Mark Sanna, DC, ACRB Level II, FICC

Change is in the air in all areas of healthcare reimbursement and this is particularly true when it comes to the workplace. Employers are dealing with rising insurance costs that are taking a big bite out of their bottom line. They are searching for an answer that will help them reduce costs and maximize the productivity of their employees while protecting their profitability. At the same time, chiropractors are searching for ways to decrease their dependence on third-party insurance reimbursement with cash-based services. This confluence of factors creates a significant opportunity for those chiropractors interested in expanding their role in occupational healthcare.

Post-offer Examinations            

Many workplace injuries can be prevented by performing an assessment of prospective employees’ abilities to perform the functions required by the job they are seeking. These assessments, performed once an offer of employment has been tendered, are referred to as “post-offer examinations.” Post-offer examinations provide employers with a functional baseline of performance and help to ensure that the employee will be able to meet the physical demands to perform the essential functions of the job safely. They also reduce the costs associated with employees’ unidentified pre-existing conditions. A post-offer baseline examination can identify any pre-existing disabilities and separate them from any disability resulting from future on-the-job injuries.

The post-offer process involves setting up a job-specific examination procedure that tests the essential functions and demands that will be performed by the employee. These evaluation procedures include testing the frequency of various work postures and work activities such as reach up, reach out, bend, stoop, and squat, along with other functional assessments. Physical demand levels and dynamic lifting procedures are also performed and evaluated. The more objective your evaluation procedures, the more likely they will protect employees from injuring themselves on a job that they do not have the physical abilities to perform. An objective examination will also help to protect employers from the financial risks of hiring workers who will be prone to future injury.  For these reasons, computer-assisted assessments are preferred to manual assessments due to their validity and reproducibility. There are several reputable manufacturers of computerized functional assessment equipment and training that service the chiropractic profession.

Not the Typical Fit for Duty Exam

Most employers perform some sort of cursory screening physical examination of prospective hires to determine if they are fit for the job. However, these screenings typically do not evaluate the essential functions of the position, nor do they establish a pre-employment functional baseline or identify any pre-existing functional impairments. This means that employers are essentially blind to an employee’s ability to perform the job being offered, as well as their potential future liability should that employee be injured on the job. You might be asking yourself why employers would pay for these types of inadequate screening exams. The reality is that many employers are asking themselves the same question.

The Rules of the Game

An important first step in the post-offer examination process is to obtain a thorough understanding of rules and regulations that are involved as they relate to the Americans with Disabilities Act (ADA). According to the ADA, a post-offer examination can only be performed after the prospective employee has received a “real job offer.” A job offer qualifies as “real” if the employer has evaluated all of the relevant non-health related information that it reasonably could have obtained and analyzed prior to tendering the job offer. After a real job offer has occurred, an employer can ask disability-related questions and require a functional health-related examination. The job offer may be conditional based on the results of post-offer disability-related questions and functional examination findings.

When an employer asks post-offer disability-related questions or requires post-offer functional examinations, specific procedures must be followed. All prospective employees in the same job category must be subjected to the same standardized examination or inquiry, regardless of their disability. The objectivity and design of your post-offer examination help to ensure the ADA standardization requirements.

For example, an employer may ask potential hires at the post-offer stage, whether they have had back injuries. If the employer learns that some of the individuals have had back injuries, the employer has the right to require functional examinations designed to diagnose back impairments on all prospective candidates for the position as long as the examinations are related to the back injuries identified in the initial inquiry and are standard in format.

The First Line of Defense

Employers must comply with the ADA when revoking an offer of employment based upon post-offer examination findings of a disability that would limit the employee’s ability to perform the job. The employer must notify an individual (orally or in writing) if his or her placement was in any way adversely affected by the results of a post-offer examination or disability-related questions. In addition, when possible, an employer must provide reasonable accommodations to the employee to assist him or her in performing the job being offered. Once again, your post-offer examination provides employers with the confidence that they can legally revoke an offer of employment.

Your post-offer examination results provide the first line of defense for an employer should a potential employee question the reason for revocation of an offer of employment based upon a disability. When an individual alleges that the disability affected his or her hiring, the U.S. Equal Employment Opportunity Commission (EEOC) carefully scrutinizes whether a disability was a reason for any adverse action. If disability was a reason, the EEOC will determine whether the action was job-related and consistent with business necessity.

Where to Begin

Do your homework before picking up the telephone to contact employers to propose providing post-offer examinations. Your point of contact will most likely be Human Resources or Risk Management managers.  An important component of the post-offer process is to have a thorough understanding of the essential functions and demands that must be performed.   Ask if the employer has a written Job Description in place and review the information so that you can design a job-specific examination.

You may offer to perform a walk-through of the employer’s facility. Employers typically like to show off their facilities, and it’s important to listen, evaluate, and digest the information they share. Allow the decision-makers to have the stage, and they will show you around their facility so you can evaluate the employees’ work environment. This information gathering process will enable you to custom-tailor job specific post-offer examinations.

Opportunities for Growth

Post-offer examinations are non-insurance reimbursable and are paid for by the employer directly to the provider. This provides a sustainable source of non-insurance income for your practice, while you provide a valuable service to the employers and employees in your community. As you begin to develop relationships with employers in your area, more opportunities will arise. Many employers are actively seeking healthcare professionals to give safety talks, and to have a presence at their health fairs or wellness screenings. Because of your high-quality post-offer examinations, you will be their natural choice. There has never been a better time for chiropractors to embrace occupational healthcare and to step off of the “hamster wheel” of insurance reimbursement.


Dr. Mark Sanna is a member of the Chiropractic Summit, the ACA Governor’s Advisory Cabinet and a board member of the Foundation for Chiropractic Progress. He is the president and CEO of Breakthrough Coaching (www.mybreakthrough.com 1-800-723-8423).

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