Coronavirus (COVID-19) in the Chiropractic Physician office Updated April 1, 2020, 4:00 pm
Editors Note: This article is being constantly updated as new information is made available. Please continue checking this article for updates.
At the ICS, we have never been more acutely aware that many chiropractic physicians operate as solo practitioners or small businesses who may feel more isolated than large group practitioners. The ICS continues to serve as a bridge and information link to our chiropractic community and to assist in any way we can. We are working diligently to provide the most current guidance to our community.
The following information addresses the most common inquiries received by the ICS office at this time. 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 CDC recommendations and this document frequently for revisions.
In this article:
Financial and Business Aid
Significant Help in CARES Act via SBA Forgivable Loans – [Updated 4/1/2020 4:00 pm]
There was an important section in the “Coronavirus Aid, Relief, and Economic Security Act” (CARES Act) passed by Congress last Friday (3/27/2020) that provides for SBA loans that ultimately can be forgivable. Most people refer to this section as the “Paycheck Protection Program.” At this point, the Small Business Administration (SBA) has until April 11 to establish the regulations or rules for this act, which will be necessary to answer some additional questions and to begin the loan application process.
These loans will have different requirements than those found in most SBA rules. Some requirements are more restrictive, and some s are significantly loosened. The information below is based on our understanding of the law now and may be adjusted based on new information and the release of regulations by SBA.
How the CARES loan different than typical SBA loans and the basic CARES loan requirements:
- Do NOT have to prove that you cannot receive credit from other sources. This is a typical SBA requirement, but it appears this has been removed for these loans.
- NO personal guarantee will be required.
- 100% guaranteed by the federal government.
- No federal government guarantee fees or prepayment fees.
- The borrower MUST make good faith certifications that they have been impacted by COVID-19 AND will use the funds to maintain payroll and other debt obligations. This language includes, i) “that the uncertainty of current economic conditions makes necessary the loan request to support the ongoing operations of the eligible recipient; (ii) acknowledging that funds will be used to retain workers and maintain payroll or make mortgage payments, lease payment, and utility payments”; and no other SBA loans applications are pending.
- Must have fewer than 500 employees.
- Funds must be used to cover payroll costs, benefits and leave, mortgage interest, rent, and utilities.
- Interest is capped at 4%.
- The borrower can defer payments (including the low interest) between 6-12 months.
- The amount of the loan can be up to the average monthly payroll from 2019 times 2.5 (i.e. 2019 total payroll expenses are $240,000, then 240,000/12 = 20,000 x 2.5 = $50,000 maximum). However, the loan amount is reduced by any amounts paid to individuals greater than $100,000.
- $1 million loan amount maximum.
- Section 1106 of the Act, titled “Loan
Forgiveness,” provides that the Government will forgive up to the original
principal amount of a loan under the Act that a recipient can document was used
to pay: (1) payroll costs; (2) mortgage interest; (3) rent and (4) utilities—in
each case for up to eight weeks following the issuance of the loan. Additional
- 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).
- The forgiveness is reduced proportionately based on that 8-week period vs. last year.
- Employees must remain employed through the end of June.
- Employee pay cuts greater than 25% will reduce the forgiveness proportionately.
- 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 the end of next week.
- They have indicated that they anticipate the loans MAY be able to be disbursed the same day. However, the local banks may have a longer review process.
- If you have laid-off employees, you can rehire employees; after accepting the loan you are credited with their wages.
- 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. You could choose which one to use OR re-finance the EIDLA loan into the PPP loan.
- 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 the 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 to determine your next steps and proper timing for your situation and practice.
Economic Injury Disaster Loans (EIDL) and Loan Advances [Updated 3/30/2020]
The Small Business Association Economic Injury Disaster Loans (EIDL) and Loan Advance are available to businesses (including Doctors of Chiropractic) that have been impacted by COVID-19.
This program includes an emergency advance of up to $10,000 to small businesses affected by COVID-19. To access the advance, you must first apply for an EIDL and then request the advance. The advance does not need to be repaid under any circumstance. The funds may be used to keep employees on the payroll, to pay for sick leave, meet increased production costs due to supply chain disruptions, or pay business obligations, including debts, rent, and mortgage payments. You may also qualify for funds above the emergency advance to help your practice.
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.
Federal Stimulus Package – [Updated 3/27/2020]
Both the House and the Senate have passed a $2 trillion federal stimulus package. 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.
Please note, the legislation will still need to be signed by the President. We will update with you more information as it becomes available.
State Loans for Small Businesses [Updated 3/31/2020]
During Governor Pritzker’s daily presser today, he announced new financial assistance options for small businesses. The applications for these programs will not be available until the end of the day on Friday, March 27, 2019, at the DCEO website. The two options are as follows:
Illinois Small Business Emergency Loan Fund
The Illinois Small Business Emergency Loan Fund was established as a partnership between the Illinois Department of Financial and Professional Regulations (IDFPR) and the Illinois Department of Commerce and Economic Opportunity (DCEO).
- Low-Interests loan for up to $50,000
- No payments for the first 6 months
- Fixed payments at 3% interest rate
- 5-year term loan
- Loans must be used for working capital with at least 50% of the loan going towards payroll or other eligible compensation. This could include salaries, wages, tips, paid leave, and group healthcare benefits.
- Any compensation over $100,000 will not qualify.
- Borrowers are required to commit to hire or retain at least 50% of their workforce for six months
- Small business must be outside of Chicago
- Fewer than 50 employees AND
- Less than $3 million in revenue in 2019
- Must have a loss of 25% from COVID-19
- Located in Illinois and have a valid business license
- Previous bank statements and tax returns will be required
For more information, please visit the DCEO website here.
Downstate Small Business Stabilization Program
- Grants of up to $25,000 for working capital to small businesses that are served by DCEO’s Office of Community Development
- Partnership between business and local governments
- Local governments have to apply for the business
- Fewer than 50 employees
- Focuses on downstate and rural counties
- Local government will need to check with the Department of Commerce and Economic Opportunity to ensure they are located in an eligible area
For more information, please visit the DCEO website here.
Chicago Small Business Resiliency Fund
If a business is located in the City of Chicago, they can apply for a small business grant through the City entitled the Chicago Small Business Resiliency Fund. This loan comes from the City of Chicago and was NOT part of the Governor’s announcement today.
- Loan Amount of up to $50,000
- Required to be used for working capital
- At least 50% of the proceeds are required to be used for payroll
- Low-interest loan with a 5-year repayment period
- Employs fewer than 50 employees
- Less than $3 million of revenue in 2019
- Had a revenue loss of more than 25% revenue strictly due to COVID-19
- City address or City business license
- Cannot have any pre-existing tax liens
For more information and application for this loan please click here.
Federal and State Tax Deadline Extended – [Updated 3/25/2020]
Both the Internal Revenue Service and the State of Illinois have extended the deadlines for filing and paying federal and state taxes from 4/15/2020 to 7/15/2020.
SBA Loans and Other Information for Small Businesses Affected by Coronavirus [Updated 3/23/2020]
All Illinois small businesses (according to SBA’s size standards) and private non-profits can now apply for loans of up to $2 million through the U.S. Small Business Administration’s Economic Injury Disaster Loan Program. If your businesses have been affected by the coronavirus pandemic, this program offers working capital to meet needs including payroll, accounts payable, and fixed debt payments until the situation improves. Interest rates are 3.75% for small businesses and 2.75% for non-profits. Your businesses may apply now at https://disasterloan.sba.gov/ela/
- Economic Injury Disaster Loan Program FAQ
- Daily Webinars will be available at www.sba.gov/il
- Disaster loan information at https://disasterloan.sba.gov/ela/Information/Index
- Information for small businesses affected by coronavirus at www.sba.gov/coronavirus
- All coronavirus-related federal government resources: www.usa.gov/coronavirus
Find more information for small businesses affected by coronavirus at www.sba.gov/coronavirus. Go to www.sba.gov/local-assistance to find a counselor or mentor. You can also email Illinois.email@example.com 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
ICS Recommendation – Chiropractic Maintenance Visits [Updated 3/23/2020]
To be clear, the following section is NOT for patients who are in pain. As we have contended from the beginning, in the absence of chiropractic physicians’ care, these patients would need to turn to emergency rooms, which would tax and already-overly burdened system who may not even be able to serve them, or they would turn to treatment such as opioids and other addictive medications, resulting in increased opioid use disorder cases.
Based on all of the above, including the Governor’s Executive Order 2020-10 issued March 20, 2020, the ICS strongly recommends that our doctors postpone or cancel any appointments for in-office maintenance care or care for patients who are close to or have reached maximum medical improvement (MMI). The ICS also urges doctors to postpone or cancel non-medically necessary or ancillary in-office services (such as non-therapeutic massage and other services). Our doctors should continue the process of moving to telehealth for any services that may be provided as an alternative to in-person care, including functional medicine, rehab services (e.g. range of motion and therapies), and some primary care services. We believe that, for all physicians, limiting in-person patient encounters to the extent practicable is an ethical and medically responsible way to comply with the Executive Order while helping patients in need and facilitating the leveling off of the Coronavirus in the coming weeks.
Again, the ICS believes that chiropractic care is extremely important to the health care of patients, and in the current COVID-19 environment, chiropractic care is essential for musculoskeletal pain patients. In the absence of our doctors’ care, these patients would need to turn to emergency rooms, which would tax and already-overly burdened system or may not even be able to serve them, or they would turn to non-contact treatment such as opioids and other addictive medications, resulting in increased opioid use disorder cases.
The basis of our recommendation:
- The Illinois Department of Public Health issued an alert on March 18, 2020, stating that all health care workers are at some risk of exposure to Coronavirus and asking that they self-monitor and isolate themselves at the first sign of any symptom: “Additionally, in the setting of a pandemic with widespread community transmission in Illinois, all healthcare workers are at some risk for exposure to COVID-19, whether in the workplace or in the community. Therefore, IDPH is asking ALL healthcare workers, regardless of whether they have had a known SARS-CoV-2 exposure, to self-monitor by taking their temperature twice daily and assessing for COVID-19-like illness. If healthcare workers develop any signs or symptoms of a COVID-19-like illness (for healthcare workers, fever cutoff is 100.0oF), they should NOT report to work. If any signs or symptoms occur while working, healthcare workers should immediately leave the patient care area, inform their supervisor per facility protocol, and isolate themselves from other people.” Additionally, the IDPH alert states: “Healthcare facilities are also encouraged to implement plans now for canceling elective admissions and procedures.”
- CMS announced through the Task Force, “All elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak.”
- Lastly, on March 20, 2020, the Governor issued Executive Order 2020-10 – the “Stay at Home” Order – that orders that non-essential operations must cease activities and essential operations must keep activities within “minimum basic operations.” (See pars. 2 and 13.) Link to Executive Order here.
Offices that continue to provide in-person services must comply with the Governor’s Executive Order regarding social distancing, including by maintaining social distancing for employees as possible and six-foot requirements for members of the public in waiting rooms, in addition to other infection prevention protocols.
Telemedicine Options [Updated 3/30/2020]
Our members should consider using telehealth for appropriate services, such as functional health services or rehabilitation services that could be performed by video (such as consultations, examinations, range of motion assessments, recommended exercise therapies, therapeutic exercises, etc.). The ICS recommends that physicians make a careful assessment of the types of services they can render via electronic technology, making certain to meet the usual standard of care and not to abuse the telemedicine delivery format. See the links here for telehealth and insurance issues:
- Telemedicine Services in Illinois(Article)
On 3/19/2020, Governor Pritzker issued an executive order regarding telehealth coverage that makes broad sweeping changes and requires an increase in insurance coverage for services provided via telehealth. You can see the full order here. The order includes provisions that make the following statements or changes that are in place during the Gubernatorial Disaster Proclamation:
- Telehealth services can be delivered by physicians (Illinois law includes chiropractic physicians as physicians);
- Methods include “video technology commonly available on smartphones and other devices” such as FaceTime, Facebook Messenger, Hangouts, and videoconferencing (i.e. Zoom, LogMeIn, etc.);
- “health insurance issuers regulated by the Department of Insurance are hereby required to cover the costs of all Telehealth Services rendered by in-network providers to deliver any clinically appropriate, medically necessary covered services and treatments to insureds.” Thus, it does appear this applies to in-network providers only;
- Documentation and recordkeeping required (insurers may establish reasonable requirements here);
- No ADDITIONAL utilization review requirements or treatment limitations can be added for telehealth than is required for in-person services;
- IMPORTANT: Providers should, “to the extent feasible, notify patients that third-party applications potentially introduce privacy risks.” Additionally, providers should take all precautions and turn on available encryption and privacy modes.
- This would NOT apply to public communication (i.e. Facebook pages, Facebook groups, etc.). Public communication for these services would still violate HIPAA; and
- Effective as of 3/19/2020.
On-demand education available – “Telehealth 101: Strategies for Treating Patients When In-office Care is Not an Option.” The course was co-presented by Dr. Tim Bertelsman, FACO, and Marc Abla, CAE, ICS Executive Director on how chiropractic physicians can continue to deliver services to homebound patients via telehealth. This is an important avenue of care during these uncertain times. Click here to take the course.
Additionally, 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.
Business and Practice Considerations
Does Malpractice Insurance Cover Claims of Coronavirus Exposure in a Chiropractic Physician Office? Does Workers’ Compensation Insurance Cover Claims by my Employees? [Updated 3/30/2020]
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 the information provided by two major chiropractic liability carriers. Both strongly urge that physicians who choose to keep their offices open must follow guidelines recommended by the CDC and other authorities to reduce possible transmission of the virus. Following these steps MAY comply with policy requirements for the company to cover claims that a patient or employee contracted COVID-19 in your office. However, once it is determined that the insurer will cover you for a claim, whether the claim is compensable (i.e., whether your office committed the type of negligence covered by the policy) is determined on a case-by-case basis that will include expert opinions on the standard of care for your office, your practice, and your geographical area. Remember that simply because an individual has an unwanted outcome (e.g., contracts the virus) does not mean the office failed to meet the standard of care, so meeting the recommended protocols may greatly mitigate or defeat damages in these cases.
For reference, the following steps are recommended by one malpractice insurer:
- Establish and follow a thorough cleaning process for all areas of your office, including the waiting room, reception area, exam rooms, and restrooms.
- Do not allow staff members who are sick, have been sick or have sick family members to come to the office.
- Have a detailed conversation by phone with the patient on the day they’re scheduled to come in, and ask:
- If they or anyone in their family has a fever or has had one in the last two weeks. The incubation period can be as long as 24 days.
- Have they or family members had any symptoms of a cold or flu? Symptoms include fever, tiredness and a cough that isn’t necessarily productive. They may also have or have had aches and pains, runny nose or nasal congestion, and vomiting or diarrhea.
- Have they traveled abroad in the last two weeks?
- Have they been near anyone who has potentially had the virus through their own family or work contacts? People can be contagious without symptoms.
- Ask high-risk patients to delay if possible. High-risk patients are those who:
- Are undergoing chemotherapy.
- Are immunocompromised.
- Are diabetic.
- Have heart disease.
- Have high blood pressure.
- Have asthma or another respiratory issue.
- Are over 60 years of age.
- Stagger appointments to allow time for thorough cleaning between sessions.
- Ask patients to wait in their car (rather than the waiting room) until it’s time for their appointment.
- Ask anyone accompanying the patient to wait in the car during the appointment if possible.
- Remove magazines and other printed reading material.
- Remove toys or other diversions you may have in the office for children.
Another chiropractic liability insurer provides the following information regarding physician liability for COVID-19 transmission in the office:
In regard to patients:
Physicians ALWAYS have a duty to utilize “universal precautions” notwithstanding the current crisis. Universal precautions, standard precautions, and contact precautions should ALWAYS be utilized with all patients – those are the standards to prevent cross-contamination. To the extent a physician is not following current generally accepted guidelines, they may be held liable to a patient or staff member.
Offices should already have policies in place to aid in the 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 illnesses 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.
Business Issues and Steps You Can Take to Protect Your Practice [Updated 3/27/2020]
The following links provide helpful, non-state-specific information about unemployment, family and medical leave, employer tax credits, business interruption insurance, and other topics of interest to businesses:
The “Families First” law is federal and applies to all employers of 500 or fewer, so the information pertaining to employee leave under Families First will apply to most, if not all, of our doctors. Here is information from Hinshaw Law regarding Families First (https://www.hinshawlaw.com/newsroom-updates-employer-faqs-for-covid-19-coronavirus.html).
Unemployment compensation is under state jurisdiction, so doctors should refer to the Illinois Department of Employment Security for specific guidance in Illinois:
General Information (https://www2.illinois.gov/ides/Pages/default.aspx), and
COVID-19 Specific Information (https://www2.illinois.gov/sites/coronavirus/FAQ/Pages/Unemployment-FAQ.aspx).
The ICS is continuing research to answer questions about the interplay of unemployment compensation and physician abandonment, treating patients while receiving unemployment compensation, and whether business structure has an impact on eligibility unemployment compensation. We will update as soon as we have reliable information to share.
Additionally, the ICS is offering an on-demand course on “Protecting Your Chiropractic Business During the Covid-19 Pandemic.” Click here to take the course.
Temporary Closing of Offices [Updated 3/24/2020]
At this time, the ICS recommends that doctors use their best professional judgment, applying relevant guidelines, such as those of the CDC and the White House Coronavirus Task Force, to determine whether to close offices.
- The ICS recommends closing any office that does not have staff or resources to maintain strict CDC disinfecting protocols, social distancing, and other prevention tools. Here are the CDC Guidelines for healthcare settings.
- Any office that has more than 10 persons present at a time should close or schedule staff and patients to reduce the number of persons to 10 or fewer.
- Additionally, the ICS notes that the Illinois Dental Society has recommended closing offices. Chiropractic physicians may want to review their release to assist in deciding whether to remain open or temporarily close.
- Offices that close should make certain that patients have access to medical care during this period to avoid patient abandonment. The ICS recommends including a section in your closing letter to patients advising that you are available for phone calls for emergencies and providing a phone number. The letter should indicate your availability to triage patient issues by phone and make the best recommendation for their care, based on their symptoms and condition, as well as the status of the Coronavirus pandemic. Doctors should provide a health care alternative for their patients to contact, such as the County Health Department, for additional advice and/or necessary services.
- Physician offices should let patients know that they will make every effort to comply as quickly as possible with medical record requests during the closure period. Provide information about how patients may obtain records (such as providing phone and/or email contact information) and respond to requests promptly.
If you have unopened Personal Protection Equipment (PPE), the state is in dire need of these items. Please visit the Illinois COVID-19 PPE site to find out how your PPE can make a difference in the state and how to make it available.
Hereis a template letter for patients to notify of a temporary closure.
Offices Remaining Open – Consider Limiting In-Person Services [Updated 3/25/2020]
The Governor’s “Stay at Home” order (Executive Order 2020-10) has classified healthcare services as essential services. The order permits individuals to visit health care professionals and for clinics to remain open to provide healthcare services, applying social distancing and strict disinfecting protocols. However, to minimize the possibility of transmission, many offices have chosen to limit in-office visits to urgent and/or medically necessary services and to use telehealth whenever possible and appropriate. Additionally, physicians should check with their general, professional liability, and workers’ compensation carriers to determine coverage for possible claims by employees and patient visitors that they contracted COVID-19 in your office.
For offices that remain open for any services, the ICS recommends applying the most current CDC guidelines to the following steps:
- Screen patients who call with concerns that they
may be infected with Coronavirus (see link below) and refer the patient to
their county health department;
- Reschedule staff and patients so that no more than 10 persons are in the office at a time, and comply with the Governor’s Executive Order regarding social distancing, including by maintaining social distancing for employees as possible and six-foot requirements for members of the public in waiting rooms;
- Conduct “pre-screening” of staff at the beginning of the shift and prior to any patient contact, assessing the presence of symptoms and risk, and sending staff home or referring for testing where appropriate. ;
- Screen all patients who come to the office for services 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;
- Apply infection prevention protocols (see links below), including using personal protective equipment such as single-use only medical exam gloves and gowns that should be disposed of after EACH patient to avoid potential cross-contamination. 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 webinaron using telehealth in a chiropractic practice).
Advertising and marketing caveat [Updated 4/1/2020 4:00 pm]
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.
Lastly, based on the White House Coronavirus Task Force guideline to cancel events with more than 10 people, the ICS strongly suggests chiropractic offices should cancel all practice marketing events, such as health fairs or informational seminars, for the foreseeable future.
Physician License Expiration and Renewal Deadline Change – [Updated 3/18/2020]
The ICS office has been asked whether the Illinois Department of Financial and Professional Regulation (IDFPR) will extend the regular license expiration date of July 31, 2020, due to the Coronavirus pandemic. On March 18, 2020, at 6:30 pm, IDFPR announced several variances for many different licenses. Chiropractic physician license expirations have been extended to September 30. 2020.
In addition to the variance for license renewal, the department included the same extension for completing required continuing education (CME). As a result, all requirements for renewal (fees, CME, etc.) now have a deadline of September 30, 2020.
CDC Guidance For Health Care Practitioners Who Have Tested Positive For Coronavirus And Notification To Patients [Updated 3/31/2020]
The ICS has been asked what steps should be taken by a health care practitioner (HCP) who has tested positive for the virus or who has been exposed to a person who tested positive, called “secondary exposure”. The CDC has published interim guidance to help with the 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: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
The CDC has taken a conservative approach to work restrictions in health care settings because HCPs often have extensive and close contact with vulnerable individuals in the office setting. The CDC’s approach is to quickly identify early symptoms and prevent transmission from potentially contagious HCP to patients, HCP, and visitors, and to err on the side of early evaluation and testing of symptomatic HCP. particularly those who fall into the high- and medium- risk categories described in the guidance. CDC does not include secondary exposure (i.e. the spouse of a patient tests positive) in its risk assessment as the tool focuses only on possible direct exposure of HPC to an infected person.
The recommended action for monitoring and work restrictions will depend on whether the HCP’s exposure is considered low, medium, or high risk. CDC has provided a detailed chart for multiple scenarios, incorporating epidemiologic risk factors, exposure category, recommended monitoring for COVID-19 (until 14 days after last potential exposure), and work restrictions for asymptomatic HCP.
Steps to Take Following Primary Exposure:
- Notify the local county health department of the exposure,
- Work through the CDC Risk Assessment tool,
- Healthcare providers, in consultation with public health authorities, should use clinical judgment to assign risk and determine the need for work restrictions.
The ICS is not aware of any general mandate for physician offices to notify all recent patients when a HCP tests positive for the virus. However, physicians should use their judgment depending on the makeup of their practices. For example, a physician may consider notification if the office treats a large number of elderly persons or a large number of rheumatoid arthritis patients taking immunosuppressants. Of course, physicians should comply with all mandates and recommendations of their local health authorities.
Donations and Volunteering
Volunteering to Assist in the COVID-19 Response – [Updated 3/30/2020]
The State of Illinois has developed Illinois HELPS, which is the healthcare professional emergency volunteer program. Illinois HELPS allows healthcare professionals to register to volunteer to assist in the state coronavirus effort. Volunteers may be placed at both hospital surge and alternative housing sites throughout the state. Currently, the state does have certain placements they are trying to fill but are also signing up volunteers for future opportunities.
Chiropractic physicians that would like to volunteer should do so at the website link below.
For more information and to sign up for Illinois HELPS visit: www.illinoishelps.net
Donation of Personal Protective Equipment (PPE) [Updated 3/26/2020]
The State of Illinois, as well as the Illinois Health and Hospital Association, have issued a call to action for all unused Personal Protective Equipment (PPE). They are asking anyone who has unused, unopened PPE to donate it to hospital personnel and first responders.
The type of equipment being requested includes masks, gowns, gloves, and many other PPE items. For a full listing of items being requested and requirements please visit the State donation website site by clicking here.
Please note, the state requires all donated PPE to be unopened and in the original packaging from the manufacturer. To donate, please email the state at PPE.firstname.lastname@example.org.
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.
Paid Sick Leave and Tax Credits for Coronavirus-Related Employee Leave [Updated 4/1/2020 4:00 pm]
The Families First Act provides relief for both employees and employers affected by Coronavirus. Affected employees can receive up to two weeks (80 hours) of paid sick leave, at either 100%, 80%, or 2/3 of their regular pay, depending on the reason they are unable to work. However, employers are to receive full reimbursement for amounts paid for this type of leave, in the form of an immediate dollar-for-dollar tax offset against payroll taxes. Where a refund is owed, the IRS will send the refund as quickly as possible. These provisions apply to employers of less than 500.
There are two potential exemptions: one for healthcare workers and one for small businesses under 50. The principal exemption for our doctors would be for healthcare workers. You can find the definition in the Department of Labor clarification document and it includes “For the purposes of employees who may be exempted from paid sick leave or expanded family and medical leave by their employer under the FFCRA, a health care provider is anyone employed at any doctor’s office…” The apparent purpose of the exemption is to avoid creating a health care worker shortage in facilities treating a large number of patients, which does not apply to most chiropractic physician offices. Nonetheless, the plain meaning of the language allows chiropractic physician employers to claim the exemption and not pay this type of sick leave to their employees.
The second exemption indicates “An employer […] with fewer than 50 employees (small business) is exempt from providing (a) paid sick leave due to school or place of care closures or child care provider unavailability for COVID-19 related reasons and (b) expanded family and medical leave due to school or place of care closures or child care provider unavailability for COVID-19 related reasons when doing so would jeopardize the viability of the small business as a going concern.” Department of Labor gives specific requirements in the document. At this time, it appears this exemption is self-determined by the employer. The ICS suggests our physician employers who claim this exemption run some basic calculations as to the projected cost of providing additional COVID-19 sick leave to document that it would jeopardize the office’s financial viability.
Note that although employees may be exempt from paid leave for COVID-19, they are still entitled to take ordinary accrued sick and vacation leave (if any) in accordance with the physician office’s usual policies.
The IRS issued a release summarizing in easy-to-understand terms the law’s provisions about paid leave, employer credits, prompt payment, and small business exemptions, with links to detailed information. Click here for that information. Employers must post the Families First poster at their places of business. Download the poster here.
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.
Governor Pritzker Orders and Requests
Chiropractic Physician Services Are Essential Services Under Federal CISA Advisory and Illinois “Stay at Home Order [Updated 3/31/2020]
Governor Pritzker’s “Stay at Home Order” has now been extended to April 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 is to broadly include all types of providers and that all physicians, including chiropractic physicians, are exempted for the delivery of healthcare. Therefore, chiropractic physicians can treat patients and patients can visit your office. However, review the Chiropractic Maintenance Visits section below for important considerations.
Additionally, On March 28, 2020, the U.S. Department of Homeland Security Cybersecurity Infrastructure Security Agency (CISA) issued a “Memorandum On Identification of Essential Critical Infrastructure Workers During Covid-19 Response”.
The advisory list identifies various workers who conduct a range of operations and services that are typically essential to critical infrastructure. The healthcare section of the list specifically names chiropractors as essential healthcare providers.
Throughout this process, the ICS has advocated that chiropractic care is extremely important to the health care of patients and in the current COVID-19 environment, chiropractic care is essential for musculoskeletal pain patients. In the absence of our doctors’ care, these patients would need to turn to emergency rooms, which would tax and already-overly burdened system or may not even be able to serve them, or they would turn to non-contact treatment such as opioids and other addictive medications, resulting in increased opioid use disorder cases.
On March 22, 2020, the governor specifically addressed whether paperworkis required to prove that doctors or staff are open or traveling for essential services and said in his press conference that they would NOT require papers for people headed to deliver or who are delivering essential services. Doctors and staff should simply say that they are or work for a doctor and are headed to the clinic to assist in delivering healthcare services.
However, if the need arises, we have created a letter on Illinois Chiropractic Society letterhead that clearly demonstrates that chiropractic physicians are included as essential in Illinois. We are making that available to all chiropractic physicians (members and non-members) as a precaution if you are questioned or asked to close. You can access the letter here.
Illinois Department of Public Health – SIREN Sign Up [Updated 3/13/2020]
On March 13, 2020, the Illinois Department of Public Health (IDPH) requested we send Illinois chiropractic physicians the steps to sign up to receive COVID-19 situational awareness/guidance through the State of Illinois Rapid Electronic Notification System (SIREN). SIREN is a secure web-based messaging and alerting system that uses various formats to provide 24/7/365 notification, alerting, and flow of critical information. SIREN is used for targeted alerting based on members’ professional roles or functions. Chiropractic physicians have been selected to participate because of their role as physicians. The IDPH request can be found here. We encourage all of our doctors to sign up to receive the SIREN notifications.
Clinical and Public Health Guidance for Managing COVID-19 Interim Guidance [UPDATED 3/19/2020]
Illinois Department of Public Health issued a SIREN alert on 3/19/2020 titled “Clinical and Public Health Guidance for Managing COVID-19 Interim Guidance (subject to change); March 18, 2020.” We believe this is a very important document that providers should read. You can find the document here.
General Information from the Centers for Disease Control (CDC) and Illinois Department of Public Health (IDPH) [Updated 3/20/2020]
The ICS has been carefully monitoring the CDC and other information on the COVID-19 (coronavirus 2019). Although the ICS is not and cannot be a primary source on this subject, we want to make our members aware of relevant information that has been published by the CDC, the State of Illinois, and other reliable sources. The spread of this virus has particular implications for physician offices, as both health care providers and as employers. On March 11, 2020, the World Health Organization declared COVID-19 a pandemic, the first to be caused by coronavirus. The WHO director said hope remains that COVID-19 can be curtailed, and he urged countries to take action now to stop the disease.
The COVID-19 outbreak is rapidly evolving, and information is constantly changing. For that reason, the ICS strongly recommends that physicians stay up to date with guidance issued by the U.S. Centers for Disease Control and Prevention (CDC). The CDC has provided a number of links (end of the article below) to general information about the virus, as well as information for healthcare professionals and businesses. CDC updates these sites continually as information becomes available. The Illinois Department of Public Health (IDPH) has also created a webpage (end of the article below) with coronavirus updates, including statistics on persons under investigation and positive cases in Illinois. The IDPH page contains links to other recommendations, such as ways to reduce community spread and guidance for businesses, travel, and households.
For a list of current COVID-19 Illinois Public Health hotlines, please click here.
CDC Information for Clinicians [Updated 3/13/2020]
The CDC presented a one-hour live webinar for clinicians on March 5th. It is now available at no cost on-demand here. The presenters reported on important updates, including recommendations for office protocols for control of the spread of the virus. The experts recommend similar protocols for other infectious diseases, such as influenza. Aside from the obvious standards for the physical facility and staff (sanitizing surfaces, handwashing, etc.), if a patient presents to the office with symptoms, the patient should be separated from others in the waiting area and masked to prevent the spread of droplets.
The CDC also discussed how to determine which patients to refer for testing. CDC recommends using professional judgment to assess the presence of the following factors in presenting patients:
- Epidemiological factors such as being in close contact with a diagnosed patient or having been in an area of known community transmission
- Symptoms including:
- Acute respiratory illness – cough, shortness of breath, difficulty breathing
- Persons over 65 years of age
- Persons with underlying conditions and comorbidities
Physicians are to use their best judgment in assessing patients and refer those for testing as appropriate. Due to the general scarcity of testing kits, the CDC currently recommends that physicians should refer “persons under investigation” (PUI) to state and local public health laboratories in their areas. Additionally, the CDC states that “Healthcare providers should immediately notify their local or state health department in the event of a PUI for COVID-19.” Additionally, on March 9, 2020, Governor Pritzker announced that the Illinois Department of Public Health has a statewide COVID-19 hotline and website to answer any questions from the public or to report a suspected case: call 1-800-889-3931 or visit IDPH.illinois.gov. Thus, it appears that a call to the IDPH 800 line would be an appropriate way for a physician to report a suspected case.
Testing [Updated 3/16/2020]
The ICS is aware that there have been concerns about the limited supply of testing kits. On March 10, 2020, the Illinois Department of Public Health (IDPH) issued a helpful release about testing:
- To provide information on the availability of commercial lab testing for SARS-CoV-2 [the virus that causes the disease COVID-19];
- To clarify what testing will be prioritized through IDPH Public Health Laboratories;
- To clarify which persons under investigation should be reported to local health departments.
The IDPH reports that SARS-CoV-2 testing is now available through a limited number of commercial laboratories and availability through the hospital and reference labs will continue to grow. Expected turn-around time is longer at commercial laboratories (1 to 4 days) than at IDPH laboratories (1 to 2-days). Because IDPH has limited capacity/reagents to perform SARS-CoV-2 testing, it will target its testing to higher priority specimens (see IDPH Public Health Laboratory Testing section on page 2 of attachment). This will enable higher-risk patients to be identified sooner, assist with the care of patients with more severe illness, and inform response efforts, including critical infection control decisions. The full IDPH alert is attached below.
Of course, the availability or non-availability of testing kits should not change physician office protocols for identifying and handling of possibly exposed or infected persons. In any event, we encourage physician offices to review CDC information daily for updates to their recommendations for in-office procedures. In addition to evaluating symptomatic patients, many physicians are choosing to screen all patients by asking at each visit if patients fall into any of the above categories. It may be appropriate for some asymptomatic patients to be referred for testing if they have been in close contact with an infected person and/or are positive for some of the other factors (age and comorbidities).
CDC Environmental Cleaning and Disinfection Recommendations [3/17/2020]
The ICS is not aware of a specific CDC-issued cleaning and disinfection protocol for physician offices. However, 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 3/27/2020]
The ICS is working on a number of webinars for doctors during this time:
- “Telehealth 101: Strategies for Treating Patients When In-office Care is Not an Option.” On-demand. Click here to take the course.
- “Protecting Your Chiropractic Business During the Covid-19 Pandemic.” On-demand. Click here to take the course.
Toolkit – Resources Available for Use in Your Office – [Updated 4/1/2020 4:00 pm]
The ICS is making available to our members a template letter for our doctors to provide to their patients regarding the COVID-19 virus (coronavirus). The letter explains the steps you are taking in your offices to protect your patients, as well as your recommendations for measures your patients should take outside of the office. The template will need to be tailored to reflect your individual office procedures and policies. The template letter developed by the ICS can be found here (Template letter for patients – Spanish).
Electronic version of the patient notification of non-covered services. This document can be transmitted, signed, and returned electronically.
As the ICS will continue to monitor CDC and other resources, we against encourage members to regularly check CDC and IDPH information in the links below, as they are revised to update the public, healthcare providers, and employers on this rapidly developing issue:
- General Information on Coronavirus (COVID-19)
- Healthcare Professionals
- Illinois Department of Public Health Coronavirus Updates
- NCMIC Insurance Company COVID-19 Information
- Guidance on Preparing Workplaces for COVID-19
[i] Thank you to ChiroUp for providing these resources to ICS Members.
[ii] Thank you to ChiroUp for providing these resources to ICS Members.