physicians” – On-Demand. Click here to take the course.
Toolkit – Resources Available for Use in Your Office – [Updated 4/28/2020]
The ICS is making available to our members a template letter for our doctors to provide to their patients regarding the COVID-19 virus (coronavirus). The letter explains the steps you are taking in your offices to protect your patients, as well as your recommendations for measures your patients should take outside of the office. The template will need to be tailored to reflect your individual office procedures and policies. The template letter developed by the ICS can be found here (Template letter for patients – Spanish).
Electronic version of the patient notification of non-covered services. This document can be transmitted, signed, and returned electronically.
Optional noticethat physician employers may use to notify their staff that all employees of healthcare offices are exempt from receiving additional sick leave.
As the ICS will continue to monitor CDC and other resources, we against encourage members to regularly check CDC and IDPH information in the links below, as they are revised to update the public, healthcare providers, and employers on this rapidly developing issue:
- General Information on Coronavirus (COVID-19)
- Healthcare Professionals
- Illinois Department of Public Health Coronavirus Updates
- NCMIC Insurance Company COVID-19 Information
- Guidance on Preparing Workplaces for COVID-19
Videos [Updated 4/23/2020]
The information provided in this article and on this website does not, and is not intended to, constitute legal, medical, financial, or other professional advice. All content and materials available in this article and on this site are for general informational and educational purposes only. The ICS regularly reviews new developments, and the guidance we provide represents information believed to be current and accurate at the time of posting. However, due to rapid changes in some of the content, the ICS does not guarantee that all of the information in this article and website constitutes the most up-to-date information.
Additionally, this article and the ICS website contain links to other third-party websites. The ICS provides links solely for the convenience of the user. The ICS neither controls, verifies, nor endorses the content of third-party sites. Physicians should always exercise their own professional judgment in connection with the provision of any services. All users of this article or website should contact their attorneys to obtain professional legal advice with respect to any individual legal matter. The content of this article and website represent ICS’ best information, but information is posted “as is,” and ICS is not liable for any actions take or not taken based on the contents of the ICS website. By using this document or the ICS website, you agree to waive and hold harmless the iCS from any claims or damages related to your use of the information on our site.
[i] Thank you to NCMIC, professional liability insurer, for its presentation “Malpractice Defense in the Time of COVID-19,” which provided some of the information for this section.
[ii] Thank you to ChiroUp for providing these resources to ICS Members.
[iii] Thank you to ChiroUp for providing these resources to ICS Members.