Good afternoon. Hopefully everybody's not too tired after having a nice lunch and, you know, getting on into the afternoon. My name is Peter Grant. I'm the first of three speakers. We've got sort of a past, present, and future of electrodiagnostic quality in the United States, and there's certain things that we're each going to talk about, and we'll have some question time at the end. With regards to, I'm in private practice in Medford, Oregon. I've been there for 37 years. With regards to my talk today, I'm mainly coming from the fraud and abuse consulting I do with the FBI and the OIG and private insurers, as well as being chairman of the American Board of Electrodiagnostic Medicine with regards to the maintenance of quality. So there's some alternate titles to my talk. Where have all the EMGers gone? Did you know that someone in your community is charging $10,000 for one EMG study and does multiple times throughout the day? They are. They are there. So CMS has allowed PTs to perform and get paid for EMG and nerve reconnection for how many years? Why should I be doing EDX studies when there was such a heavy reimbursement cut back in 13? So each of these alternate titles sort of embodies a problematic truth that affects EDX quality. All of those concerns and others are, I'm going to go through in my talk today. I don't think that you're going to get any new novel research from my talk, but I hope that everybody walks out the doors understanding some principles of electrodiagnostic quality and some areas that were failing. So the percentage of poor quality EDX testing is increasing in the United States and has been over the last probably 20, 15 or to 20 years. It has to do with a number of factors, and I'm going to mention them real briefly. So there's less electrodiagnostic offerings, not only at this meeting, but also at the AAN, the American Academy of Neurology. From our perspective, it's understandable. I don't want to cut the AAPMNR too much slack, but still it's understandable. The field of PMNR, since I left my residency training in 1985, the field of PMNR has continued to grow. And so I have two sons that recently joined my practice after finishing their physiatry residencies, and what I saw them learning was a lot more than I did. They have EDX, they have ultrasound, especially if you're under Jeff Stokowski. You learn a lot of ultrasound. You have, you know, Botox. You have spinal intervention. You have all kinds of ultrasound guided joint. I mean, there's a lot more out there, so it gets crowded out. I can understand that. Less ABEM, less people becoming certified by the ABEM to do EDX testing. Now, I put that 91 pass rate there for a reason. That's a memory jogger for me. When I took the test a while ago, the pass rate was 64% my year, and that was about what it was. About five years ago, we changed that actually to come in line with what most boards are doing. There's a different viewpoint now. We want to get more people involved, be inclusive. Our pass rate over the last five years for the ABEM has been 91% for first-time takers. I encourage anybody in this room that it's not ABEM to do it. It's not that hard. There's less EDX training in PMNR residencies. Again, being crowded out in PMNR for sure. And by the way, AAN, they've taken a different approach. In 2013, they made a decision for their specialty that they would not be supporting electrodiagnosis and advocating for it. So all the work that I'm going to talk about that I and others have done in D.C. to promote the House Bill 8344, they're not wanting to be a part of it all. So some other reasons for this trend. There's less involvement in the AANEM. There's loss of skills by people that have been out in practice for a while that maybe are not getting, brushing up on it by being, attending conferences and the like. And then the two that I have in red are the ones that I'm really going to hit home in the rest of my talk today. Less trained physicians doing the testing, and I'll talk to you about the reasons why we have less trained physicians out there. Well, when that happens, there's going to be others, and I'll talk about who the others are that are actually performing these studies and being paid for them. And then the last one is electrodiagnostic fraud and abuse. So we have less, a less number of well-trained physicians that are out in the communities, and that leads to others that are going to be performing these tests. So why do we have less trained? As I mentioned before, there's less interest in residents. They're getting less exposure to EDX and their residency training. Some come out of residencies just not having the numbers or the training such that they don't feel confident in doing the test. Some physicians that are already in practice are not maintaining their competence, or some of them, maybe even back at the 2013 reimbursement cut, said, I'm out of it. I'm not doing it anymore. All of these have opened the door for others to say, okay, I'm going to step into this, and I'm going to start doing it myself. So we have poor quality EDX testing that's out there that's by a physical therapist, by chiropractors, by PAs, by MDs and DOs that aren't trained well that are performing poorly. They have inadequate or inappropriate training leads to that. Often these decisions are financial, and they're not by medical ethics. There's a lot of pressures in a practice, and so sometimes people say, okay, I'm going to go back into doing EDX. I can make some money doing it. Well, it doesn't matter. I haven't done it for 10 years. It's okay. I'll remember it. What ends up happening a lot of the time is we see fraudulent EDX schemes, and I'm going to talk about those in particular, and I think you'll be rather astounded. But all of these factors result in poor quality of EDX testing. So what physicians or other providers are performing these tests, EMG and nerve conduction? This was a question that was in the digital newsletter of the AANEM last year. Who can be paid for nerve conduction studies and needle EMG by Medicare? This is just Medicare. Neurologists and PMNR, well, we're the only ones that supposedly have it in our residency training. Actually, I think you may know this, PMNR, we require 200 studies, correct, six months. That's a good thing. Neurologists don't have that. Neurology, the ACGME guidelines for neurology residencies, there is no guideline. They don't have to do any EMGs. Usually neurologists will do a fellowship to gain their practical skills. So B is physical therapists who have the certification from APTA, orthopedic surgeons, neurologists, I mean, excuse me, rheumatologists, or all of the above. Surprisingly, it's all of the above. Any physician with an MD or DO after their name can do these tests and perform them, and can bill for them. In the same way that I could do cardiovascular surgery. Now, I wouldn't say that any of you should come under the knife if I'm holding it for cardiovascular surgery. But I think that points out the converse of that, is that there's a lot of people out there that are doing the EDX that shouldn't be doing it. So under current Medicare guidelines, physicians of any type are allowed to perform and bill for EDX testing, and PTs. The Medicare ruling was in 1997. It was put into the local care determinant, or LCDs, across the country in 2001. PTs have been able to bill and perform EMG and nerve conduction since 2001. Now, they don't do it everywhere, and there's only 204 of them that are currently having gone through the APTAs sort of certification. But they are out there. Vast majority of states don't have any statutes to govern that, by the way. And there's a lot of nurse practitioners, family, I mean, family nurse practitioners and PAs, APPs that are allowed to perform and interpret. Now, in some states, they say you can't make a diagnosis. So they get around it, they do the test, and they say test results are consistent with carpal tunnel syndrome. They're not making the diagnosis, they're saying it's consistent with. So there's loopholes, okay? Also, Medicare, the problem is that Medicare puts these things out there in their LCDs, but they don't say what, they say they should be trained, but they don't say what the training is, and they don't have any enforcement of it anyway, so it almost doesn't matter. These are the most recent statistics we have of 2019, looking at Medicare, this is only Medicare patients, and if you see, it's the codes for, the group codes for nerve conduction, and the three codes for EMG. Well, two-thirds of those studies across the United States are being done by neurologists, about a third are PM and R docs. I'll take the little gray 1% sliver, and I'll put that, that's pain medicine, I'm gonna put that with PM and R docs, because I think most of them are PM and R trained. But we still have 5% of studies that are being performed and billed by PTs and by other provider types. Now again, this is only Medicare, you gotta multiply this logarithmically to talk about everything that's out there with other insurances, and there's a lot of EDXers that don't even take Medicare, especially the fraudsters. It used to be that, they've gotten emboldened, but it used to be that they wouldn't bill Medicare, TRICARE, anything government, because they'd have the FBI and OIG coming after them. They've gotten a lot bolder over the years, but still, there's a lot of people that don't see Medicare patients that wouldn't show up in these statistics. So if we say that there's five to six million EDX studies done in the United States in a year, and you multiply two and 3% by that, basically you have PTs doing 100,000 or more studies and non-EDX trained physicians, MDs or DOs, doing 150 to 180,000 studies a year. Are you okay with those numbers? I'm not. So these are a list of some of the Medicare billing specialties. I mean, basically any specialty you can think of is up there, including sleep medicine and plastic surgery. Now, these statistics are, again, Medicare statistics from 2019 that show the percentage of billing of only nerve conduction, meaning of these specialties, what percentage of them only billed nerve conductions? Nerve conductions, when they're done with a little handheld device, and I can't say any names, nerve conductions should most always be accompanied by an EMG. I think we all know that, okay? I think that the accepted guidelines, even though I do an EMG with every nerve conduction, that's just the way I do it, and I will fight anybody on that, and I'll give you all the reasoning, but I will say that five to 10% is the accepted number of EDX studies that you could, maybe a simple carpal tunnel that you could do nerve conduction and not do the EMG. Well, in the year 2019, every podiatrist that did this, it was only nerve conduction, 100% of them. So basically, any number over about 10% is too much, and so I'm gonna go just quickly scroll through all these, and when you finally get down to it, neurology is at 10% and PM&R, we're right at 5%. So, now I wanna move into more of the, we've learned who else is doing these studies. Now I'm gonna talk about the fraud and abuse stuff, and as a little bit of a background, there's two things I wanna go over just to form a foundation. One is the 2014 OIG report about fraud and abuse in our specialty, in EDX, and then the other is the 2013 reimbursement cuts. Some of us, Dr. Bradham, Dr. Hubbell, Dr. Pease, we're old enough to remember when they happened to us. A lot of you that I see out here are too young, and maybe you were only told by your attendings about that bad cut back in 2013. I'm gonna do the 2014 OIG report first. Basically, the Office of the Inspector General, in April of 2014, brought out a report that said that there was $147 million of what they called questionable billing in EDX. Now, questionable billing is nice words for fraud. Now, the problem with that report is that is tip of the iceberg. I have had cases, Dr. Bradham, I'm sure has had cases that have gone for, I mean, I had a case in Houston, I'm gonna give you some details about in a minute. It was over 20 million, one case. There was a case adjudicated just this year, settled for 40 million. It was only EDX studies. One case, 40 million. So 147 is actually very small. It's probably about a 10th or a 20th of what it really is. But what was good about this was that it put us on the OIG's what they called hit list, or 10 most wanted list. We had some notoriety now. We had people that were taking notice of the fraud that was in our specialty. Now, the 2013 reimbursement cuts, going back to 2012, the AANEM was contacted by CMS and they said, you know, we've got a big overutilization. The codes have doubled for nerve conductions. What can we do? Well, we developed our own plan to address that, and that plan was gonna have about a 15 or 20% cut. We knew that it's budget neutral and they're gonna pull from one and take from another, but we said, okay, we'll take that, that sounds acceptable. Then we were blindsided by Medicare, by CMS. Basically in the end of November, when the national register came out, boom, there it was, 40 to 70% cuts. And we had no time, we had one month. They were gonna be enacted January 1st of 13. I mean, Barry Smith from the PM&R, I represented the AANEM and Bruce Sigsbee was the president of AAN at the time. We three sat in the office of John Blum, the deputy director of Medicare, and said, this is gonna have disastrous consequences. He said, this is what we need to do to stop the bleeding. There's fraud. And unfortunately, that cut that they did has actually promoted more fraud, and we'll talk about that in a minute. So anyway, the AANEM, we hired a lobbyist. We've been working for the last five to seven years on what now is called HB or House Bill 8344. And I'll mention that in a few minutes. It's a very simple way to promote quality and to knock out about 95% of the fraud that's in that space. One of the problems is that CMS avoids what we call scope of practice issues. That's why they let me do cardiovascular surgery, right? Because they don't want to be, if you go to medical school, you should be able to do it all, and we're not gonna try to tell you otherwise. That's sort of their take on it. Now, the legislation that I mentioned is to hit two primary goals. The first is to stop fraud and abuse, okay? We wanna try to get something that says, yes or no, you can do this study before the study's done. Because the way it is now, it's called a pay and chase model. All the insurers, CMS, privates, everybody, they pay it, and then they have their SIU or special investigative units that look out afterwards and review charts. And then say, oh, this looks like a red flag. Let's go look at that. That's why the cases that I do are sometimes five, six, eight years old. So the second thing that we wanna do with the legislation is promote quality and have competent providers that are doing this. We had great support early on from my own representative, Representative Greg Walden. He was the chairman of the Energy and Commerce Committee, which is over healthcare, so that was huge. And then, fortunately, a good friend of mine from high school, Pete Sessions. He's a very powerful guy on the Hill, and he has helped reintroduce the bill as 8344. And I've talked about the two simple mandates, but basically one is that you have the right training. Everybody in this room already has the right training. You've done a PM&R residency training program. And the second thing is you have to use the right equipment. And if you go downstairs to the, I'm sure they have an exhibit hall, and any of the people that are here, Natus, Cadwell, I mean, any of the people that have, those are acceptable equipment. I'm gonna mention in a minute the pieces of equipment that are not acceptable. So now that we have sort of a framework, I'm gonna get into the fraud and abuse that is in your community. And again, if you say that it's not, you're wrong. I could easily prove it to you, and I think you've probably heard this before. I think you probably may have smelled a little bit, sniffed a little bit coming across your desk from time to time. You may recognize some of the things that I bring out. The bottom line with the fraud and abuse in electrodiagnostic medicine is that money becomes more important than giving an accurate diagnosis, than having quality EDX testing. There's a couple different types of fraud. One is called a mobile diagnostic lab. The second is when they use inappropriate equipment, and I'm gonna talk about that as well as, the last one, I put just EDX fraud schemes. These are people that are trained in PM&R or neuroresidencies. These are people that are members of this organization. I've had a couple of them, cases, or maybe members of AAN. Some that are even ABEM certified, and they're still going over to the dark side. So, mobile labs. Basically, you have an unsupervised technician that is sent out to another doctor's office, family physician, internist. I've seen them go into pulmonary doc, cardiologist's office. They do a lot of tests. Because they don't do a history or physical, they don't know how to guide it, so they do 20 or 30 nerve conductions on every patient. The same shotgun on every patient. Typically, I'm gonna show you some of the waveforms. Typically, the waveforms are very poor, mostly unreadable. The MD or DO sits back and interprets the studies. Thousands of miles away often, weeks later. How accurate could you be if you never saw the patient, talked to the patient, touched the patient, or even saw their chart, and you got to see some waveforms that had 60 cycle interference all over them a month later? I don't think you could be very accurate. So, the whole setup is rigged for poor quality. Usually, no EMG is performed. If there's any EMG, they slap on a surface electrode and bill it as a needle EMG. So, my first case, back in 1997, where I said, something's wrong here, and then decided to get involved, was a 47-year-old guy that an orthopedist came to me, that I was working out of his office in Mount Shasta, California, where I went one day a week at the time. And he said, Peter, this doesn't seem right. This guy, they're saying he has a pinched nerve in the leg. I just don't think so. So, three weeks after he had his first test, I did a second test. I didn't get paid for my test. I knew I wouldn't. It's for my friend. Well, he had ALS. 47-year-old guy with ALS. He was just billed $7,500, which is about $10,000 in today's money. My test at the time would have been just under $700 to spend an hour with the patient, do a history, do a physical, get the right answer. That was when I said, something's wrong here. That was a mobile lab that had come in and had given him that diagnosis. Now, these labs are sophisticated. They know how to keep the red flags down. They don't have a physical address. They use PO boxes, and they change them every three to six months. When we went to the group codes in 2013, right? You can only do 13 nerves. After that, you can do as many as you want, but you're only gonna get paid for the 13, right? Well, what they'll do now is they'll take that patient that they used to do 30 nerves on, and they'll see him back on subsequent days. Do the left upper extremity today, right upper extremity tomorrow, left leg on Tuesday, yeah, and then they'll bill 13 for each day. Now, RepStim, 95937, that is the only code that was left that you can bill more than once. But I see it billed 5, 6, 7 times for people that have low back pain. No neuromuscular junction disorder. No hint of that. The CPT code book, by the way, says that when we do nerve conductions, they are to be interpreted onsite and in real time. We all do that. That's standard practice for us. But when you have a tech that goes in that gathers waveforms and they're looked at a month later by somebody, that's not onsite or real time. What ended up happening though was because of these cuts in 2013, we're supposed to do away with all this fraud and abuse, we found that the fraudsters proliferated. They do this in volume, so they're able to continue doing it, while those of us that maybe, I mean, I do EDX for the last 25 years, that's all I do. Consultative electromyography, that's it. But somebody that just does a little bit of it finally said, I'm just not going to do it anymore, it's not worth it. So we actually lost people, especially in rural areas. Here's an example. This is what I did for the Louisiana State Board of Medical Examiners, PM&R doc in Covington, Louisiana. He was sending texts to all these different offices. Always lower extremity, every chart had a generalized neuropathy diagnosis. And on every time he said, I need to see them back in three to six months so I can reevaluate. We need to guide the treatment. There's no literature that would support that. How many of us see patients back every three months with a generalized neuropathy just because we want to see it's there? No. He was charging, he just wanted to get more money. Did 22 nerve conductions on each and every patient, if you look at the AEM guidelines, the maximum number table, 10 is the most you should be doing. Very poor technique, a lot of useless waveforms. I'm going to show some in a minute. No HMP. And this is over $5,500 in every patient that I reviewed, they were billed, or their insurance company was... And when I reviewed it, looking at the histories and physicals in the chart leading up to that, none of those patients required it. They were not medically necessary. They didn't have the numbness, tingling. They didn't have the motor sensor reflex changes. They had nothing. Now, this doctor that was reading these useless studies had a day practice, got paid for that, and in the evening would sit in front of the TV and look at these waveforms and got paid over a million and a half dollars a year doing just that work. That could make you want to go to the dark side. So I'm going to switch gears. Now we're going to talk about the bad equipment that people will use. There's something called a pain fiber nerve conduction study, PFNCS, pain fiber NCS. It's a type of quantitative sensory testing, previously called a voltage activated sensory nerve, or VSNCT. There's a device. The device used to be the neurometer, then it was the Medidex 7000, then it was the Neural Scan, then the Neural Scan 2, then the Axon 2, then the Axon 2. The device changed names in the last 25 years, but the equipment is exactly the same. They only changed the name because they were running from the law, so to speak. This test needs to have a patient response. I tell when I'm dealing with this test and I'm on the stand, I look at the jury or talk to the judge and I say, I can do my test on a patient that's comatose in the ICU, and I can evaluate their nerves and muscles. This test, they put a stimulus and say, tell me when you can feel this. It's subjective. Who knows if the patient's telling you the truth. They have lots of reasons to not tell you the truth. So they don't even generate a true waveform. Sanjeev Nandekar, you may know him, he's a very big name in EDX and electrical engineering. He basically looked at it and said, these are not even biologic waveforms that are being generated. So it's an inappropriate equipment and it also is used, typically they diagnose, you will see a report that will say, C5, C6, C7 radiculopathies bilaterally and a right C8. Seven radiculopathies in one patient. Oh my gosh, that's great. Send them down the hall and let's start doing injections at every level. That's what it's all about. Get money at the front end, get money at the back end. If you look at their website, they say that their test is 97% sensitive for identifying a radiculopathy, while standard tests that we do is only 37%. And there's a lot more that goes into that organization. Your certification, you fill out a form, you pay a fee, you make a video, you take an open book test, and there you go, you're off and running. Going to switch to handheld devices. These have been around for a while. The company has done some revamps, have some new and improved stuff. They make their results immediate now. You used to have to put it in a dock and press the button and then it would come as an email later. Basically, the problem with this is, I don't even have to get into whether it gives good results or not. Most of the studies that are out there say that the results are adequate, but that there's a number of problems that lead to errors, so they're not consistent or completely accurate like our testing. But the biggest problem is that these people should be using a 95905 code. This was something that the AAPMNR and the AANEM actually got CPT codebook to change, right? Big process, took a couple of years to use this thing we call using pre-configured electrode arrays. That means they put that big sleeve on and they press the button and get the test results. And the 95905 is only paid, it's only reimbursed at about half of what you get for the very lowest nerve conduction code that we can use. So that's why they don't want to use it. So they hide it. They make it look like it's done by one of us with the graph and with everything there, and then they charge the wrong code. They charge the 9590, the ones that we charge so that they can get more money. They now have a new device for the lower extremity. It looks at a sural nerve. All it gives them is a nerve velocity and an amplitude. There's no latency. It doesn't say anything else, doesn't look at any other nerves. And with this one test, they can tell that you have a peripheral neuropathy before it shows up clinically. It's preclinical, they can do. And it's predictive of the complications of diabetic neuropathy. This device that they can do predicts the complications. So there's a lot out there that's just a little bit shady. They also say that at the bottom there, it can be used to monitor the progression of neuropathy and response to therapy. Well, I already told you before, I don't believe that our standard studies can do that, let alone this one study that only does one nerve and doesn't even do it completely. Here's some EDX fraud schemes. That's the third one of my fraud and abuse. The first one, those three docs, I'm happy to say, are in prison right now. This was a case I did in Houston with the FBI and a US attorney there. Here's the deal, and this is going to sound a lot, Randy, like the one we talked about earlier that you did in New York. Here's the deal. These guys put out a weight-loss Groupon coupon. So you could go in and you want to have a little weight loss, right? You go in the door the first time you're there, they take some history, and the chart reflects that you said you had numbness and tingling in your arms and hands. So off you go to get your nerve conductions that were $35,000, by the way, nerve conductions of your upper extremities. The next time you come in, you had low back pain and leg pain. You got EDX of your lower extremities with surface EMG, so they could build that too. The next time you came in, you were having some pain in your chest, so they did cardiac ultrasound. They did an EKG. They did, oh, the list goes on. Skin sensitivity testing, pulmonary function studies. If you stayed for all of it, which a lot of patients did, I reviewed 32 charts in this case, and they were all about this thick of patients. If you stayed, it was over $97,000 worth of testing, of which 35 or more was nerve conductions and EMG. So by the way, another thing that they did, in the state of Texas, you can have a hospital without any brick and mortar. You fill out the right forms and you have a hospital. As a hospital, of course, we know you get facility fees. So they got about 30% more on each patient than we would get in the office. I asked the FBI, just when I first started reviewing this, I said, who would pay? What insurance company? I'd like to know what insurance, I'll bill this insurance company. What insurance company would pay $30,000? And they said, well, we did a study and we found that only one out of every 23 studies was paid. But one out of 23, when you're billing $30,000, is enough. And so they kept doing it. My next case, U.S. v. Moz, that was a Michigan case with the OIG. And this was interesting because they sent me video and they sent me still shots of everything in the office. It was almost like I got to go and tour the office and open every drawer and every cabinet. And one thing I noticed was there were no EMG machines anywhere, but they billed every patient for an EMG. So that was fictitious or they were using a sensory or they were doing surface EMG. And then the second thing was I got to look at the appointment book. And their appointment book every morning had between 17 and 25 studies done. They only had one machine in the office, only one person that was doing this. Can you do, oh, and they had 20 to 30 nerves and EMG of both extremities. So 25 patients in a morning that are going to have all that testing done is humanly impossible, of course. I already mentioned the Louisiana one. The others I'm not going to go into right now. But I did mention some waveform problems. I think you can see, if you're trying to get any sensory response parameters, you know, an amplitude, a latency, I mean, all you're seeing there is 60 cycle interference going across there. There's no way to get an accurate result from a sensory study that looks like that. And this is what I call huge stimulus artifact. The sensory nerve response is riding this huge stimulus artifact, making any of the measurements unreliable. So in my conclusions, you know, we're not the only ones that are doing EDX testing. So we need to be the best, okay? And if we're not doing good EDX studies, somebody else is going to fill that space. And it may not be somebody that's doing them well at all. They may be interested only in the money. CMS and other payers have basically shown us that despite our efforts to convince them otherwise, they will allow less qualified people and pay them to do these tests, mainly because of the scope of practice problems. So what can we do? Well, the AEM is continuing our advocacy efforts to promote quality in this space. We, the 8344, that bill has been introduced. We're looking to get support by, we've got lots of patient advocacy groups, you know, MDA and GBS Society and ALS Society, you know, all of them that are lining up behind us because they want their patients to have good tests. We've got lots of organizations that are lining up behind us as well. We're talking with AAPMNR about supporting this. Basically this legislation, as I said, is only two things. It only requires that a person has the right training and uses the right equipment. Everybody in here should be able to jump that hurdle very easily, right? And it won't be at much of a cost either. Also, the AEM has the EDX Lab Accreditation Program, which is a higher, much higher bar, I would say. Maybe not much, but higher bar. And that's something that really promotes quality in the people that have the lab as well in the community that those show up in. Also, as EDX practitioners, I think we need to call out the bad quality we see. We all see it from time to time. And we need to promote the best quality practices that we can. Last thing I want to point out, next to me there with the beard is my son Colin that joined my practice a year ago. On the very left side is my son Austin who joined a couple months ago. And we took our four-month waiting list down to two weeks now, so that's a good thing. We're going to have question time at the end, but if anybody has any things where they're worried about some fraud in their community, look me up. I'm happy to give you my card afterwards. I'm not looking for business out of this. I'm looking to squash fraud that might be in local communities around the country, and I'm happy to help you do that. So with that, I'm going to turn it over now to Ben Warfel. And I hope I haven't gone too long. Ben's going to be talking to you about some more stuff dealing with the present. Thank you, Peter. Can we? We need, yeah. Okay. Thank you. Hi, everybody. My name is Ben Warfel. I am a physiatrist and a medical director of our accredited lab in UPMC Central Pennsylvania. And I was asked today just to give my perspective of having an accredited lab in the community for the last 10 years, and some caveats on that from the perspective of, what did we decide? A mid-career physiatrist, I think. So whether you're late, early, or mid, we'll get started here. I already told you that. So let's talk about AANEM laboratory accreditation. Peter laid out the problems in electrodiagnostic medicine that we've all seen in the communities. Who has seen a case come across your desk like Peter has described in your community? Can I just see hands? If you've been doing it long enough, you've seen it. It's not good. The question is, how do we address that? So at the AANEM, neurologists and physiatrists got together a little over 10 years ago, and CMS let us know what was going on out there in the OIG. And we came up with laboratory accreditation to try to give some parameters for quality for patients and for insurance companies and institutions. So when I talk to people about lab accreditation, these are typically the questions that I'll see. Why me? Will my patients appreciate it? Will it improve quality? And will it be useful in my practice and career for our young physiatrists here? Will it be a hassle? It always comes down to that, too. So let's just touch on some of those things. I always tell them, well, why not you? I can look here, can't I? As I say here, you can show your patients and colleagues that you have a commitment to quality. It's just a great objective we to do it. And you can show the insurance companies that you have met nationally peer-reviewed quality standards. It's that simple. And you can protect your quality standards from external institutional pressures, which I was in private practice with my practice partner for over 20 years. I don't know how many private practice electrodiagnostic physicians are left. Peter's one of them. But it's getting harder and harder. It is in Pennsylvania. I have been an employee for the last 26 months, and I now have to work with an institution. And let me tell you, anybody that's an employee knows that there are external pressures from non-physicians about we need to justify our quality and our methods and techniques. And let me tell you, this gives you a nationally peer-reviewed kind of a backboard to help you with that. Let's go with how easy this is. Can I use that word, easy? So if you get on the AANEM website, who here has an accredited lab? Does anybody here have an accredited lab? One, two, three, four. All right. Okay. Who's thinking about having an accredited lab? Okay. More. So when you get on the AANEM website, and I don't want to sound like a commercial here, but I don't want this process to seem that intimidating because it's not. You get on there. It couldn't be easier. You submit online. There's a link for all of the different... I think I have a laser pointer here, don't I? There we go. I think I got one right here. There we go. Basically, you can submit online. You just fill it out. They give you all the prompts. There's an application review. You get notified of what you need to remediate if you have any shortcomings of all the stuff that's all listed for your checklist. You have accreditation every five years. We just went through one. It really wasn't a big deal. You complete your annual compliance report, and then it goes back to the beginning, and it just goes in a cycle like that. So this is just right off the AANEM website. All you got to do is get on the AANEM website. You hit the accreditation panel, and you're just... It's a link to everything that you need to know, and all of you that have staff that can help you with a lot of these things. It's really not that difficult. You can hit on any of these links, and you can read them for yourself. Let's just click on one. Okay, so you click on the report checklist. This is all very basic stuff. I mean, patient demographics. It's just a list of things that you need to have for accreditation, which all of us learned in our training. It just helps you... It really objectifies the process. And again, it links you to the national standard, and that's what you can kind of prove to your colleagues. You can prove to the community. You can prove for your patients. They need some way to know that you're adhering to national standards. And it's that easy. I kind of blew up. I wanted to make that bigger to look less intimidating. But anyway, you can see the kind of things they're asking. Reason for referral. Very, very basic stuff. Does anybody know what that is? It's not a PATH specimen. It is a fruit. I'll give you a hint. It's the largest native North American fruit. But now that I got you awake, we'll go on to the next thing. And we'll go over that at the end if anybody's got a guess for me. You get points if you get extra points. Will my patients appreciate it? This is the next question. And again, this is more anecdotal. For the last 10 years, we were the first accredited lab in Pennsylvania. Let me know if I'm hitting my time. We were the first accredited lab in Pennsylvania. And I've had patients, they tell me they found me online because the lab was accredited. And those are just the ones that tell me. So it only helps you in that way. And again, I think it provides insurance to patients to know what they're getting. You heard the problems that Dr. Grant brought up. It gives them some way to know that they're getting a nationally accredited level of care. Will it improve quality? I can tell you if you go through the process, and those of you that did go through the process, we're all creatures of habits. We've got these little tracks in our brain where we've done EMGs for years and years and years. I've done tens of thousands of them. It makes you rethink the process, and some things are even, you get perspectival, why am I doing that? And it just kind of helps you retool a little bit. It actually is, it sounds painful at first. It makes you rethink things, and I think you'll find it enjoyable at the end. You'll be happy you did it. Will it be useful in my practice and career, especially for you young physiatrists? Should I take the time to get accredited? Let me tell you that, again, anecdotally, we had success negotiating with insurance companies for reimbursement, referrals from certain workers' comp carriers. Again, we showed we met national standards, and I will tell you that accreditation really surpassed expectations of how much it helped and protected our quality practice. And I'm probably like many of you out in the room, I was in private practice for a couple decades, and we got acquired, and it really was an excellent negotiating tool. They were, I'll give credit to UPMC upper management, they were very interested in quality parameters, because that's all the talk from CMS and Medicare is quality parameters, and this gave them an objective way to show quality, and it definitely helped our negotiations and our acquisitions. Again, if you're an employed physician, it is very useful in holding your own against, let's call this administrative pressures. How many employed physicians do we have out here? Can I see a show of hands? I probably don't need to talk much about this, you know what you're facing out there. For people with no knowledge of electrodiagnostic medicine, there's nothing better than three rooms going and more RVUs per hour. But at some point, quality does matter, and this helps you protect your practice and helps you protect quality for patients. Again, we talked about how it was hopeful for negotiating packages each year as an employed physician. We exceeded expectations as far as my partner and I when we sold our practice. So at the end of the day, I think lab accreditation promotes quality electrodiagnostic care. It safeguards quality standards from external pressures, and it increases your negotiating power. That has been our experience over the last 10 years. Again, I would call it a useful tool. It allows patients and institutions to differentiate highly trained and qualified physicians from subpar entities and work that Dr. Grant just told us about. I mean, we did all this work to get there to give our patients the highest quality care. Unfortunately, it's not enough to just sit back and maybe put your diploma on the wall. You're going to have to advocate for yourself a little bit, the skills you're bringing to the community, and that's just the way it is. And at the end of the day, it's going to help us preserve the positive potential of electrodiagnostic medicine. We know where we make a difference. We know the group of patients we make a difference with. And if what keeps happening, what Dr. Grant's been fighting, like he said, these cuts had a paradoxical effect for CMS. The fraud and abuse is bigger than ever because people have maybe cut down the number of EMGs they're doing. But if you get accredited, I think it's going to help you preserve some quality in your community. And believe me, and then it'll increase you being known for it. Thank you. Okay. My name's Crystal McClellan. We'll get our slides up here in a second. I'm an associate professor at the University of Missouri in Columbia. There we are. So a show of the hands in the room. How many are academic? How many are academic? Okay. Okay. Fair amount. Good. How many residents do we have here? Trainees? Medical students? Okay. Okay. Great. So I'm also the lab director for our PM&R electrodiagnostics, and I'm chair of the lab accreditation committee for AA and EM. So no financials. A little bit about me and my institution. So University of Missouri is a level one trauma center in the center of the state. We serve the greater mid-Missouri area. We have two electrodiagnostic labs. One at our academic Missouri Orthopedic Institute. It's our academic orthopedic department. And then one at Rusk Rehabilitation Center. That is where our PM&R department's housed. So we have five faculty that are doing electrodiagnostics. Our department has 17 faculty total. The residents rotate through three of those faculty. Our training program is a medium-sized training program. So we have four residents per year from PGY2 to PGY4, and they do six months of electrodiagnostics. They get about 260 to 300 studies upon graduation. So my experience with the lab accreditation process, I was junior faculty when I came to my chair and said, I want to get our EMG labs accredited. And I talked to our fellow faculty, and my explanation was, I think it's going to increase our referrals. That's what I had heard at the AA and EM. I was being pretty bold. They totally rejected it. They said, no, we're in academics. Our referrals are kind of baked in. I don't think that's going to be the case. So I thought about it a little bit more, and I came back at them a week or two later, and I said, I think we're training the future physiatrists to do electrodiagnostics. So I think we need to hold ourselves to the national standards to show to them that we are training them with the most quality. And they finally then agreed. So I began the process of doing the lab accreditation. There was a lot to it, especially being junior faculty, but the first thing I did was create a team. So I reached out to the administrative assistants who were able to compile the documents for the training of the physicians. I reached out to our clinic staff, our clinic nursing director, and she was able to help compile the laboratory institutional policies that we needed for the lab accreditation. And then they directed me to clinical engineering who could help me find who helps me with the equipment, who maintains the equipment to get the documentation for that. So that part went relatively well. Getting my fellow faculty to standardize the techniques and the normative data, that was something because we were all doing things a little bit differently. So we also compiled our lab reports and had to look at things, and we realized we were doing things differently, and we had to compare them to the national standards. So that was a learning experience. It was quite humbling when you realize we do things so much differently. But we began communicating, and eventually we got on the same page, and then we were able to submit the documents, and we got our labs accredited. We had to also submit a quality improvement project, ongoing quality improvement project. So we chose to do monthly meetings. We called this EMG Case Review. Initially, it was faculty-led, but then it became more resident-led more recently. So it was a good process, and it went pretty well. Over the years, I've noticed a lot of improvements since we've done our lab accreditation and our electrodiagnostics, both teaching and patient care. But I would talk with other people at other institutions, and they would say, yeah, we're not accredited. I can't get my fellow faculty to agree. They don't see the value. And so this was interesting to me. So I set out to survey other academic institutions. We did this in April. I had a medical student that was really interested in this topic as well, and helped me out, Dr. Burris. So we sent in a survey email through the AAP listserv to all the program directors around the country, and we just asked many questions, but the most important was, do your residents train in electrodiagnostic labs that are accredited by AANM, A-A-N-E-M? If they are, what value have you seen by having them train in these accredited labs? And if your labs are not accredited, why not? We had 40 of the 96 institutions respond with a 42 response, 42% response rate. So there's definitely a practice gap that we saw in our survey that most academic institutions are not accredited. 42.5 responded saying that they were accredited. I asked AANM what their internal data said, and they only could find 15 institutions, 15% of the academic centers that were accredited. So probably most of the people that responded to my survey were more likely to have been accredited, and there was some bias there. So either way, you can see there is a practice gap in academics with the lab accreditation. So for those people that said that they were accredited, we asked what value do you see in the accreditation, and 94% said that it improved the quality of the electrodiagnostic training for their residents. Most of the comments after that would say that it clarified the normative data, which was helpful for teaching. The consistency in the normative data was helpful. And then about 23% said that it improved resident participation in quality improvement projects. For those that were not accredited, we asked why are you not seeking the accreditation? About a quarter said it was too much burden, too much administrative burden. Another quarter said that they just didn't see the value, and then 17% said they didn't even know about the accreditation. So this is, in my experience, what I've seen since the lab accreditation, how it's improved patient care. So again, initially, my electrodiagnostic faculty were not communicating. They were doing different things in different locations. So we began communicating and talking, and we standardized our normative data. So just improving that communication was big. As we talked and realized that we were standardizing our normative data, we also agreed that we should also be trying to interpret the data consistently. So we developed some protocols. That's what this example is here. For some of our basic diagnosis, like carpal tunnel and cubital tunnel, to just say, you know, let's standardize the interpretation of the data as well. So that if a referring physician sends a patient to me, they should get similar results as if they sent them to others in our lab. So that would increase the intra-lab reliability. Referring physicians really like this. We've gotten a lot of positive feedback from them. The standardization and lab accreditation, I believe, has helped with resident teaching. I've heard this from numerous residents. It's much easier to learn what's normal and what's not when every physician has the same normative data. You know, if every physician has a different normative data, it's just harder for them to know what's normal, what's not. And then with our protocols, by standardizing how we interpret the data, then residents can quickly learn how to interpret, and they can quickly learn how to generate a report. So they're writing reports in their fourth, fifth month of their electrodiagnostic training. It's a confidence booster, you know, because then they, okay, you know, got it right. Right, I have some here in the room. Yeah. And then we can move on to other things like neuromuscular ultrasound. So they're not getting so hung up on their interpretation on the studies. By having them do the EMG case review, the ongoing quality improvement project, the residents present relative literature, and then we sit down and talk about these difficult cases, and we've had quality improvement projects spun off of those that they can participate in. By helping me, I ask the residents to help me with the lab accreditation process, help me gather the documents, so they learn about the fraud, waste, and abuse. You know, I got out of residency, I had no idea that this even existed. So by teaching them early, they learn about it. It's motivating. They want to protect their profession, and they like to get involved. So they can follow up on some of these things and help me get the accreditation, reaccreditation done, which helps to reduce my administrative burden as well. And then this helps fulfill the ACGME milestones for quality improvement for residency training. I have the list there. ACGME milestones are going more towards system-based practice and quality improvement. So by them participating in this, it helps achieve those milestones. This is an example of my EMG case review guide for the residents, so they kind of know what to do in their presentations. And at the end, we focus on, you know, what could we have done better? How could we improve the quality in our electrodiagnostic labs? The other thing about this EMG case review is we have junior faculty that have come in, and they watch the resident presentation. We have senior faculty. The junior faculty can bring up any questions. You know, they're still learning to do EMG on their own, and so it allows them to be mentored during that, and they've really appreciated that. So it allows for mentoring of the junior faculty. And then the value of the lab accreditation for me as an early career physiatrist in academics. Well, first of all, when I got out, I didn't know anything about fraud, waste, and abuse. I was totally oblivious, so I learned about that by going through this process, and it motivated me to get more involved to protect my profession when you realize that this is all going on. By going through the process, I learned leadership skills. You know, I initially had to articulate why do we need to do this lab accreditation process to get faculty and share buy-in, and then I had to create a team to help me get through the process and to help me get us accredited. And then once we were accredited, I was the medical director of the lab. It gave me kind of a small leadership role in the department, which kind of helped catapult my career. I learned a lot about the institution. You know, we work in these academic institutions that are really big, so you learn who to go to when you need help for things, and they helped me reduce the administrative burden. And then by being the medical director of the lab, I was invited to be on the subcommittee for the AANM lab accreditation committee, and I reviewed reports. And then, so that service on the national committee has grown now, and I'm now chair of the accreditation committee. So all these things have enhanced promotion efforts for me in the academic setting. You know how important that is when you're going to, if you're a clinical track like I am, non-tenure track, and you're going up for promotion, you need to demonstrate clinical excellence. So by accrediting your lab, you're showing that you're holding yourself to those national standards, and it helped in preparing my personal statement and my dossier, which helped me get promoted, which helps with salary, correct? Okay. So we've already talked about this. This is just my wrap-up of the AANM legislative efforts. This is HR 8344 that Peter talked about. It was introduced in July of 2022. It's called the Electrodiagnostic Medicine Patient Protection and Fraud Elimination Act. It's on the House and Ways and Means committee currently, and we're working to hopefully get this moved through. But it basically will require lab accreditation up front before you're able to bill for the studies, and the lab accreditation is a much more simplistic accreditation. You basically have to show that you're qualified and you've had the training to do the electrodiagnostic studies and that you have the proper equipment, and this has been done in mammography labs and sleep labs. So this is something that's already been done in other specialties. So in conclusion, in summary, if you're in academics, there is a value to getting your labs accredited. It'll help with patient care. It will help with resident teaching, and it'll help you with your career. So go out and get your labs accredited. I'm done. If you have any questions, please let me know. Thank you. I just wanted to mention something real quickly. I appreciated Chris's comments about lab accreditation and how it helps when you're in the academic sphere, and I think Ben touched on lab accreditation for private practice. I've been in private practice 37 years, and it has helped me in a number of ways. It's helped me with regards to... I have that certificate that Chris has showed. I have mine. I have copies of it in each of my exam rooms. That's the only thing I have in there besides some other pretty pictures, and I can't tell you how many patients will say, oh, that's really cool that you did that, and then I tell them a little bit about it, but I know that a number... and I also have the little logo. It's on my letterhead that says exemplary status, lab accreditation, and it's on my business cards, but I have lots of referral physicians that have taken notice of that over the years, so it helps everybody. Now, I also want to make sure that we distinguish between lab accreditation, which is a little bit more involved process, a little bit higher bar that Krista was talking at length about, versus the lab accreditation... we might even want to call it government lab accreditation or something that is the two things that you need to be part of H.R. 8344's mandate, okay? And that, again, is just the right training, which everybody in this room has, and the right equipment, and that's it, okay? I wanted to make sure you weren't thinking, oh, that stuff on the website, I got to do that. Not true, okay? There's two different lab accreditations. We're going to have to try to sort it out and get different names for them at some point, I think. Any other questions for any of us? Yes, sir? Yeah, sorry, I just had a quick comment, but you almost said exactly what I was going to say there. I'm a pediatric physiatrist and actually have an accredited lab with exemplary status, which is absolutely wonderful. And part of that's because I went to a residency program that believed kids actually needed EMGs as well, and actually have a fellowship program that believe kids need EMGs as well, believe it or not. But one of the things I started to do at the bottom of my EMG reports is actually put that direct comment that said, thank you for referring to this laboratory, which is an A&M accredited laboratory with exemplary status. And now I get referrals from a six state area around the Midwest. So I think that's one of those success stories that I've never had a three year old care if I was accredited by any means, and maybe not even parents, but I will tell you that the referral patterns that I've had have shown that that's been a valuable contribution to our lab. So thanks. Thank you for what you've done. Thanks for sharing. I appreciate it. And Dr. Grant, I would say the only case where we may not want to do EMGs, needle EMG study is on some of these four year olds that I can't even hold down. So we may get away with that more in pediatrics than you may do in the adult world, you know? So. Dr. Bradham, my buddy, Randy, you're not going to come after me, are you? No. Just a quickie. You might want to clarify, how many of your doctors, if any, have to be AANEM certified to be able to get the certification? Oh, like ABEM. In other words, if it was a physiatrist. AAM boarded or AANEM? If there's a physiatrist who has a laboratory, they've never gone to the, not a member of the AANEM, can they still get this certification? Yes, they can. As far as within the context of the lab, and I don't want to, you know, get into the weeds too much, but there is what's called a laboratory medical director, an LMD. That's the person that sort of heads up the lab. Even if you have 40, like we do have, like Cleveland Clinic and some that are part of this, and they've got lots of EMGs, but still to designate one is the LMD. That person has to be either a BEM or a BPN through AAN, right? Extended qualifications. But otherwise, you do not have to be AANEM members to be the physician in the lab at all or have a lab that... I think that's only to be exemplary status, right? You don't have to be a board. To get exemplary status, the medical director has to be... Oh, okay. ...the AANEM board certified. So to get the exemplary status, you have to have the ABEM boarded person as the LMD, sorry. Yeah, you don't have to be ABEM certified for your lab, right? Okay, good. Yes, sir. Hi, Josh Levin. I'm a resident at Stanford. And thank you all for the great talk. That was really great to hear. I just had a suggestion for people in academics. So a lot of our residents were not going on to take the boards. And then maybe only, I think, two years ago, I think this is our second year, we just started paying for our PGY-4s to take the SAE in EMG. And it's too early. I don't have data yet. But just anecdotally, it sounds like more of them are going to go on and take the boards, I think, after graduation. So that might be one way to get residents interested. That's a great comment. Thank you. And when we talk about the SAE for EDX, I would like to, I mean, my own push is that I'd like to see all residencies do that, sort of the way it used to be. I mean, all PM&R residencies did that. Now, again, things are getting crowded out. There was a time, not too distant, maybe 10 years ago, where I went down three years in a row and gave a half day of lectures to your department, because I'm just up in Medford, right across the border of Oregon. Loved it. If you have me back, let me know. But I know that a number of the residents that I lectured those days just got on fire with it and did. And some of them were ABEM, Lisa Williams. I mean, there's a number of them that did. So I think a lot of it is just exposure. It's getting exposure. Understanding that this is a test that needs to be in every PM&R docs toolbox. That it's something, no matter what facet of PM&R you're doing, it can be helpful in diagnosing and guiding treatment of patients. Any other questions? That was too easy. That was way too easy. What is the meaning of reality? Answer asked by Dr. Randy Bradham. Did anybody figure out the fruit? Oh, yeah. Okay, we got it. You've had one. I go on board with you all the time. Okay, so this man, it's a pawpaw. It's North America's largest native fruit. Yeah. I'll have to put a picture up of it again. I do have a question. Oh, yes, Sue. Does the House bill have a grandfather provision for people that are doing EMGs now? Or is it starting at this, when that goes into effect, that everybody will have to do the qualifications? I'm not sure I understand that question, Sue. Well, there's a lot of things where if you've been doing it for years, your grandfather, you don't have to meet a new law. And I didn't know if this law was doing that. Well, unfortunately, legislation's a little different. But again, you have the right training and you're using the right equipment. Bingo, you're there. Oh, I'm not talking about myself. I'm just asking for people. You want to improve quality, so does that mean that when that goes into effect, anybody to get paid has to do what's in the bill? They are going to have to. But again, the bar is so low. I mean, I understand what you mean, like APM&R, I got grandfathered in, I never had to take it again every 10 years. But that isn't a provision because we're dealing... This is not something we can make the rules on. This is something that is nationally legislated because of the bill itself. But it's so minimal that I just can't imagine that would be a stumbling block for people. I would sure hope it wouldn't be. Writing down where you did your residency training, and I don't know how they'll do it, but they may just have you write down the serial number and the type of equipment you use, and that's it. You're done. You're there. I agree that it shouldn't affect anybody that really should be doing EMGs, but if it doesn't apply to everybody from that point on, then it wouldn't be as effective. Yeah. What's that, Bill? We're going to apply to PTs right away. Well, PTs... This is the interesting thing. A lot of people get so upset about the PTs doing EMGs, which when I found that out, I was surprised too. What this legislation gives us, though, we are going to be, we as the AANEM, are going to be overseeing those that come in, meaning that we can even look at reports to make sure if we feel like somebody has a questionable experience or questionable training. This actually gives us some jurisdiction over the people that come into the program, including PTs, which we've never had before, meaning since 2001, when that was enacted in the LCDs of Medicare, PTs have been allowed to do it with no oversight by anybody. This gives them, and as well as anybody else that's doing these studies that I pointed out, oversight, oversight by us. In that sense, it's a good thing. It gets us back to having a little more control of the situation, if I could say it in that way. Thank you, Bill. Yes, sir. You know, I was thinking your prior cases were all physicians and PT prior cases as well? Yeah. I didn't show any of them right there. I actually have a good friend of mine that works at U of U, University of Utah. In their lab, they send me, because Utah is ... Different states are different. You can look up your own state. Utah is one of the worst, because the big training facility for PTs is the Rocky Mountain Healthcare Center in Provo, Utah, and so a lot of them stay in the Utah area. I have some physician friends that are there, as well as some at the U, and they send me cases, the bad cases, names redacted, and I keep them. I have a little file folder on my computer. In the last year, there were four cases of ALS that were misdiagnosed or not diagnosed by PTs. As far as a case, I've had a couple cases over the years, but I'm collecting a file of not just PTs, but other providers that are not doing it appropriately, either. I think that answers your question. It's definitely out there. It's just sad to see people that are well-trained, like us, that move to the dark side and end up doing a lot of this. It's the seedier side of humanity, for sure, to be involved in this type of work. Another question? Thanks. Sorry. I might have missed it, but the bill stipulates appropriate training and appropriate equipment. What's defined as appropriate training? PT training and PM&R or neuro? That's it. ACGME. When you mention jurisdiction over people who don't have that training, what do you mean by that? It sounds like if anybody doesn't have that training, then they can't do it. What do you mean by jurisdiction? I have to run back what I just said. Because of what Medicare has put in, we can't turn that around. PTs, of which, as I said, there's only 204 right now, PTs that have that special ECS certification through the APTA, they're brought into this, too. That's what I was alluding to when I said that we have some jurisdiction over them that we didn't have before. Because now we're the certifying, accrediting organization, AANAM is. If we see anybody that we may not think has the appropriate training, we can ask for more. A lot of this hasn't been drawn up yet. This is a lot of backroom talk. You're hearing it up front now. Yeah, the legislation has not been written yet, but that's... The legislation has been written and has been introduced into Congress, but all the details haven't been borne out. We'll put it that way. It's not finalized. It's not finalized. Let's put it that way. But the idea that... Oh, I'm sorry. Go ahead. But the idea that we could then form PTs or anybody else, say, this training is maybe not the part, or there have been reports of such and such, we would like to look at five reports or we would like to, you know, something like that. That comes into play when that was never even a possibility before. Yes, sir. First, I'd like to thank Dr. McClellan for putting this together. So thank you. This was excellent. Thank you. If I wanted to get a lab certified or whatever, we all know it, not just the work and indirect costs. What's the financial cost? Is it gradated or the cost to become accredited? If I went... This is not an ABEM session, I don't think. I believe it's still a PM&R. And I'm going to go with both sides very quickly. I can tell you the second accreditation that's for the bill where you just have to have the right training. There's no cost to that. I mean, right now, if there is going to be a cost, it's going to be minimal. The higher level accreditation that we talked about, I believe it's $1,000 for a lab. We might have to look that up. It used to be, anyway, $1,000 for a lab. And then when you reaccredited, it was either $250 or $500 at that five-year mark every five years. Because I've just done my second reaccreditation. I've had mine for 11 years now. And just for people to know, the boarding, because I am one of those 64% old ones, I'm not sure why 90 is good or we want to lower it. But this is... It's not an ABMS board. Correct. And so I don't want people to get that mistaken. Yeah. We need to be aware of that. American Board of Medical Specialties a long time ago decided that you cannot have a specialty that's defined by a test. And that was after the radiologists, and since they all had a test, we're already grandfather den. But when we, in the late 40s or 50s or whenever, decided we wanted to try to look into that, that's what they told us. And that's not changed, unfortunately. But I will say that despite not being ABMS, the ABEM is still a very well-recognized board as far as substantiating competency in electrodiagnostic testing. Yeah. Sue. So, if we're working in our lab and we see a patient that has had testing by someone else and we look at it and recognize it's really terrible, what is your recommendation? Should we report that to someone, or who, and is there anything we can do to help the situation? I'm going to tell you up front. That's a great question, Sue, and it's a real on-the-ground practical question. And I'm going to tell you up front that sometimes it's frustrating. I want you to know it's frustrating because, as an example, I finished that case in Louisiana with Louisiana State Board of Medical Examiners. I got to review, like I said, 30-something charts. I got to see all the insurers, you know, Cigna, UnitedHealthcare, all these Louisiana insurers that these people were getting built, right? These companies were getting built. I went to a couple of them afterwards after this was adjudicated and I said, I've got a ready-made case here. I've already done all this work. I can even share with you my report. I didn't get a call back from any of them. So sometimes there are people at the other end of the phone or the email that listen, that care, and that want to do something about it. And other times, you're not going to get a response. But I don't think that that would mean, hopefully, that you won't try. And then it comes down to, and I think you would know this, Sue, I mean, Sue was my program director when I was at Ohio State. I learned a lot from her. But I think that we would all know that, you know, sometimes you see reports that are just sort of bad quality, but they don't rise to the level of abuse or fraud. And other times, you see the stuff that is truly fraud. I mean, when I saw one of my first mobile diagnostic cases, it was somebody that was in a chiropractor's office in Medford, Oregon. The technician had come from Chicago. You know they're making a bunch of money if they're flying their techs all over the country. And when I looked at the waveforms and saw the results, I said, this is ridiculous. And that's, again, one of my very early cases. So you have to sort of surmise, is this something that is fraudulent? And if so, then you actually, I circumvent the insurers, and I go directly to the feds. I go to FBI healthcare fraud field agent for that region, or I go to the U.S. attorney for that jurisdiction for that region. They're more interested, especially if you've seen it multiple times. And they're responsive, because this is their gig, and this is what they look for. And so you've given them pointers. And so now they go, and they just look up and see if they can find more of that by that individual or that entity. And then they might even come back to you to help sort it out at a later time. If it's lesser, I think the insurance companies are better. But again, it's a 1-800 number. Is anybody going to answer? You know, you leave a message, are they going to call you back? Who knows? Sometimes they do. Often they don't. Kevin from El Paso, my buddy, how are you? Hey, I'm doing very well, thank you. One question for you. Do you know what the training is for the physical therapist electrophysiology technician certification? Is it something we're helping them with? Is it something we should help them with? Because in my community of 870,000 people, there's only two of us doing EMGs, maybe three. And so we see a growth of physical therapists starting to do them in our city. But most of us are over 61 that are doing EMGs, so I don't know what's going to happen in El Paso for the next three or four years. Those are great questions, and that's a unique situation that you have with the ages of your individuals. But it isn't a unique question with regards to what sort of training they have. It's sometimes hard to get good information on, but what I have gotten, because I've done a lot of research on it, is they do have at least listed some basics of a curriculum. They don't have the details of it. And they talk about, I believe it's 100 or 150 hours of training that there's supposed to be practical training under the guidance of... They don't really say who. Is it another physical therapist that learned on their own, or is it a physician? I've not heard from a lot of physicians that intimated what you just did about that you might be willing to help them out. I don't know if you meant that, but... Well, if you're looking for quality... I know. You would be the best one in that area to teach them. I know that. Honestly, I probably wouldn't be inclined. It's hard. It's a given situation, it's hard. But that's as much as I know about their training. And of course, I also know that no matter whether their training is good or bad, they're there to stay for now anyway. There's no way to really walk that back when it's already been enacted by an LCD of Medicare. Now, that doesn't mean that the privates have to follow along, and most of them don't, but it at least gives them a foothold. And from there, you see them start to do things like motor vehicle stuff and workers' comp stuff, and then sometimes they even squeeze into the private stuff. Dr. Bradham, who also does a lot of fraud work, by the way, and you can't talk about a lot of it, I know, but your question is? It's more of a comment and an encouragement for people about what happens when they find really awful studies in their area. About 10 years ago, I was in a meeting of the CEOs of a number of insurance companies, and they have these meetings occasionally, but they have a lawyer there to make sure they don't say anything monopolistic. If they started to say anything that might be construed as being collusion or monopolistic, the lawyer says, stop, can't talk about that. But one of the things I was brought in for was to talk about EMG fraud, electrodiagnostic fraud. And basically they said, one CEO said, look, we know all the studies that we get are worthless. Nobody even refers to them in the chart. And so we're considering not paying for any electrodiagnostic services. So what happens is if people out there who are doing bad things, they can affect you because sometimes people just give up paying for the stuff, or what happens is, like in the case of CMS, they just cut the how much you get paid by 50%. They say, look, we'll just cut the pay, and that'll make most of the criminals go away. And they think like that. So it is important that we kind of police this and clean it up, because otherwise other people will start to affect us by making rules, regulations, or refusing to pay. I couldn't have said it better myself. Thank you, Randy. Do these people do needle EMG scores, or do they do both? They do both. Sometimes they do needle EMG, and they don't know what they're doing. And then a lot of times they do surface and bill it as a needle EMG, because surface EMG is experimental. It's not used for diagnosis, and there's no billing code for it. Great. Okay, thank you. Yeah, thank you. Have a great day. Thank you.

electrodiagnostic quality

United States

conferences

lack of training

fraud and abuse

House Bill 8344

requirements for training

equipment

lab accreditation

patient care

career development