Coronavirus (COVID-19) in the Chiropractic Physician office Updated May 13, 2021

CORONAVIRUS (COVID-19)

Editor’s Note: We continue to review and update this article. On 11/16/2020 we removed irrelevant sections and updated many others. See the Recent Updates section and updated dates for reference.

If you have questions regarding the May 13, 2021, CDC face-covering guidance click here to watch a video to provide guidance regarding face-coverings in healthcare settings.

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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.

Patient and Staff Screening Tools

Face Coverings for Patients, Staff, and Doctors

Recent Updates

Consolidated Appropriations Act of 2021 – [Updated 12/28/2020]

Illinois Phase 4 and Current Mitigations [Updated 11/19/2020]

Massage Therapy in the Chiropractic Office During the COVID-19 Pandemic [Updated 11/19/2020]


Financial and Business Aid

Consolidated Appropriations Act of 2021 – [Updated 12/28/2020]

Federal Small Business Assistance (SBA) for Counties Impacted by Civil Unrest [Updated 11/5/2020]

More Money – New Provider Relief Fund Grants Available [Updated 10/7/2020]

DCEO Announces 2nd Wave of Funding [Updated 9/17/2020]

$20 Billion More Under Provider Relief Fund – [Updated 8/13/2020]

Provider Relief Fund Providing $30 Billion and Includes Chiropractic Physicians Under CARES Act – [Updated 8/13/2020]

Paycheck Protection Program Forgivable Loans – [Updated 7/6/2020]

DCEO Business Interruption Grants [Updated June 26, 2020]

Ameren Illinois Power Company offers Hardship Credit [Updated June 9, 2020]

Medicare 2% Reduction Suspended (Sequestration) – [Updated 5/26/2020]

Employee Retention Credit – Another Potential Avenue for Assistance [Updated 5/7/2020]

Unemployment for Self-Employed, Sole Proprietors, or Independent Contractors – [Updated 5/5/2020]

Medicare Advance Payment (Loan) – [Updated 4/27/2020]

Federal Stimulus Package – CARES and CARES 2 – [Updated 4/24/2020]

Student Loan Assistance (Federal and Private) – [Updated 4/22/2020]

Economic Injury Disaster Loans (EIDL) and Loan Advances [Updated 4/16/2020]

Business Interruption Insurance Coverage – [Updated 4/14/2020]

State Loans for Small Businesses [Updated 3/31/2020]

Federal and State Tax Deadline Extended – [Updated 3/25/2020]

SBA Loans and Other Information for Small Businesses Affected by Coronavirus [Updated 3/23/2020]


Treatment Recommendations and Potential Alternatives

City of Chicago Guidelines [updated 11/16/2020]

Massage Therapy in the Chiropractic Office During the COVID-19 Pandemic [Updated 11/19/2020]

Telemedicine/ Telehealth Options [Updated 4/7/2020]


Business and Practice Consideration

Face Coverings for Patients, Staff, and Doctors [Updated 11/13/2020]

New CPT Code 99072 Added for Expenditures Due to Public Health Emergency [Updated 11/04/2020]

Patient and Staff Screening Tools [Updated 7/16/2020]

Workers’ Compensation – Amendment Makes Essential Workers and COVID-19 Claims Presumed Compensable with Employer Right to Rebut [Updated 6/2/2020]

Required and Important Signs to Post in Your Office [Updated 5/29/2020]

Annual Report Now Due on Original Filing Dates – Illinois Legislative Committee Suspends Extension of Annual Report Deadlines For Corporations And LLCs [Updated 5/29/2020]

Collections During the Pandemic [Updated 5/27/2020]

Employees Refusing to Return to Work – Unemployment Considerations [Updated 5/19/2020]

COVID-19 Antibody Assays, Scope, and Warnings [Updated 5/14/2020]

Return to Work Guidelines for Healthcare Personnel and Staff with Confirmed or Suspected COVID-19 [Updated 11/16/2020]

Considerations for Expiring Certifications and/or Diplomates [Updated 5/11/2020]

Advertising and marketing caveat [Updated 5/11/2020]

Resources for Reopening the Chiropractic Physician Office [Updated 5/7/2020]

Does Malpractice Insurance Cover Claims of Coronavirus Exposure in a Chiropractic Physician Office?  [Updated 4/28/2020]

IDPH After Work and at Home Guidance for ALL Healthcare Providers [Updated 4/27/2020]

Recommendations for Defense of COVID-Related Liability Claims and License Discipline [Updated 4/27/2020]

Screening and Protection Protocols [Updated 11/16/2020]

OSHA and Illinois Outline Risk and Reporting for Employees and Employers [Updated 4/20/2020]

Business Issues and Steps You Can Take to Protect Your Practice [Updated 3/27/2020]


Donations and Volunteering

Volunteering to Assist in the COVID-19 Response – [Updated 3/30/2020]

Donation of Personal Protective Equipment (PPE) [Updated 3/26/2020]


Scam Warnings

Important Public Health Alert about KN95 Masks [Updated 4/17/2020]

Coronavirus Scams [Updated 4/15/2020]


Employment

Paid Sick Leave and Tax Credits for Coronavirus-Related Employee Leave [Updated 10/20/2020]

Employer and Employee Rights about Returning to Work during the Pandemic – Fear and Coronavirus [Updated 4/29/2020]

Employee Layoffs as a Result of COVID-19 [Updated 3/20/2020]


Mental Health Information and Resources

Mental Health Resources [Updated 4/13/2020]


Governor Pritzker Orders and Requests

Illinois Phase 4 and Current Mitigations [Updated 11/19/2020]

Chiropractic Physician Services Are Essential Services Under Federal CISA Advisory and Illinois “Stay at Home Order [Updated 4/24/2020]

Illinois Department of Public Health – SIREN Sign Up [Updated 3/13/2020]


Public Health Guidelines

CDC Guidance For Health Care Practitioners (Including Staff/ Employees) Who Have Been Exposed to COVID-19 [Updated 11/16/2020]

Guidance For Health Care Practitioners Who Have Tested Positive For Coronavirus And Notification To Patients [Updated 5/11/2020]

CDC Environmental Cleaning and Disinfection Recommendations [Updated 4/6/2020]

Clinical and Public Health Guidance for Managing COVID-19 Interim Guidance [Updated 3/19/2020]

General Information from the Centers for Disease Control (CDC) and Illinois Department of Public Health (IDPH) [Updated 3/20/2020]

CDC Information for Employers [Updated 3/13/2020]

CMS Release for Providers [Updated 3/13/2020]


Resources and Webinars

Toolkit – Resources Available for Use in Your Office [Updated 4/28/2020]

Videos [Updated 4/23/2020]

Relevant On-demand Courses [Updated 4/17/2020]

Financial and Business Aid

Consolidated Appropriations Act of 2021 – [Updated 12/28/2020]

The Consolidated Appropriations Act of 2021 (including the latest stimulus package) addressed several issues that will impact chiropractic physicians. The ICS has worked and is continuing to work with other key stakeholders and reviewing the 5,592-page bill’s full impact.

The items of interest include: Medicare Fees (some relief for the looming cuts), Paycheck Protection Program changes (non-taxable and calculation of revenue changes), small Provider Relief Fund changes, Section 2706 Non-Discrimination rulemaking requirements (a welcome change), and surprise billing restrictions (apparently limited impact).

Medicare Fees

Since August, the Illinois Chiropractic Society has been requesting action from doctors around Illinois regarding the looming Medicare Fee cuts. To see the most recent call to action with some background, click here.

Congress attempted to address providers concerns with the new relief package. Unfortunately, Congress only partially assisted providers with these Medicare fee cuts in the Consolidated Appropriations Act of 2021. Here are the three changes that impact Medicare reimbursement:

Small Increase to 2021 Fee Schedule – This legislation apparently increases, by 3.75%, the previously released 2021 fee schedule with the 10% average cuts for chiropractic physicians. The end result will be an average 6.625% reduction from the 2020 fee schedule. However, due to the slightly ambiguous nature of the bill’s language, some experts believe that the fee schedule cuts may only be 3.8%. Once Medicare has released the new fee schedule, we will notify ICS members.

As a result of these pending changes to the Medicare fee schedule, we are recommending the following:

Participating Providers:  If you are a participating provider for Medicare, we encourage you to continue to bill Medicare at your normal fees.  Your bills will be processed based on the appropriate fee schedule once it is released.

Non-Participating Providers: If you are NOT a participating provider for Medicare, we recommend that you wait to submit your bills until the correct schedule is released.  However, based on the information we have, you may be able to process your claims using the currently published 2021 rates and inform your patients that additional amounts may be owed or require refunding.

New HCPCS Code G2211 – As a part of the 2021 E/M changes, CMS-developed an office-visit complexity code, G2211. Congress estimated that this addition would cost CMS approximately $3 billion and made up 30% of the budget neutrality hit that necessitated the fee cuts. This legislation delays the implementation of that new code until 2024 (three years). This change MAY further lower the 2021 Medicare fee cuts.

Medicare Sequestration – At the beginning of the pandemic, the CARES Act suspended the 2% Medicare sequestration reduction. This legislation provides for another three-month delay of these payment reductions, through March 31, 2021.

Paycheck Protection Program

There are several important changes to the Paycheck Protection Program (PPP) loan forgiveness program in this legislation. If you will remember, the ICS notified doctors in September that the SBA and the IRS made policy changes detrimental to the program.

Taxing of Allocated Expenses – Congress forced the IRS to revert their previous ruling that the expenses used to cover the forgiven PPP loans would be taxable. Now, neither the forgiven amounts nor the allocated expenses will be taxable. In short, the bill states, “no deduction shall be denied, no tax attribute shall be reduced, and no basis increase shall be denied, by reason of the exclusion from gross income provided.”

No EIDL Reduction – Previously, the PPP forgivable amounts were to be reduced by the EIDL loan advanced funds. This law reverses that decision, and EIDL loan advances will NOT reduce your PPP reduction.

PPP2 – Additional funds ($285 billion) will be available for first-time borrowers, certain previous borrowers, and previous borrowers who could have borrowed more under the new rules. There are specific requirements for each of these allocations, and as the SBA develops the provisions in the coming weeks, the ICS will release more information to assist doctors with the new process.

Provider Relief Funds

Potential new money – The new legislation adds $3 billion to the fund and directs HHS to release more of CARES’s original allocation. However, it did not provide particulars, and we await HHS information on the next phase of Provider Relief.

Calculation of Revenue – As you may remember, HHS announced in September that providers would have to calculate losses based on lost net income rather than revenue, as previously indicated. For some providers who took aggressive cost savings approaches, this policy may have forced a return of funds. However, Congress reversed that policy and now requires the calculation to be performed on lost revenues. Additionally, they indicate that providers can use lost revenues vs. budged 2020 revenues instead of 2019 only.

Taxing of Relief Funds – As the ICS previously announced and addressed with Congressional Leaders, the IRS ruled that Provider Relief Funds are taxable. It appears that Congress did not address this problem, and the funds remain taxable.

Non-Discrimination

Section 2706 of the Affordable Care Act provided non-discrimination protections for many providers. However, due to the ambiguous language and lack of a federal rule to provide a full explanation and requirements, the protections have not been enforced. The ICS has attempted (and continues to pursue) these protections with the Illinois Department of Insurance, but we have been unsuccessful due to the lack of federal rules.

This law now requires HHS to implement rules for non-discrimination by the end of 2021. Once released, the rules will go through the normal comment period and become final no later than July 1, 2022. The Illinois Chiropractic Society will monitor this process very closely and work with our coalition of state chiropractic associations along with national associations to protect the interests of chiropractic physicians.

Surprise Billing Restrictions

Although the surprise billing issue primarily impacts non-participating providers in hospital settings, requirements outlined in this legislation may require some small adjustments for providers in private, non-emergency settings. This legislation addresses and prohibits surprise billings to patients beginning in 2022.

The ICS will keep our members up-to-date as HHS clarifies the details throughout 2021.

Medicare 2% Reduction Suspended (Sequestration) – [Updated 5/26/2020]

Please read the Consolidated Appropriations Act of 2021 section for the most recent information on Medicare fees

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

You should

  1. File for unemployment today,
  2. Wait for the initial denial (due to your self-employed status), and
  3. Apply for PUA on May 11.

Here is the announcement from IDES.

$20 Billion More Under Provider Relief Fund – [Updated 8/13/2020]

Please read the Consolidated Appropriations Act of 2021 section for the most recent information on the Provider Relief Funds.

HHS has reopened the opportunity and added requirements for those that received funds initially. There are two important parts to this reopening: 1) It is not too late for a second payment and once you submit financial information, you are most likely eligible for additional funds; 2) If you received funds from HHS (either one or both), you are required to submit financial information, including uploading tax return documents.

If you have NOT received a second grant/distribution from HHS, you can now apply for the second distribution grant. Here is the statement from HHS: “Providers who have received a payment under Phase 1 of the General Distribution are no longer prohibited from submitting an application under Phase 2 of the General Distribution. Providers who received a previous Phase 1 – General Distribution payment are eligible to apply and, if they have not yet received a payment that is approximately 2% of annual revenue from patient care, may receive additional funds [emphasis added].” Please take the time to apply, if you have not previously applied. To determine how much you may receive, you can take 2% of your total annual revenues and subtract the amount you received in the initial distribution. For example, if your annual TOTAL revenues from patient care are $200,000 and you received $500 in the initial distribution, this distribution may be as much as $3,500. Check eligibility and apply here.

If you received funds in the initial ($30 billion) distribution and you have not previously submitted financial information (i.e. applied for the second general distribution), you are required to submit financial information to HHS online. You can submit that information here.

Recently, the IRS released their opinions that funds received through the Provider Relief Fund General Distributions (all $50 billion) would be taxable to for-profit entities (see announcement below). As a result, the Illinois Chiropractic Society formed a coalition of 36 other state and national associations representing 32 states and sent a letter to congressional leadership including: Speaker Nancy Pelosi, Leader Kevin McCarthy, Chairman Richard Neal. Representative Kevin Brady, Leader Mitch McConnell, Leader Charles Schumer, Chairman Charles Grassley, and Senator Ron Wyden. In that letter, we asked Congress to make the funds non-taxable and also keep the expenses related to those funds tax deductible. Click here to see a copy of that letter and the many state signatories.

Additionally, although the statute required reporting for entities receiving more than $150,000, HHS announced the reporting will now be required for those receiving funds as low as $10,000. That means that beginning in October, if you received $10,000 or more of funds from the Provider Relief Funds (i.e. HHS moneys), then you will have reporting requirements. Here is more information.

On July 14, the IRS quietly announced that the PPP forgiveness amounts will be considered taxable income (to either the corporation/entity or sole proprietor/person). You can see the announcement from the IRS here. Additionally, you can see the updated FAQ for this action from the SBA here. The ICS will continue to follow this closely, as Congress may address this issue in the coming months. Please watch our updates for more information.

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.

General Distribution Portal

General Distribution Portal FAQ

Full Provider Relief Page

Provider Relief Fund Providing $30 Billion and Includes Chiropractic Physicians Under CARES Act – [Updated 8/13/2020]

Please read the Consolidated Appropriations Act of 2021 section for the most recent information on the Provider Relief Fund.

HHS has reopened the opportunity and added requirements for those that received funds initially. There are two important parts to this reopening: 1) It is not too late for a second payment and once you submit financial information, you are most likely eligible for additional funds; 2) If you received funds from HHS (either one or both), you are required to submit financial information, including uploading tax return documents.

If you have NOT received a second grant/distribution from HHS, you can now apply for the second distribution grant. Here is the statement from HHS: “Providers who have received a payment under Phase 1 of the General Distribution are no longer prohibited from submitting an application under Phase 2 of the General Distribution. Providers who received a previous Phase 1 – General Distribution payment are eligible to apply and, if they have not yet received a payment that is approximately 2% of annual revenue from patient care, may receive additional funds [emphasis added].” Please take the time to apply, if you have not previously applied. To determine how much you may receive, you can take 2% of your total annual revenues and subtract the amount you received in the initial distribution. For example, if your annual TOTAL revenues from patient care are $200,000 and you received $500 in the initial distribution, this distribution may be as much as $3,500. Check eligibility and apply here.

If you received funds in the initial ($30 billion) distribution and you have not previously submitted financial information (i.e. applied for the second general distribution), you are required to submit financial information to HHS online. You can submit that information here.

Recently, the IRS released their opinions that funds received through the Provider Relief Fund General Distributions (all $50 billion) would be taxable to for-profit entities (see announcement below). As a result, the Illinois Chiropractic Society formed a coalition of 36 other state and national associations representing 32 states and sent a letter to congressional leadership including: Speaker Nancy Pelosi, Leader Kevin McCarthy, Chairman Richard Neal. Representative Kevin Brady, Leader Mitch McConnell, Leader Charles Schumer, Chairman Charles Grassley, and Senator Ron Wyden. In that letter, we asked Congress to make the funds non-taxable and also keep the expenses related to those funds tax deductible. Click here to see a copy of that letter and the many state signatories.

Additionally, although the statute required reporting for entities receiving more than $150,000, HHS announced the reporting will now be required for those receiving funds as low as $10,000. That means that beginning in October, if you received $10,000 or more of funds from the Provider Relief Funds (i.e. HHS moneys), then you will have reporting requirements. Here is more information.

On July 14, the IRS quietly announced that the PPP forgiveness amounts will be considered taxable income (to either the corporation/entity or sole proprietor/person). You can see the announcement from the IRS here. Additionally, you can see the updated FAQ for this action from the SBA here. The ICS will continue to follow this closely, as Congress may address this issue in the coming months. Please watch our updates for more information.

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.

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.

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.

More Money – New Provider Relief Fund Grants Available [Updated 10/7/2020]

Please read the Consolidated Appropriations Act of 2021 section for the most recent information on the Provider Relief Funds.

As the ICS reported earlier in 2020, HHS previously made grants available to chiropractic physicians (and many other providers, hospitals, and systems) to the tune of $50 billion, in what was called a General Distribution. These distributions, which were covered extensively in our COVID-19 article, amounted to 2% of doctors’ annual revenue (total patient care revenue, not just Medicare). The initial General Distribution was for $50 billion.

Recently, HHS announced a NEW distribution of the Provider Relief Fund – Phase 3. Providers can now apply for a new round of General Distribution funds totaling another $20 billion. Phase 3 now opens the door for even more chiropractic physicians to acquire funds through this program, including doctors who were new to practice in 2020. In fact, HHS indicates that, “Providers may be eligible regardless of whether they were eligible for, applied for, received, accepted, or rejected payment from prior PRF distributions.”

Which health care providers, including chiropractic physicians, are eligible? 

Those who billed Medicare or Medicaid between January 1, 2018-March 31, 2020.  Other providers include dentists, assisted living facilities, and behavioral health providers.

Requirements for eligibility require providers:

  • “Filed a federal income tax return for fiscal years 2017, 2018, 2019 if in operation before Jan. 1, 2020; or be exempt from filing a return; and
  • Provided patient care after Jan. 31, 2020; and
  • Did not permanently cease providing patient care directly or indirectly; and
  • For individuals providing care before Jan. 1, 2020, have gross receipts or sales from patient care reported on Form 1040 (or other tax form)”

If you believe you meet the requirements, simply visit the Provider Relief Fund Application and Attestation Portal, sign in (or create a new account), and complete the application. You can start that application here.

How much will providers receive?

This section is directly from HHS:

  1. “All provider submissions will be reviewed to confirm they have received a Provider Relief Fund payment equal to approximately 2 percent of patient care revenue from prior general distributions. Applicants that have not yet received Relief Fund payments of 2 percent of patient revenue will receive a payment that, when combined with prior payments (if any), equals 2 percent of patient care revenue.
  2. With the remaining balance of the $20 billion budget, HRSA will then calculate an equitable add-on payment that considers the following:
    1. A provider’s change in operating revenues from patient care
    2. A provider’s change in operating expenses from patient care, including expenses incurred related to coronavirus
    3. Payments already received through prior Provider Relief Fund distributions.”

Deadline

Applications must be received by HHS by November 6, 2020. This is an intentionally short time-frame, so DO NOT WAIT!

Reporting requirements for the Provider Relief Fund recipients:

Recipients of provider relief funds are required to file reports as described in HHS’ reporting requirements document. A few weeks ago, HHS modified the reporting requirements document… again. First, they lowered the reporting threshold to include any provider that received more than $10,000 (previously the threshold was much higher). Thus, some of our doctors will now be required to provide a post-payment report on the funds received.

One additional notable change in this document was to significantly change the definition of “revenues.” Although previous guidance indicated that the funds could be reconciled against lost revenues, HHS is now defining revenues as “a negative change in year-over-year net patient care operating income (i.e., patient care revenue less patient care related expenses for the Reporting Entity, defined below, that received funding).”

This change results in a reconciliation against patient care INCOME and not revenues. In other words, it now is not just total revenues, but instead they require the reconciliation to be patient care revenues less patient care expenses (profit vs. revenue). Of course, this offset is in addition to any expenses directly related to coronavirus.

Reminder – you cannot use the same losses for different grants. Thus, if you are attributing some of your losses to a DCEO grant or a forgivable PPP loan, then you would not be able to use them to reconcile your Provider Relief Fund amounts.

Based on HHS’ statement that providers may be eligible for the new phase of funding regardless of their previous eligibility or rejection, the ICS would strongly encourage doctors to submit an application for this round of funding.

HHS Announcement for Phase 3

Provider Relief Fund Information Page

Application Portal

Reporting Requirement Notice

Federal Small Business Assistance (SBA) for Counties Impacted by Civil Unrest [Updated 11/5/2020 11:30 am]

The Small Business Administration (SBA) has approved economic injury disaster loans to assist qualifying businesses recover from economic loss arising from civil unrest that occurred between May 26 and July 30. Businesses that qualify include those located in 60 Illinois counties and are eligible for up to $2 million in loans that can be used for a variety of expenditures, such as working capital, payroll, PPE and more.

The 60 counties include Adams, Boone, Champaign, DuPage, Kane, Knox, LaSalle, Macon, McLean, Morgan, Peoria, Sangamon, St. Clair, Stephenson, Tazewell, Will and Winnebago. Businesses in the contiguous counties of Brown, Bureau, Carroll, Cass, Christian, Clinton, Cook, DeWitt, DeKalb, Douglas, Edgar, Ford, Fulton, Greene, Grundy, Handcock, Henry, Jo Davies, Kankakee, Kendall, Lee, Livingston, Logan, Macoupin, Madison, Marshall, Mason, McHenry, Menard, Mercer, Monroe, Montgomery, Moultrie, Ogle, Piatt, Pike, Putnam, Randolph, Schuyler, Scott, Shelby, Stark, Vermilion, Warren, Washington, and Woodford.

The filing deadline to return applications is July 13, 2021.

Applications can be accessed by visiting the Small Business Administration at https://www.sba.gov/funding-programs/disaster-assistance .  When at their site, search by State and select Illinois, where the application for civil unrest can be found. Those who wish to apply are encouraged to do so online, by clicking here.

Application assistance is being provided by the Virtual Business Recovery Center, operated by the SBA.  It is open 7 days a week to help applicants with their applications. The Virtual Business Recovery Center can be reached by email at FOCE-help@sba.gov or by phone at 800-659-2955.

Illinois Small Business Development Centers are also assisting applicants with the application process. To find one near you, please click here.

To view Governor Pritzker’s  full press release, click here.

Ameren Illinois Power Company offers Hardship Credit [Updated June 9, 2020]

Ameren is offering a hardship credit of up to $500 for small businesses that have suffered during the pandemic. The application process is fairly simple and we have had members apply and receive a credit.

Here is the application and details.

Paycheck Protection Program Forgivable Loans – [Updated 7/6/2020]

Please read the Consolidated Appropriations Act of 2021 section for the most recent information on the Paycheck Protection Program.

Two important new items of note:

  1. Congress and the President extended the deadline for PPP loans to August 9, 2020. This means that if you have not previously been approved/received a PPP forgivable loan, you can still apply. We are strongly urging our doctors to take advantage of this program, as there are over $130 billion remaining of these forgivable loans. Remember, the loan is only 1% and the requirements for forgiveness are not a stretch (see information below, including the newly broadened forgiveness rules passed by Congress in early June).
  2. IDFPR held webinars that you can view to assist with the forgiveness process. Please see the release here and watch the webinar here.

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.

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.

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.

Loan details:

  • 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.

Loan Forgiveness:

  • 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.
    • 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.”

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).

Other FAQ:

  • 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.

Remaining Questions:

  • 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]

Please read the Consolidated Appropriations Act of 2021 section for the most recent information on the Economic Injury Disaster Loans.

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.

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.

DCEO Business Interruption Grants [Updated June 26, 2020]

Beginning today, June 26, 2020, the Illinois Department of Commerce and Economic Opportunity (DCEO)will take applications for the Business Interruption Grants Program and will close the application process on July 7, 2020 at 5:00 p.m.

A portion of the first round of funding includes grants for bars and restaurants, barbershops and salons, gyms and fitness centers, and other businesses located in the Disproportionately Impacted Areas (DIA) where there was recent property damage in  that area (not specific to the businesses applying). 1,000 grants for $20,000 each will be awarded to businesses that apply, meet all eligibility criteria in the DIAs, and are selected by DCEO. This grant requires your business to be in specific DIA areas (areas impacted by property damage), as well as other eligibility criteria.

At this time, some chiropractic physicians may qualify for the businesses located in the DIA where there was recent property damage. DCEO has put a list of zip codes where businesses are to be located to qualify. PLEASE CHECK THIS LIST TO SEE IF YOUR ZIP CODE IS LISTED.

To ensure your business has met all criteria, please go to this link and look at #4 Severe Disproportionately Impacted Areas , which specifically discusses the DIA Grants. Please note, based on information the ICS received from DCEO, priority will be provided to those businesses that did NOT receive funding from the Paycheck Protection Program (PPP).

For more information and to see the full application please visit DCEO’s BIG page.

DCEO has indicated there will be future funding rounds and we will keep our members informed of this information.

DCEO Announces 2nd Wave of Funding [Updated 9/17/2020]

Illinois Department of Commerce has announced it will begin accepting applications for the second round of Business Interruption Grants this coming Thursday, September 17, 2020. This second round of funding is a total of $220 million dollars.

The second wave funding will prioritize the following:

  • Heavily Impacted Industries (indoor recreation, amusement parks, etc.)
  • Disproportionately Impacted Areas (areas defined by law.  See DCEO list at: https://www2.illinois.gov/dceo/SmallBizAssistance/Pages/C19DisadvantagedBusGrants.aspx)
  • Businesses in Downstate Communities
  • Priority Businesses (independently owned retail and hospitality industry)
  • Agriculture
  • Grants and Loan Forgiveness for Illinois Small Business Emergency Loan Recipients (Grants to offset loans for those businesses that received the Illinois Small Business Emergency Loan-qualifications must be met)

The state has indicated that businesses not included in these categories may still eligible for funding but will not be prioritized. DCEO will score applicants based on their processes. For more information on qualifications, terms and conditions, and the application please click here.

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:

  1. Employers that received Paycheck Protection Program (PPP) funds are not eligible and cannot take the credit.
  2. The business must have been affected by COVID-19 in one of the following ways:
    1. The business must have been fully OR partially suspended as a result of governmental orders, OR
    2. 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]

Please read the Consolidated Appropriations Act of 2021 section for the most recent information on the Paycheck Protection Program.

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.

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.

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).

Details:

  • 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

Qualifiers:

  • 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

Details:

  • 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

Qualifiers:

  • 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.

Details:

  • 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

Qualifications:

  • 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/

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.do@sba.gov 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

Massage Therapy in the Chiropractic Office During the COVID-19 Pandemic [Updated 11/19/2020]

Some chiropractic physician offices offer massage therapy that is not a part of a treatment plan (i.e., relaxation massages, rather than part of therapeutic treatment). In these cases, these offices would also be subject to massage therapy service limitations as required by the various Executive Order operations phases and mitigation Tiers. Beginning November 20, 2020, new mitigations have been put into place regarding massage therapy that is not deemed necessary by a medical provider. Please refer to our current mitigations section which can be found here.

City of Chicago Guidelines [updated 11/16/2020] 

If you practice in the City of Chicago, you should be aware of the city’s requirements. Although many of those requirements mirror the Illinois requirements, there are a few differences. The biggest difference to note is the Emergency Travel Order. If you are in a listed state for more than 24 hours and return to Chicago, you will have specific Chicago requirements. If you reside in the City of Chicago and plan to travel, please check the status of the State to which you are traveling. The City is categorizing states in either Red, Yellow, or Orange category. The categories indicate the following restrictions:

Red: When returning to Chicago a 14-day quarantine is required.

Orange: When returning to Chicago a 14-day quarantine is required OR obtain a pre-arrival negative test result (no longer than 72 hours prior to arriving) and enforce strict social distancing, masking, and no in person gatherings.

Yellow: Must maintain strict social distancing and masking.

The map is updated on a weekly basis. For the latest status of each state, please click here.

There are some exceptions for essential workers (chiropractic physicians included), but the exception applies to travel being necessary to carry out the essential worker’s primary work. This means that if you travel to a listed state on vacation, you would still be subject to the quarantine order. Please see the city’s page on this issue here.

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.

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:

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.

UnitedHealthcare telemedicine/telehealth policy issued 3/27/2020.

BCBS telemedicine/telehealth policy issued 3/18/2020.

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.

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.

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

CPT Code 99072 Added for Expenditures Due to Public Health Emergency [Updated 11/04/2020]

The pandemic has required healthcare offices to expend additional resources, including supplies and clinical staff time, to maximize the safety of office visits.  On September 8, 2020, the American Medical Association (AMA) published an update to the Current Procedural Terminology (CPT®) code set that includes a new code 99072 to report some of these costs.  The questions become: can we bill insurance, can we bill the patients, and is the reimbursement worth the potential challenges that may come with billing 99072?

The “CPT® Assistant Special Edition: September Update” lists 99072 as “Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s) when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease.”

The AMA reports that the addition of CPT code 99072 “…was approved in response to sweeping measures adopted by medical practices and health care organizations to stem the spread of the novel coronavirus (SARS-CoV-2), while safely providing patients with access to high-quality care during in-person interactions with health care professionals. The additional supplies and clinical staff time to perform safety protocols described by code 99072 allow for the provision of evaluation, treatment or procedural services during a public health emergency in a setting where extra precautions are taken to ensure the safety of patients as well as health care professionals.”

When and for what visits can we use this code?

First, 99072 is only to be used during a declared public health emergency due to respiratory-transmitted infectious disease. Our current pandemic does meet both requirements.

Of course, due to the nature of the costs, the code is only to be reported for in-person patient encounters and would NOT apply to telehealth visits.

What is included and what is not included?

Based on the description of included costs as “supplies, materials, and clinical staff time [emphasis added],” the ICS believes administrative staff time is not included.  For example, staff time to screen a patient is probably included because it is clinical in nature, whereas staff time spent ordering PPE is not, because it is purely administrative.

Here are examples of what would be included:

  • Pre-visit phone calls – only the additional time used for this pandemic screening purposes can be used in your fee calculation. In other words, if you already call your patients in advance of their appointment, you can only use the ADDITIONAL time used for infectious disease screening in your calculation.
  • In-office screening and instruction – again, only the additional time specific to the infection disease screening can be considered.
  • Time to apply and remove PPE – for most chiropractic offices, this time will be very, very short and should only be considered in rare circumstances.
  • Cleaning – Only the time in addition to normal cleaning practices of the examination, treatment, imaging, equipment, and supply rooms, can be considered.
  • Cleaning exceptions – This code does NOT include time spent cleaning employee areas and administrative areas. Performing these tasks is not considered clinical staff time.
  • Lost revenue due to cleaning time – You CANNOT include any reduction in patient volume due to cleaning time.
  • PPE – Although the code includes “three surgical masks,” you cannot include these costs if you are not using the product. Only include the exact costs of the PPE you are utilizing for each patient visit (i.e. if you only use one mask per day, then the cost of one mask divided by number of visits that day).
  • Cleaning supplies – This includes “additional quantities” of hand sanitizer and disinfecting wipes, sprays, and cleansers.

How much should you charge?

You should take into consideration the exact costs, and no more, associated with the above for each patient visit. You should NOT use this code as a profit center. It is an “over-and-above” cost recoupment code in pandemic situations. Those choosing to bill excessive amounts for this code could come under regulatory scrutiny from IDFPR or the state’s attorney general for over-charging or price-gouging.

Are insurers paying for this code?

Based on a recent conversation with several chiropractic leaders from around the country, we are hearing that insurers are not covering the code at this time. If you choose to bill an insurer with which you have a PPO agreement, then you are contractually obligated to only bill the patient for the patient responsibility portions. Many insurers are indicating that providers cannot balance bill patients for this code, as they consider this the current cost of doing business or incident to the other services being rendered and paid. The AMA’s addition of CPT code 99072 is an acknowledgment of required additional expenses, but it does not alter coverage of these costs under existing language of health plans and network agreements. 

When can I NOT charge for this code?

You cannot charge for this code if you are using any of your stimulus money (CARES, CARES2, or FFCRA) to cover these expenses. For example, if you choose to charge this code then you could NOT use your Provider Relief Fund monies for PPE and cleaning or any of the expenses listed above.

Should I charge this code?

In short, this becomes a business decision that you will have to personally consider. You should consider all of the factors above to help make that determination, but do not make this a profit center.

Additionally, you should consider the patient mindset now. How will your patients react? And is it worth losing a patient over what will most likely be a small charge? These are the considerations you will need to utilize when making this decision.

Doctors should take all the factors above into careful consideration when making the determination to bill for additional expenditures under CPT code 99072. At this time, the ICS is not making specific recommendations other than to follow the information above and to refrain from charging in excess of the actual additional costs.

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]

We have previously informed you that there are required signs in places of business.

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. Additionally, although not required for healthcare only locations, we believe that many of these signs will assist patients with their confidence in your protocols.

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 11/13/2020]

A new study that was released at the end of October is leading to several changes in guidelines related to face coverings and facemasks. These guideline changes are primarily for the public, but they also can be applied to the chiropractic office setting.

As you are all aware, face coverings are now required in “public indoor spaces,” which includes chiropractic physician offices. These face coverings can be N95 masks or simply cloth masks (new CDC guidance regarding mask layers should be followed – see below).

As a result, the ICS recommends that all chiropractic physicians and staff wear face coverings AND require patients to wear face coverings.

Chiropractic Physicians and Staff:

All staff, physicians and non-physicians, in a chiropractic setting, should wear appropriate facemasks anytime the person will be with patients, with other staff members, or in an area that either another staff member or patient could enter. In short, facemasks should be worn unless the staff member is in a closed-door space with no one else in the room.

The ICS is receiving an increasing number of calls from chiropractic physicians about how to respond to COVID exposures within their offices. When these physicians query their local Departments of Public Health about a possible requirement to close or quarantine, the Public Health officials base their answers on the mask procedures followed by doctors, staff, and patients.  Physician offices that have been compliant with facemask guidance are generally less restricted in their ability to continue operating their practices.

There are three different regulatory entities to consider when determining what is required: CDC, OSHA, and IDPH. All three have guidelines, and IDPH and OSHA currently have enforcement capability.

The CDC offers the most comprehensive information and guidance. They indicate that health care providers “should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.” This is for continued protection for the doctor, staff, and patients.

What Masks Should You Use in Your Office?

Based on current information from the CDC, OSHA, and IDPH, the type of mask depends largely on your overall risk. Most chiropractic physician offices would be considered “medium risk” by OSHA, and the CDC would indicate that you would primarily be concerned with source control. Source control refers to use of well-fitting cloth face masks or facemasks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. However, if you are performing COVID-19 testing at your office, then your risk would increase to high or very high and you should be concerned with more than simply source control.

Surgical masks or procedure masks would be the preferred face covering in a chiropractic physician office. They should be FDA approved and used according to the labeling for tight fit. According to the CDC, physicians and staff “should consider continuing to wear the same…facemask throughout their entire work shift.”

Cloth face masks are not preferred. However, the CDC does allow for the consideration of PPE shortages by indicating that “when available, [surgical masks or procedure masks approved by the FDA] are preferred over cloth face masks for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others.” OSHA also weighs in and provides explanation for different masks and purposes here. Additional PPE should be considered according to OSHA that includes “some combination of gloves, a gown, a face mask, and/or a face shield or goggles.” Based on healthcare worker exposure information from the CDC, the most appropriate combination should include facemasks and eye protection (not glasses).

The CDC also has provided some updated information regarding mask wearing for the public.  The ICS believes this information provides additional clarification for the requirements chiropractic physicians should impose on patients in their offices. Based on CDC guidance for mask wearing by the public, chiropractic practices should, of course, require face coverings for all patients. You should not risk your health and the health of your staff with leniency in this area. Additionally, in the unfortunate circumstance of a positive case exposure, work exclusions will apply if the patient is unmasked.

Here is the new CDC guidance for masks. One of the recent changes indicates that single layer cloth coverings are no longer acceptable. Please see the guidance for more information.

Enforcement:

The State of Illinois already has enforcement rules in place.  If businesses and organizations are not enforcing social distancing rules and requiring face coverings for their employees and their patrons, they could face a fine. Enforcement will take place in three steps.

Step 1:  The first step would allow an enforcing entity, such as law enforcement or local health department, to provide the business with written notice that they are not in compliance with rule. The business will be given time to correct the action.

Step 2: If the business continues to be non-complaint, the enforcing entity will be allowed to ask patrons of the business to leave until the business follows the rules.

Step 3: If the business continues to be non-compliant, the business could be liable for a Class A misdemeanor. For a business this penalty could be up to a $2,500 fine. For the fine to be implemented, the State’s Attorney would have to file charges and the court would agree to the fine amount. 

The ICS therefore concludes that chiropractic physicians (and all staff) must continue to wear appropriate face coverings AND must require patients to wear face coverings.  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:

CDC information on making cloth face coverings,

IDPH information on face coverings,

Shop towel face covering instructions.

ICS members can download a sign for the  office front door here.

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.

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:

  1. 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”;
  2. The doctor breached the duty or standard of care;
  3. The doctor’s breach (failure to act reasonably) caused the injury; and
  4. 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; howeverit 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.

License Discipline

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:

  1. Accuracy,
  2. Continued question surrounding whether having antibodies is equivalent to having immunity, and
  3. 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.

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] 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.

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:

https://www.ncmic.com/webres/File/coronavirus/NCMIC-Guide-to-Reopening-Your-Practice.pdf

https://www.ama-assn.org/system/files/2020-05/physican-guide-reopening-practices-covid-19.pdf 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]

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:

  1. Establish and follow a thorough cleaning process for all areas of your office, including the waiting room, reception area, exam rooms and restrooms.
  2. Do not allow staff members who are sick, have been sick or have sick family members to come to the office.
  3. Have a detailed conversation by phone with the patient on the day they’re scheduled to come in, and ask:
    1. 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.
    2. 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.
    3. Have they traveled abroad in the last two weeks?
    4. Have they been near anyone who has potentially had the virus through their own family or work contact? People can be contagious without symptoms.
  4. Ask high-risk patients to delay if possible. High-risk patients are those who:
    1. Are undergoing chemotherapy.
    2. Are immunocompromised.
    3. Are diabetic.
    4. Have heart disease.
    5. Have high blood pressure.
    6. Have asthma or another respiratory issue.
    7. Are over 60 years of age.
  5. Stagger appointments to allow time for thorough cleaning between sessions.
  6. Ask patients to wait in their car (rather than the waiting room) until it’s time for their appointment.
  7. Ask anyone accompanying the patient to wait in the car during the appointment if possible.
  8. Remove magazines and other printed reading material.
  9. 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 7/16/2020]

The CDC updated the list of symptoms without fanfare a few weeks ago and most of those changes have been reflected in the new screening documents below. Although there are a few symptoms on their list that are not included in the screening documents below, we are using both IDPH symptom listing and the symptoms listed in the CDC self-checker. If you downloaded these screenings before 7/16/2020, please download the new versions below.

ICS Members can download a Patient Screening Document form here.

ICS Members can download a Staff Member Screening Document form here.

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. [Updated 7/6/2020] CDC added several more symptoms a few weeks ago. Please see the 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:

Protecting Your Practice During the Coronavirus Shutdown

https://www.hinshawlaw.com/newsroom-updates-employer-faqs-for-covid-19-coronavirus.html

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.

Screening and Protection Protocols [Updated 11/16/2020]

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;
    • Apply infection prevention protocols (CDC cleaning and OSHA Guidelines);
    • 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).

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 – Masks should be worn at all times, unless behind a closed door with no one else in the same room. Here is more information on masks.  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. Other considerations:
    • 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.

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.

Guidance on Preparing Workplaces for COVID-19CDC Cleaning Information

Return to Work Guidelines for Healthcare Personnel and Staff with Confirmed or Suspected COVID-19 [Updated 11/16/2020]

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. The federal CDC guidelines may be found here.

Initially the State of Illinois adopted CDC guidance that provided options for both symptom-based and testing-based strategies.  However, the CDC now prefers a symptom-based strategy, as explained below.    Because return-to-work guidance for health care providers may be adapted by state and local health departments to respond to rapidly changing local circumstances, 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).

The CDC return-to-work standards were  updated in August 2020 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). A symptom-based strategy is now preferred. Here is the CDC information available as of August 10, 2020:

“Symptom-based strategy for determining when HCP can return to work.

HCP with mild to moderate illness who are not severely immunocompromised:

  • At least 10 days have passed since symptoms first appeared and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved

Note:  HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive viral diagnostic test.

HCP with severe to critical illness or who are severely immunocompromised1:

  • At least 10 days and up to 20 days have passed since symptoms first appeared
  • At least 24 hours have passed since last fever without the use of fever-reducing medications and
  • Symptoms (e.g., cough, shortness of breath) have improved
  • Consider consultation with infection control experts

Note:  HCP who are severely immunocompromised but who were asymptomatic throughout their infection may return to work when at least 10 days and up to 20 days have passed since the date of their first positive viral diagnostic test.

As described in the Decision Memo, an estimated 95% of severely or critically ill patients, including some with severe immunocompromise, no longer had replication-competent virus 15 days after onset of symptoms; no patient had replication-competent virus more than 20 days after onset of symptoms. The exact criteria that determine which HCP will shed replication-competent virus for longer periods are not known. Disease severity factors and the presence of immunocompromising conditions should be considered in determining the appropriate duration for specific HCP. For example, HCP with characteristics of severe illness may be most appropriately managed with at least 15 days before return to work.”

Test-Based Strategy for Determining when HCP Can Return to Work.

The CDC acknowledges that, in some instances, a test-based strategy could be considered to allow a health care practitioner to return to work earlier than if the symptom-based strategy were used. However, the CDC believes this approach has limited utility, because, many individuals will have prolonged viral shedding.  The CDC criteria for the test-based strategy may be viewed here.

CDC Return to Work Practices and Work Restrictions

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 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).

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.”

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.

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.

The dental guidance from IDPH also addresses when the provider could return to work and treatment again and what restrictions to apply. Please refer to that document for more information.

CDC Guidance For Health Care Practitioners (including staff/employees) Who Have Been Exposed to COVID-19 [Updated 11/16/2020]

CDC has issued guidance on evaluation of work restrictions for asymptomatic health care personnel (HCP) who have been exposed to COVID.

Steps to Take Following Primary Exposure:

  1. First, following a primary exposure, you should contact your local health department. This is a critical first step and will give you the latest requirement. Make sure that you let them know that you are a healthcare worker.
  2. Work through the CDC Risk Assessment tool. (See explanation and link under primary exposure circumstances below.)
  3. Review the information below from IDPH.
  4. Review the information below regarding healthcare workers from the CDC.

For additional information, there have been a number of updates regarding exposure recently from both the CDC and IDPH. This section will assist chiropractic physicians who have had contact with someone who has tested positive for COVID-19 or who have an employee with contact.

IDPH covers exposure in their FAQ “What should I do if I had close contact with someone with COVID-19 but I am not sick and I am a health care worker?” and you can find that information here.

The CDC has identified three primary exposure circumstances for providers:

  1. Prolonged close contact exposure with improper PPE (see link for more information).
  2. Prolonged close contact exposure with proper PPE. In short, both the provider and the patient MUST be wearing a mask, or the provider must be wearing both a mask and goggles (or face shield).
  3. Exposure outside of a clinical setting (community or family exposure).

In each of the first two circumstances, exposure must be prolonged (a cumulative time period of 15 or more minutes during a 24-hour period)  close contact (currently under 6 feet) with a patient, visitor, or another provider or staff member with confirmed COVID-19. 

The guidance depends on the circumstances. In general, if a HCP does not have prolonged, close contact with a COVID-infected person, no work restrictions apply.  However, a HCP who did have such prolonged contact and who was not using proper PPE will have restrictions.  For example, there is a 14-day work exclusion for circumstance #1 vs. precautionary work environment for circumstance #2. Please have all staff wear a mask and require patients to wear face coverings at all times.

If you have exposure in circumstance #3, you can look at the community exposure information here. For additional guidance, you should review the Critical Infrastructure Workers Who May Have Had Exposure to a Person with Suspected or Confirmed COVID-19 document. 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 work spaces: Clean and disinfect all areas such as offices, bathrooms, common areas, shared electronic equipment routinely.”

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]

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 (PLLCsmedical 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 

OR

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

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.donations@illinois.gov.

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.


Scam Warnings

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.

Stimulus Payments

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.


Employment

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.

The Families First Coronavirus Response Act (FFCRA) requires many employers to pay employees for sick leave related to COVID-19 in specific situations. Although there are exemptions for healthcare, the Department of Labor (DOL)has recently changed its rules to make the definitions less broad. In short, some of your employees will be eligible for this sick leave (required) and some may be exempted. If you are required to provide the paid sick leave, you are also eligible to receive reimbursement for payments made to employees for COVID sick leave. Additionally, as the employer you can choose to provide COVID sick leave even for those who are exempted from FFCRA.

The following list summarizes employee eligibility for FFCRA Sick Leave Pay, based on duties the employee performs in your office:

  • Reception only – Eligible for FFCRA Sick Leave Pay
  • Billing only – Eligible for FFCRA Sick Leave Pay
  • Reception and Assists with Health History and Screening – Rules are uncertain as to Eligibility
  • Reception and Administration of Modalities – Can be deemed ineligible by employer
  • Administration of Modalities only – Can be deemed ineligible by employer
  • Administration of other Delegated Direct Patient Care – Can be deemed ineligible by employer
  • Associate physician – Can be deemed ineligible by employer
  • X-ray technician (i.e. Limited Rad Tech) – Can be deemed ineligible by employer

The full article below explains COVID Sick Leave eligibility issue in detail, along with your requirements as clinic owner/ employer.

Full Explanation and Details

The FFCRA provides relief for both employees and employers affected by Coronavirus.  Affected full time 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. (Click here for DOL’s instructions, including calculation of amount of paid leave and eligibility: https://www.dol.gov/agencies/whd/pandemic/ffcra-employee-paid-leave).  Part time employees are eligible for leave for the number of hours that the employee is normally scheduled to work over the leave period to which they are entitled.  For example, an employee who works 20 hours per week can receive up to two weeks, or 40 hours, of paid sick leave.

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. In the original version of the rule, “healthcare workers” was defined very broadly, which allowed physician offices to deny Coronavirus-related sick leave to anyone employed at the office.  It included not only medical professionals but persons who are necessary to keep the office supplied and operational.  This version of the healthcare worker definition has been challenged in court as overly broad.

In response, the Department of Labor (DOL) issued a rule revision on September 11, 2020, that narrowed the exemption and expanded the types of employees who can claim this type of leave. This revision may affect physician offices who employ administrative and other personnel who have no patient care duties; i.e., these offices may now be required to provide COVID-related paid leave to those employees.  The news release summarizing the revised rule can be found here. For the detailed revision published in the Federal Register, click here.

Physician offices may still exempt employees who are “healthcare providers” under the new definition, which includes only employees who “provide diagnostic services, preventative services, treatment services or other services that are integrated with and necessary to the provision of patient care which, if not provided, would adversely impact patient care,” or those employees who qualify as “healthcare provider” under the Family and Medical Leave Act regulations.  Generally, providers under the FMLA are licensed providers, including physicians and other licensees.  The question for most chiropractic physician offices pertains to the other category — which types of employees, including unlicensed employees, are included in those who provide diagnostic, preventive or treatment services, or other services that are integrated with patient care.

The DOL has provided some guidance to help interpret the new rule.  First, DOL explains that included within the definition are licensed personnel as well as unlicensed technicians and assistants, and any other persons who directly provide diagnostic, preventive, treatment services, or other services that are integrated with and necessary to the provision of patient care are health care providers.  However, “health care providers” also include employees who may not directly interact with patients, but nonetheless provide services that are integrated with and necessary to patient care. For example, a laboratory technician who processes test results would be providing diagnostic health care services, even though the technician does not work directly with the patient, because the services are nonetheless an integrated and necessary part of diagnosing the patient and thereby determining the proper course of treatment.  DOL gives another example of performing an x-ray as integrated into diagnosing a broken bone.

On the other hand, DOL says that Individuals who provide services that affect, but are not integrated into, the provision of patient care are not covered by the definition.  DOL provides a non-exhaustive list of examples that includes information technology (IT) professionals, building maintenance staff, human resources personnel, records managers, consultants, and billers (in a hospital setting, the list also includes cooks and food services workers). While the services provided by these employees may be related to patient care—e.g., an IT professional may enable a physician to maintain accurate patient records—they are not considered to qualify as integrated and necessary components of actual patient care.

Applying this guidance to a chiropractic physician office, receptionists and billers who perform only administrative tasks do not appear to fall under the definition of “health care provider” and would thus be eligible for COVID leave.  However, a receptionist who also screens patients or assists in taking their health histories is less clear. DOL has not specifically provided a statement on those employees, but if such an employee requests COVID leave, the employer could deny the request and argue that their services are integrated with and necessary to the provision of patient care.  However, without specific cases or opinions at this early stage, of the rule, the ultimate outcome of the request cannot be predicted.

Click here for a link to DOL’s FAQ “Who is a “health care provider” who may be excluded by their employer from paid sick leave and/or expanded family and medical leave? [Updated to reflect the Department’s revised regulations which are effective as of the date of publication in the Federal Register.]”

 
To minimize the spread of the virus associated with COVID-19, DOL encourages employers to be judicious when using this definition to exempt health care providers from the provisions of the FFCRA. For example, an employer may decide to exempt these employees from leave for caring for a family member, but choose to provide them paid sick leave in the case of their own COVID-19 illness.

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. 

Also, note that employers are eligible to receive reimbursement for payments made to employees for COVID sick leave.  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. Here is the FAQ from the IRS on how to claim the credits (including collecting them in advance). Employers must post the Families First poster at their places of business. Download the poster here. The ICS has also provided an optional notice that physician employers may use to notify their staff that some employees of healthcare offices are exempt from receiving additional sick leave. Physician employers may post this notice or print in the form of a letter to hand to staff.  Although this notice is not required, providing it may be useful to advise ineligible 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.

Template letter for employees (layoffs)

Template letter for patients (after closure) – English

Template letter for patients (after closure) – Spanish


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.

The Governor’s 5/1/2020 stay-at-home order will make several changes. Of those changes, the following impact chiropractic physicians as follows:

  1. 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;
  2. 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. 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 paperwork is 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.

Link to Executive Order 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.

Illinois Phase 4 and Current Mitigations [Updated 11/19/2020]

Although Illinois continues to be in Phase 4 of the COVID-19 Response, Illinois has broken down the state into different regions and potentially different Tiers of mitigation. This means that although certain Phase 4 operational standards remain in place, more restrictive Tier 3 Mitigations have applied in some regions.

You can find the existing Tiers and breakdown here.

However, all regions have now been placed into Tier 3 Mitigations, beginning November 20, 2020. There are now new specific requirements that will apply to all “covered businesses,” which appears to be broadly defined and includes chiropractic physician offices.

The new Executive Order requires reduces operating capacity to 25%, with the intent of minimizing exposure to the greatest extent possible.  Therefore, the ICS strongly recommends that physicians use strategies such as limiting visitors, having patients fill out forms online in advance, and requiring patients to wait in their automobiles until the office is ready to see them.  Additionally, all offices must continue to follow CDC guidelines, including consistent physician use of appropriate PPE such as gloves and masks, and patient use of masks or face coverings, social distancing, handwashing, and scrupulous facility disinfection protocols

The new Executive Order effective November 20 also provides guidance that applies specifically to facilities providing personal services, including massage therapy. In those facilities, massage therapy is allowed only when all the following conditions are met:

  • As deemed necessary by a medical provider;
  • Appointments must be separated by a minimum of 15 minutes. According to our best information, this means that for each treatment room, there must be at least 15 minutes from the end of one person’s appointment to the beginning of the next person’s appointment, to allow for disinfection and air circulation. 
  • Facilities should take steps to sanitize service rooms before and after each service (physicians should already be practicing these guidelines, as this has been in place since the beginning of the pandemic); and
  • Circulate clean air through service rooms before and after each service (this could take the form of a fan or other form of continual air circulation with the door open).

The ICS has been asked whether a chiropractic physician may issue a note to a specific individual stating that massage therapy is necessary for that individual, in order to meet the condition for services under the Executive Order.  The ICS believes that a physician may issue such a note for a current, active patient whose condition is known to the physician.  However, physicians should not blankly issue these notes for patients that the physician has not recently seen or may never have seen.  We believe this activity could constitute a breach of standard or care, as well as unethical, unprofessional conduct that could violate the Medical Practice Act.

The ICS understands that some of our members provide both therapeutic and non-therapeutic massage in their offices.  Based on the new Tier 3 mitigation guidelines for facilities offering massage therapy that is not deemed necessary by a medical provider, chiropractic offices (as well as stand-alone massage therapy offices) that are offering massage therapy not deemed necessary by a medical provider should stop those services effective November 20.

The new Tier 3 mitigations have been assigned to the entire state at this time.  However, mitigations for individual regions may be revised later if regional statistics change. You can review the current limitations for your area by clicking on the Mitigations Measures link here.


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 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

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.

Electronics

  • 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:

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).

[Updated 4/28/2020] ICS Members can download a Patient Screening Document form here.

[Updated 4/28/2020] ICS Members can download a Staff Member Screening Document form here.

Template Informed Consent with COVID-19 Section

The ICS has also developed a consent to treat via telehealth. That is available here.

Electronic version of the patient notification of non-covered services. This document can be transmitted, signed, and returned electronically.

Template letter for employees (layoffs)

Template letter for patients (after closure) – English

Optional noticethat physician employers may use to notify their staff that all employees of healthcare offices are exempt from receiving additional sick leave.

COVID-19 Infection Control Policy for Manual Therapy Offices[i] 

A “Stop Coronavirus” sign for physician offices[ii]

Additional Resources:

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:

Videos [Updated 4/23/2020]

COVID-19: Resources For You and Your Office

Business Challenges and Other Aspects during COVID-19

COVID-19 and Business Resources

Pride in the Chiropractic Profession

4/6/2020 COVID-19 Article Update

April 9, 2020 COVID-19 Article Updates

COVID-19 Updates for Chiropractic Physicians

Dr. Erin Ducat Presents Her Cleaning Process

Dr. Huffman Demonstrates How to Put on/Take off PPE


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.

About Author

ICS Staff

The Illinois Chiropractic Society staff works collaboratively on many topics to bring the most comprehensive and relevant information to our members. We have over 60 years of chiropractic experience and understand the heartbeat of the profession. We all look forward to providing relevant information to our members for years to come.

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