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The "F*#%" Word Series Part 3

PHYSICAL THERAPY FRAUD, ABUSE and WASTE


We must understand that the problem begins at home and that we must collectively prove our value to society. We must produce better outcomes than the pretenders do.
— (D.W. Clifton, Utilization Review: "PT on the Radar Screen", PT Magazine, July 1995, 32-34

                  

                  This quotation was embedded in an article that cited real life examples of physical therapy fraud, abuse and waste as it occurred in outpatient settings. Here is a sampling:

  • 59 consecutive ultrasound applications to the cervical spine of a 3 yr-old for ‘migraine headaches’

  • 560 “work hardening” sessions, 14 separate CPT codes daily, $500.00-$600.00 per session. Discharge goal: for 71 yr. old patient was to military press/overhead 150# painfree.

Dx: grade 1 rotator cuff strain, job-letter courier, Total billed: &160,000 dollars.

  • 10 yrs of daily PT for lumbar strain/sprain, Texas workers compensation case

  • 292 consecutive cold laser applications (an FDA experimental device)without informed consent

  • Land-based therapy and aquatic therapy in same session in a group setting but billed as individualized programs

 

Fortunately, these examples are outliers however they may be the first impressions that others have of this profession. First impressions can become permanent ones and, we only get one. Because of the relative youth and obscurity of the PT profession, the impact of unscrupulous providers is potentially greater.  

 

Physical therapy through much of the twentieth century was an unknown or poorly understood profession particularly, among payers.  Physical therapy for the most part has been viewed as a discretionary or elective service. Although the growth in primary care physicians as “gatekeepers” continued to grow and the desire of managed care to restrain costs deepened; physical therapy remained in the shadows despite, the value proposition it offers especially, when compared to the costs of hospitalization, surgery and pharmaceuticals. Physical therapists are THE functional therapists (along with our occupational therapy or OT colleagues).

 

Physical therapy essentially practiced in the shadows of mainstream medicine but by the mid-1980s physical therapy had finally made it onto the radar screens of other healthcare stakeholders.  Regrettably, it was often for the wrong reasons. Abusive examples of physical therapy were routinely seen by claims adjusters, case managers, utilization reviewers and employer because PT was viewed as a “cash cow”. The 1980s was defined by a “gold rush” of publicly-traded corporations competing for profits. This was also a time when “pretenders” or many non-physical therapists profusely billed for so-called “PT”.  

                A Pretender or a PT?

               A Pretender or a PT?

Yes, physical therapy was finally on the radar screen, but for some it looked like an enemy bomber not, the relief ship we know it to be. For skeptics who may believe that “these kinds of cases {examples above don’t exist anymore”, they may be right; in many instances it has gotten worse! It is now common to see millions of dollars of fraud from single clinics or providers (see Part 1 of the Fraud series, May 23, 2016).

This is an ultimate tragedy for the involved patients/clients many of whom have lost control of their medical and legal destinies because they have trusted unscrupulous providers. The late great Jules Rothstein, a physical therapist change agent and former editor of the APTA journal opined that the physical therapy profession would be judged by others through encounters with “average” not, exceptional therapists. In reality, the profession may be judged by our worst therapists and the non-therapist pretenders who masquerade as “physical therapists”. This is a tragedy unfolding at the worst possible time as the physical therapy profession strives to produce only Doctors of Physical Therapy/DPTs by 2020 (APTA Vision Statement 2020).  

 

A vast majority of physical therapists are compassionate, ethical, conscientious, and law abiding healers trying to make a difference in patients’ pain and disability status.  The best of physical therapy is on the horizon with the nexus of the millennial generation, evidence-based practice and advances in technology. In the meantime, all health care stakeholders have an ongoing role of eliminating fraud, abuse and waste, which is a cancer of the American healthcare system especially, government-funded programs. 

 

 The first and foremost responsibility for combating fraud and abuse resides with physical therapists. Here are some recommended actions that will ultimately serve the needs of our patients while doing no harm.

 

  1. Identify and report fraud, abuse and waste when you see it.

  2. Appeal only legitimate cases when you are denied reimbursement that is supported by evidence and sound outcomes documentation. 

  3. Embrace don’t resist pre-authorization of services, its good risk management.

  4. Educate payers through your clinical documentation, websites, blogs, presentations and other media.

  5. Distinguish physical therapist from the generic label “physical therapy”.

  6. Share studies that support your treatment interventions especially, randomized control trials, meta-analysis and patient/client testimonials.

  7. Perform peer review both internally and for payers.

  8. Contact licensure boards to report aberrant behaviors and unscrupulous providers.

  9. Use the correct codes (Medicare’s Correct Code Initiative)

  10. Provide documentation that explains how extenders of care are supervised and task delegated to them.

  11. Liberally distribute APTA educational materials (e.g. Core documents, Code of Ethics) and bring special circumstances to the attention of APTA practice, reimbursement and legal staff.

  12. Educate your referral sources that Physical Therapists are autonomous practitioners who perform independent evaluations/re-evaluations, formulate “physical therapy” diagnoses, develop plan of care with treatment goals, and ultimately determine when and why to discharge a patient from PT. In 36 years of peer review experience the number one excuse/alibi that treating therapists when questioned about overutilization express is; “the doctor keeps referring the patient to me” or “the doctor wants PT to continue”. A therapist cannot have it both ways meaning out of one side of their mouth they assert that they are autonomous practitioners then use the referrer as the scapegoat when over-utilization of services occurs or bills are questioned. 

  13. Know when ‘restorative care” becomes ‘maintenance care’ or when the patient has reached a functional plateau. If a ‘maintenance program’ is medical necessary, provide the evidence to support it.  Hint, read the health plan exclusions and limitations sections.

  14. Clearly documented what constitutes ‘group vs individual’ treatment, ‘work conditioning vs work hardening’, clinically required therapeutic exercises and home exercise plans/HEPs, clinic-based thermal agents vs home heat/ice.  

  15. Provide an educated, evidence-based estimate of total treatment duration and costs. Be prepared to explain outlier or complex cases. Justify the use of the “55” modifier code.

  16. Become an exceptional master clinician and employ only the best so that physical therapists are no longer judged from the standard of “average” therapists.

            

 In the mid-1990s I was invited by the American Physical Therapy Association to author an ongoing column entitled “Utilization Review” in PTMagazine.  I had been involved in physical therapy peer review since 1982, when I founded Physical Therapy Review Services or PTRS, to provide “true” peer to peer review, long before it was required by statute.

There were two primary motives that spurred me to explore beyond the clinical box and venture into the unknown waters of PT review. One, relatively few people truly understood what physical therapists were trained and educated to do. The 1965 federal Department of Labor in its Dictionary Occupational Titles essentially described physical therapy as a local modality-laden profession, which some inaccurately describe to this day, as “passive modalities”. Clearly, the definition was grossly outdated and in need of reform to reflect the vital role PT served in human movement and function via therapeutic exercises. The fourth edition of DOT arrived in 1995. Secondly, physical therapy cost containment was being performed by claims adjusters, nurses, physicians and even laypersons; as was the case with a Florida-based UR company that enrolled high school graduates in a 6-week “PT UR University”. These so-called reviewers produced one page boiler plate “denials” (rarely if ever did they identify under-utilization), which resulted in a printing press for $150.00 bills for services rendered. Physical therapists with relatively few exceptions (The FOTO Group, under Mary Foto, OT, AOTA past president had performed Medicare OT/PT reviews) were not involved with PT peer to peer review especially in the outpatient arena where the profession and costs were exploding. The Workers’ Compensation Research Institute/WCRI in 1994 had identified chiropractic and physical therapy costs as the two greatest cost drivers of the medical component. A year later the General Accounting Office/GAO published, “Tighter Rules Needed to Curtail Overcharges for Therapy in Nursing Homes”. HHS Secretary Donna Shalala reported $10 dollars in recoveries for every $1 dollar spent on the joint federal-state government collaboration known as “Operation Restore Trust”, directed at Medicare & Medicaid fraud, abuse and waste in nursing homes. This was the impetus for statistical methods to target providers for investigations and audits, which continues today with greater intensity. 

Two articles were penned with the expressed goal of challenging physical therapists to do some house cleaning and differentiate physical therapist delivered care from physical therapy, which was quickly becoming a generic term (“PT on the Radar Screen” and “Tolerated Treatment Well May No Longer Be Tolerated”, D.W. Clifton, PT).  It was apparent that PT’s heightened visibility particularly on payer radar screens would not be without its costs.  

In conclusion, providers and payers are highly dependent on one another and mutual survival or destruction may be assured by whether they view one another as adversaries or partners in health.  Both sectors engage in contracts with patients/beneficiaries to whom they owe certain duties (business and/or clinical). Payers need providers to serve in a risk management capacity while providers require payers for fiscal survival as private pay is not an option for the vast majority of patients. Partnerships must be forged between all stakeholders to combat fraud, abuse and waste, which all of us pay for but relatively few engage in.  

Stayed tuned for Part 4 of the “F” word/Fraud series; “PT-PreTenders”.

  

                                               

 

CLIFTNOTES©                               

PHYSICAL THERAPY FRAUD: Part 2 in the “F” Word Series. This installment of the fraud series will focus on physical therapy fraud, abuse and waste provided in skilled nursing facilities. Future installments will address, home health care, workers’ compensation, automobile liability, group health and outpatient. 

 

  • “No physical therapist should be placed into a situation by an employer to provide excessive or unwarranted services to Medicare beneficiaries or any other patient. Physical therapists are licensed professionals and those practicing inappropriately should be reported to their state licensure boards.” 
  • Scott Ward, PT, PhD, APTA President

This quotation connotes a shared risk and responsibility between the physical therapist/PT and their employer for instances involving fraud and abuse. For me, this dilutes the real message that the PT ultimately assumes responsibility and accountability for abusive practice. At the end of the day, it is the PT’s license which is at-risk. Ward speaks to this in his quote. However, just reporting a PT to the licensing agency is not enough.  Some state licensure boards are aggressive while others are not. All must protect the publics’ health and trust. In California, the board considers fraud to be an urgent complaint which may possibly be referred on to the Office of Attorney General’s Office for further investigative and a formal charge.

Perhaps, the most common complaint by therapists who work in SNFs is that the administrator and/or rehab director places excessive pressure on them to rack up minutes of billing. I have seen some instances in which, treatment minutes exceed 480 minutes which constitutes an 8hr shift yet, the therapist’s time clock is punched out after an 8 hour shift or less.  It is quite common to see “productivity quotas” anywhere from 85% to 100%  in SNFs.

This essentially means the therapist never went to the bathroom, took a break, walked between patients/down hallways to patient rooms, completed clinical documentation or ate a meal.  These quotas are published in job vacancy notices or stated by healthcare recruiters and, should be considered a “red flag” for review. As long as PTs continue to work under these conditions and many do, unscrupulous SNF administrators will continue to press them into servitude.

Ultimately, therapists must make some difficult decisions; 1) stop taking these positions (I get 10-15 calls or emails /wk. from healthcare recruiters trying to fill SNF slots), 2) become a whistleblower under Qui Tam/False Claims Act, 3) go undercover for the FBI, Office of Inspector General, Dept. of Justice or 4) “sell out” and collaborate in what may very likely comprise fraud.  Lose your license, get a strike against your National Provider ID/NPI, go to jail, pay restitution and do further damage to patients, American taxpayers and the PT profession.    

Physical therapists/PTs choose where they work, subscribe to the policies & procedures of their chosen facility and if they disagree with them, they are free to leave. PT is perennially listed by the federal Department of Labor as one of the fastest growing professions and jobs are plentiful. Even in times of job scarcity, this is no excuse for fraudulent practice and billings, which are both unethical and in many cases, illegal. When PT’s blame the skilled nursing facility for pressuring them to bill for greater time (minutes), upcoding to achieve higher reimbursement (RUGs) or to bill as individual vs. group billing; the responsibility rests with the therapist.

Projection of culpability to others is inexcusable and as specious as faulting a referring physician for over-utilization of physical therapy services, which I should note is the number one excuse that I have heard from providers reviewed over my thirty-six year career in PT peer review; “the doctor keeps referring the patient." Readers should note that physical therapists strive to preserve autonomous practice and in every state enjoy some degree of “direct access” wherein, a patient can be evaluated without a so-called “prescription” or referral from a physician.

When therapists concurrently proclaim professional autonomy and then fault referring physicians when things go wrong they act unprofessionally because “you can’t have it both ways”. No one holds a gun to the therapists’ head. However, under Medicare a physical therapist must follow a certified plan of care signed by a physician. Although, on a personal level I disagree with this policy because I strongly believe that therapists are educated and trained for autonomous practice, it is the federal law. 

COMMON EXAMPLES OF FRAUD & ABUSE:

Medicare Part A insurance benefit reimburses for physical therapy that is a component of skilled nursing care/SNF. These services are provided in the acute care setting or in a post-hospital SNF.  

Medicare Part B or supplemental insurance reimburses for PT under defined circumstances in order to receive reimbursement:

  1. Be provided to a patient under a physician’s care

  2. Care must be recertified by the physician

  3. Meet medical necessity and reasonable criteria

  4. Be provided under the direct supervision of qualified personnel

 

WWW.STOPMEDICAREFRAUD.GOV

 

Resource Utilization Groups or RUGs:

“The Perfect Storm”

There are 66 RUGs with physical and occupational therapy involved in one-third of them. SNF’s attempt to admit patients/residents who have complex needs requiring therapy. Physical therapy utilization rates and billings are critical to SNF profitability. For years PT has been considered a cash cow. Many SNF owners do not like to directly employ rehabilitation providers substantially due to the fact that they assume greater risk for aberrant billing. By independently contracting with rehab providers, SNF’s transfer a great deal of risk to the contractor. Contracting organizations subcontract physical therapy to individuals similarly in order to transfer risk to the actual treating therapist, whose license is ultimately at risk in situations of Medicare fraud and abuse. The PT can be excluded from future Medicare inclusion, lose their license, pay restitution and face incarceration.  Physical therapists when compared to many professions are younger and with less business acumen. Of course, there are many excellent business-minded therapists however, PT curriculum is so rigorous because it must cover all body systems, has a high degree of hands-on or didactic training that, in general, lightly covers issues such as contract law, 1099 vs W-2 status etc. Training and education in this regard is dramatically improving.  However, ignorance is never an excuse under the law.

SNF administrators routinely pressure therapists to maximize treatment minutes (720 mins. in an assessment period) so that the facility can bill for “ultra- high” RUG category. The current system in my view is equally flawed to the traditional fee-for-service system where providers are paid to do more not less. For the record, 68% of all cases of Medicare fraud are for fraudulent billing with complicity for providers at sixty-two percent.

10 Common Acts of Fraud-Abuse-Waste in SNFs:

The following examples do not represent hypothetical scenarios of Medicare fraud but actual situations that have led to the successful prosecution in a multitude of cases nationwide. Actual cases related to each numbered item are available by request.

[1] Billing for physical therapy performed by unqualified personnel.

a) “Incident-to” physical therapy services. Failing to have a license physician on-site at all times when billing for physical therapist services. Physicians can bill for physical therapy if they are on-site and use therapists not, unskilled, unqualified staff. Physicians cannot supervise physical therapist assistants only, physical therapists can.

b) Billing for physical therapist services performed by a non-therapist, untrained, unlicensed staff even though a licensed physician is on-site. I have personally seen clerical staff and van drivers who performed services entitled “physical therapy”.

 [2] Physical therapist inappropriately allowed his/her provider identification number to be used to bill for services provided by someone not, under their supervision.

[3] “Phantom Billings” for services never provided, false, fraudulent, and fictitious.

[4] Physician kick-backs for referrals.

[5] Individual vs Group Billings, billing under individual codes when therapy is done in a group of 2 or more.

[6] Miscoding of physical therapist services.

[7] Physical therapist services provided without an approved/certified physician’s plan of treatment.

[8] Billing for “maintenance” not restorative services.

[9] Forging of physical therapists signatures and use of professional licensure numbers when billing in the absence of the therapist on-site.

[10] SNF administration upcoding of patient minutes to achieve “Ultra High” RUG level (720 minutes of therapy during an assessment period) after the therapist has submitted their billing. This occurs during “window periods” and involves “ramping” up of minutes to generate a higher level of reimbursement.  A patient receiving “ultra-high” minutes must have a severe condition but not too severe that they cannot tolerate therapy. These patients are very rare yet, an increasingly, many SNFs are billing for these extraordinary amounts in order to optimize reimbursement.

 

SAMPLE HEADLINERS:

Kentucky: “Nation’s Largest Nursing Home Therapy Provider,  Kindred/RehabCare to Pay.25 Million to Resolve False Claims Act Allegations”, U.S. Dept. of Justice, 1/12/2016.  

Michigan: “Novi Physical Therapist Summarily Suspended”, (Dept. of Licensing & Regulatory affairs, 12/18/13), 22 mos. Imprisonment, $2,375,000.00 in restitution for billing PT & OT to Medicare not performed. 

New Jersey: “Owner of Physical Therapy Clinics in Ewing and Cherry Hill Pleads Guilty to Multi-Million Dollar Medicare Fraud” (DOJ, 5.5.2007), billed $6.7 mil., received $3.79 mil. for physical therapy services allegedly provided to patients, unqualified staff, ”incident to” violations, failing to have licensed physical therapists perform the physical therapy on the patients.

Alabama: “HEALTHSOUTH to Pay United States $325 Million to Resolve Medicare Fraud Allegations,” (DOJ, accessed 4/16/2008. 

Texas: “Physical Therapy Clinic Operator Sentenced To Prison in Fraud Case”, (DOJ, 9/12/2006) “incident to” violations, no licensed physicians treated patients, unlicensed/unqualified staff, $4 mil billed/$1.2 mil. collected by operator. 

Florida: “In Florida, two chiropractors were sentenced to six months home detention, ordered to pay a $10,000 fine and pay $400,000 in restitution”, (HHS, 2/2005).

Billed chiropractic services as physical therapy.

Notes:

  • Conviction of Medicare fraud involves 10 yrs. in prison and $250,000 fine for EACH guilty count. The 3-yr statute of limitations on overpayment recovery does not apply to cases involving false pretenses or fraud.

  • Each violation of the False Claims Act/FCA involves a $10,000 fine plus treble damages even if the ill-gotten amount is as low as $5 dollars.  

  • As in previous installments of this series, not all physical therapy is provided and billed by physical therapists. Non-therapists are responsible for a significant percentage/amount of “fraud, abuse, waste” labeled as ‘physical therapy’.  It is critical to ascertain the professional credentials of any/all persons who provide/bill for services entitled “physical therapy” before stereotyping an entire profession. 

 

Sources:

American Physical Therapy Association, “APTA Reaffirms Commitment to Eliminating Fraud and Abuse”, Oct. 7, 2011

Federation of State Boards of Physical Therapy, Federation Forum: Fraud and Abuse: Part 1, Winter, article derived from a presentation by Gayle Lee, J.D., Senior Director of Health Finance and Quality for the American Physical Therapy Association, 2013

Rooks Franklin J., Jacobson Jared A., Blowing the Whistle on Fraud, in Advance Healthcare Network for Physical Therapy & Rehab Medicine, Nov 30, 2015, accessed: 5/19/2016

 

LESSONS FROM "ONE FLEW OVER THE CUCKOO'S NEST"

LESSONS FROM  "ONE FLEW OVER THE CUCKOO'S NEST"

CLIFTNOTES              Lessons from “One Flew Over the Cuckoo’s Nest”

 

Do you remember the character Sydney Lassick played in “One Flew Over the Cuckoo’s Nest”? Yes, Charley Cheswickis correct. My “Teaching Methodology” professor at Indiana University of Pennsylvania was a man named Leonard DeFabo.  Dr. DeFabo was a dead ringer for Cheswick. He taught in the Educational Psychology program at IUP.  This tiny man had a giant impact on my life, but I never took the time to thank him while progressing through my career. Unfortunately, he died in October of 2002. I carried his very first lesson with me to this day, forty-four years later. This is my tribute to Dr. DeFabo.

Professor DiFabo asked all of us that first day the same question as he quickly pointed from student to student; “What are you going on to teach?” “And you”?  And You”? The targeted students reflexively said ; “Math”, “English”, “Chemistry”.  With great animation, a distended vein on his forehead and deep passion [some would argue craziness]in his voice, Dr. DeFabo countered; “NO!”!,” you are not teaching Math, and you are not teaching English and you Chemistry!!!”  “You ALL are teaching children how to learn and apply math, English and chemistry”. WOW! What an epiphany for me. Dr. DeFabo had lit a spark as I went on to score a 107/100 in his course because he found a way to reach me. This was the highest I ever scored in any course.

Here is the message of this blog; when the metaphorical layers of the healthcare onion are peeled away, at its core are human beings who we are attempting to influence in a certain manner. At times we wrongly make judgements about what is right for who are under our stewardship in a given circumstance. We often lose sight of the needs of many healthcare stakeholders whether they be; a doctor, patient, employer, claims adjuster, case manager, family member or colleague.  We inadvertently apply de-personalized labels to; “amputee”, “stroke”, “low back injury”, “work comp case”, “ortho”, “malingerer” or worse.

When the phrase “patient-centered care” first entered the medical lexicon, I had a moment of confusion; “that’s strange, hasn’t it always been about the patient”? Of course, that was the clinician in me and perhaps, educator revealing himself. As a physical therapist I do not view a patient as a “shoulder”, “knee”, “diabetic” or “amputee”. I view them as persons who suffer from a shoulder or knee injury, amputation or chronic disease.  This personalization opens one’s mind to other issues and facilitates a “whole body”  approach (e.g. psychosocial, economic) that may directly impact clinical outcomes,  As technology escalates at an ever increasing pace, there is a tendency to lose sight of what we are truly attempting to accomplish. For me “high tech may lead to low touch” and a lack of personalization in our delivery of services. Physical therapy by definition is a “high touch” profession. This is important because truth be told, most patients judge treatment success based upon process and structure elements not, clinical outcomes. They value personal touch, genuine interest, clear explanations, eye to eye contact, reflective listening, sincerity and warmth exuded by clinicians. Patient satisfaction surveys consistently bear this out. Eric Swirsky in a blog article entitled; “4 Reasons Why Healthcare needs a Digital Code of Ethics” outlines a number of important considerations when attempting to balance population health with individual needs. His article should be mandatory reading in all medical & allied medical programs as well as healthcare informatics and IT programs.  Swirtsky provides three statements that touched me to the core;

“Aggregated data of treatment outcomes do not necessarily reflect the needs of an individual patient and her experiences with her health or healthcare provider”

“The record is a disembodied representation of a patient, who is deconstructed byte by byte without effectively being represented as a whole person”. 

“The health, well being and dignity of an individual are not found in the aggregate—they are discovered at the bedside along the course of provider-patient relationship”.

As an adjunct professor in three university-based physical therapy programs my mantra to my students was that; “ninety-percent of your clinical success will come from how you manage patients and only ten percent from your actual treat individuals via clinical skills”. This I have believed for thirty-six years, this I will believe for another thirty-six years both as a clinician and patient myself.

Here are ten life observations worth sharing, hopefully, they can foster a greater understanding of inter-personal relationships.

 

1. The vast majority of people resist not embrace change

2. Those who resist change often go through stages similar to those described by the iconic Elizabeth Kubler-Ross in her 1969 book On Death & Dying, e.g. denial, anger etc.

3. The vast majority of people are driven or motivated more by fear than opportunity.

4.  Common sense is uncommon.

5. Intelligence comes in many shapes and colors.

6. Change is external while transition is one’s response to it [change].

7. Encouragement is extrinsic while motivation is an intrinsic quality. We can encourage but not motivate.

8. People learn more from mistakes than from successes.

9. To gain optimal buy-in from a person one has to make them a stakeholder during the process not, a passive recipient.  

10. Human beings operate on the principle of least effort (based upon a theory from 1954 and a book about nomadictribes, the title has escaped me for the moment) 

Now back to “One Flew Over the Cuckoo’s Nest”. Think about how differently Nurse Kratched (Louise Fletcher) and Jack Nicholson (Randal “Mac” McMurphy) dealt with patient issues.  How did Jack relate to Chief (Will Sampson) when compared to others?  Who respected the patients more; Jack or the Nurse? Whose best interest did Mac and Kratched have in mind? Who was more patient-centric? Who developed the strongest interpersonal relationships?

Your answers to these and other questions may help you to determine if you teach math or people. RIP Leonard DeFabo, my esteemed mentor.            

The “F*#%*” Word….I’ve Seen It All and Then Some!

(Part 1 in an on-going “F” word series)

  • Thirty-six years of experience in Physical Therapy Peer/Utilization Review
  • Review of every possible condition and even impossible conditions
  • Approximately 200,000 cases personally supervised/reviewed
  • Testified in hundreds of depositions, trials, arbitrations
  • Addressed issues across every treatment setting
  • Medical necessity opinions all insurance lines

FRAUD is a cancer that metastasizes across all health insurance lines, treatment settings, provider types, medical conditions and patient demographics. Everyone pays for fraud not just insurance companies.  Perhaps the greatest victims are those unfortunate souls who do not receive medically necessary and reasonable healthcare services? This is a rich country by all standards, but a poor country in terms of greed and avarice exercised by a very small, but impactful minority of providers. The United States has incredible resources including some of the world’s greatest medical technology placed in the hands of gifted providers.  However, many of our riches are squandered because of the drain and disproportionate attention directed at the “players” of this serious game….fraud, abuse & waste. By “players” I mean anyone who through intentional (fraud) or unintentional (abuse, waste) behaviors imposes hardships on others as a consequence of their selfish acts. Clearly, the vast majority of Americans even in difficult economic cycles strive to do the “right thing at the right time and for the right reason”.  The medical professions as a whole are populated with compassionate people who by nature, nurture and likely both, are healers and stewards who unselfishly serve. “Players” to the contrary, are seemingly immune to their social responsibilities. 

Here is an up close and personal look at a so-called “physical therapy” case that involved “players” who fortunately, are no longer in business. They were the epitome of an old farmer’s saying; “pigs get fatter but hogs get slaughtered”.

One highly memorable evening after a long shift of delivering physical therapy services in an outpatient clinic, I settled into my family room. There I began peer review of a voluminous medical file that involved an outpatient “physical therapy” center, one of three owned by the same physician. The center in question purportedly specialized in work injury management and “work hardening”. The following facts of this case consumed me until 3a.m. the next day:

Patient: a 71 yr. old man/workers’ compensation patient, employed as a letter courier with complaint of shoulder pain. He was a Teamsters member with a labor-management contract that discouraged lifting objects greater than 50# without a two-person lift.  

Providers:  A physical therapist allegedly performed an initial evaluation with the only clinical documentation being a computer-generated page that appeared to be boiler plate. The evaluation documented a rubber-stamped signature of a licensed physical therapist. No subsequent daily treatment notes had any semblance (rubber stamp or otherwise) of a therapist’s or physical therapist assistant signature.  There was no evidence that any credentialed physical therapist or physical therapist assistant actually treated this patient. Every daily treatment note was signed by one of four persons describing themselves as “Rehabilitation Specialist”, a non-existent credential essentially equating to an aide. No professional licenses were presented upon request of the carrier or defense attorney.

Interventions: “Work hardening” without any semblance of job simulation or customization was purportedly performed and billed. There was a complete absence of a functional job description and there were no entries in the clinical documentation of any work specific tasks or critical job demands.  

Discharge plan: The discharge goal for this patient was the ability to press 150# overhead pain-free. It was not established whether this man had ever performed this task pre-injury. Again, the patient's/injured worker's union contract forbids any lifts over 50# and in fact, required a two-person lift of any object greater than 50 pounds. Patient subjective reporting was that he delivered letters carrying a plastic bin weighing less than 10#,  ambulating into and out of office buildings and driving a panel van between stops.  

Definition: work hardening
A rehabilitation program designed to restore functional and work capacities to the injured worker through application of graded work simulation. Included are activities designed to improve overall physical condition, including strength, endurance, and coordination specific to work activity, as well as means for coping with any remaining symptoms from the original problem, such as pain. Central to all work hardening programs is the reproduction of a work-like environment where tasks are designed to improve the patient's tolerance for productive work.

A goal of work hardening is to achieve an acceptable level of functional productivity for returning to one's former occupation or for meeting the demands of a new job with specific critical job demands identified. Therefore, worker behaviors and not just physical conditioning are addressed. These include having structured work times and duties, dressing appropriately for one's tasks, and conducting oneself in a worker-like manner. It is important to differentiate work hardening from
work conditioning, which does not address these added concerns. 

Visit Billing:  At least fifteen different activities were listed in repetitious daily clinical notes. These activities were then bundled under therapeutic exercise (CPT97110), neuromuscular re-education (CPT 97112), and work hardening(CPT 97545).

  • Proper lifting 1, Proper lifting 2, Proper lifting 3
  • Proper body mechanics 1, Proper body mechanics 2, Proper body mechanics 3
  • Proper posture 1, Proper posture 2, Proper posture 3
  • First aid: taught patient how to use home ice/heat
  • Goal setting 1, Goal setting 2, Goal setting 3
  • Communication conflict
  • Anatomy instruction

Total physical therapy costs to date: $224,000. Reduced to $160,000.00 after the provider learned the case was under review.

Additional findings: Please note that the same treatment frequencies, duration, billing codes and costs were seen across all cases reviewed from the three centers irrespective of patients' conditions, age, gender, or job. Also, it was discovered that the evaluating physical therapist's rubber stamp signature was found in six separate cases across three centers. He was billing for services on the same day and within the same timeframe at three locations. It was a "Scottie beam me over" situation.The average outpatient aggregate billing per soft tissue case treated at these centers routinely exceeded $100,000.  

Case disposition: The peer review report contrasted this center’s treatment methodologies to the standard of care and medical necessity for physical therapy services was not supported by the clinical documentation. A recommendation was made to the claims adjuster to consider a referral to the SIU department due to numerous fraud "red flags". The case manager received permission from the insurer to make a visit along with the peer reviewer as a courtesy to speak with the physician owner and “rubber stamp” therapist about our findings. The visit was made, but upon our arrival both providers refused to speak with us. To the best of my knowledge, the insurance company did not pursue a fraud investigation despite the facts presented. 

It should be noted that in developing my review opinions and preparation of a review report; I had analyzed eight different disability duration tables, each provided a maximum number of physical therapy visits by medical condition/diagnosis. Four tables were payer-developed and four were provider-developed (American Physical Therapy Association state chapters). 

An arbitration hearing was scheduled. The plaintiff’s attorney could not be there so an attorney from a different firm filled in. When it came time to testify I pointed out that the greatest number of visits in any of the eight tables was 120 visits. The WC defense attorney continued his direct; “And, how many visits were billed for in this case?”  I responded “560 visits”. The attorney continued;  “For what diagnosis were the 120 visits considered the maximum?”. My response, “quadriplegia sir”. He then directed his last question: “What was the presenting diagnosis in this case Mr. Clifton?”. My response; “grade one strain of the rotator cuff”.  With this the substitute attorney with exasperation in his voice tossed his file onto the conference table and stated; “That’s it, I’m withdrawing any request for reimbursement for this center”. Case closed, door slammed shut by the plaintiff attorney as he exited the room.

READER EXERCISE:
Based on the facts presented: Who were the players in this case? How is each player culpable? 

NOTE: this blog is the first installment of many to come that will identify the scope of fraud in physical therapy and will share strategies for both providers and payers who are earnest in their desire to eliminate these activities.

Sources:
Medical Dictionary for the Health Professions and Nursing, Farlex, 2012

Mosby’s Medical Dictionary, 9th edition, 2009, Elsevier

 

 

Ten Reasons to Use a Physical Therapy Expert

There is no medical specialty more qualified to provide expert opinions on physical functioning than physical therapists.  Physical therapy is the unfinished business of medicine. Physical therapy plays a pivotal role in the lives of patients who have sustained impairments leading to disability. The disability continuum pictured below illustrates the distinction between disease-pathology-impairment-disability- handicap concepts.  

Physicians play a dominant role on the disablement continuum between disease and impairment while, physical therapists are the providers of choice when attempting to differentiate and manage conditions that range between impairment and handicap status. This is not to say that physicians and therapists do not treat along the entire continuum. It simply points out the greatest impact each professional group offers. Physicians make “medical diagnoses” which are typically disease, pathology and impairment-based.

Physical therapists on the other hand make “physical therapy diagnoses” generally descriptive of physical function or dysfunction in activities of daily living/ADLs, critical job demands, and among athletes.   

The confluence of medical, legal and administrative policies & procedures produces conflict in virtually every insurance line when it comes to determining who is the best medical provider to ask a specific question or call as a medico-legal witness regarding a patient’s condition, work status, and physical function.

It is the intent of this communication to reinforce the importance of physical therapists within the medical matrix of providers and along the disability continuum. It is my strong belief that physicaltherapists are incredibly under-utilized by the following professionals who attempt to prevent, treat, manage and finance value-driven healthcare. Please note that there is a plethora of clinical documentation, legal precedence, and acceptance of the valuable professional knowledge, experience, judgement, insights and opinions that physical therapists have to offer.  Again, physical therapists do not replace, supplant or displace the medical necessity for physician services. We simply augment what others do within the complex healthcare delivery model(s). Physical therapists are not “Medical Doctors” or “Doctors of Osteopathy”. Physical therapists are graduating increasingly with entry-level “Doctorates of Physical Therapy”. Or DPT. This will become the standard in the next several decades.   

Sources:

Clifton DW: Physical Rehabilitation’s Role in Disability Management. St Louis: Elsevier Pub., 2005, pg10

Duckworth D, Measuring disability: The role of the ICIDH, Disabil Rehab; 7:338-343, 1995

Guccione AA: Physical therapy diagnosis and the relationship between impairments and function. Phys Ther 71:499-504, 1991

Nagi SZ: Disability concepts revisited. In Pope AM, Tarlov AR (Eds): Disability in America: Toward a national agenda. Washington, D.C., National Academy Press, 1991, pp309-327.

World Health Organization: International Classification of Impairments. Disabilities and Handicaps: A Manual Relating to the Consequences of Disease, vol 41, Geneva, WHO, 1993 (originally published in 1980)

David W. Clifton, a licensed physical therapist and disability expert. He serves as CEO of DplusWC, a disability & workers’ compensation solutions company. David is considered by his peers as one of the founders of physical therapy peer review in the United States; having developed the nation’s first PT-specific Peer Review Organization/PRO (1982). Many physical therapy network companies and utilization review organizations follow his teachings.

PHYSICAL THERAPY : TEN MYTHS and REALITIES

Purpose: This blog installment addresses common misconceptions about physical therapy.  It is Part 1 of an on-going series. Readers are encouraged to review the included references with regard to the realities specific to Physical Therapy.

Audience: claims adjusters, case managers, consumers, physicians, physical rehabilitation providers, risk managers, occupational health professionals, attorneys, fraud investigators.

Myth 1: “Physical Therapists do not make diagnoses!”

Truth:  Physical therapists are obligated by law, Medicare and professional practice standards to perform comprehensive evaluations before providing services. The American Physical Therapy Association (APTA) directs that the “Physical therapist shall establish a diagnosis for each patient.” Specific to physical therapists: “A diagnosis is a label encompassing a cluster of signs and symptoms commonly associated with a disorder or syndrome or category of impairments in body structures and function, activity limitations or participation restrictions.” 

 The “Physical therapy” diagnosis differs from a medical diagnosis because it focuses on function and not pathology. The physical therapist diagnosis attempts to correlate impairments with disabilities/abilities, a role for which they are uniquely educated, trained and experienced. 

Myth 2:  “Referring Doctors, not therapists determine how much therapy is needed

and when to discharge the patient.”

Truth:  Physical therapists, not physicians, are responsible for making decisions regarding the discharge of a patient who; 1) is not functionally progressing or 2) has functionally progressed but plateaued, meaning no additional benefit will be derived from ongoing therapy. Discharge planning begins with the first visit to Physical Therapy. PTs are also obligated to communicate patient changes in status or function with the referring physician. The physical therapist cannot fault a referring physician for overutilization of physical therapist services. Legal case law has established this as well as ethical standards.  

Myth 3:  “All therapy is the same.”

Truth:  Physical therapy whether provided by a licensed physical therapist or non-physical therapist can markedly differ. Even though the APTA, the largest guiding body has promulgated practice guidelines, codes for professional conduct and ethics; there is no requirement that physical therapist educational institutions provide identical curriculum. The APTA’s 2020 Vision Plan has a goal for all entry-level physical therapists to enter the field with a DPT or Doctoral of Physical Therapy. However, DPT programs differ broadly in terms of academic requirements. 

            Physical Therapist services are not synonymous with physical therapy, as the latter term is often used by persons who have not undergone the rigorous training, education and testing that therapists have undergone.

            It is considered an ethical duty to support evidence-based practice to achieve effective patient/client outcomes. Principle #3 of The APTA “Code of Ethics for the Physical Therapist” states; “Physical therapists shall be accountable for making sound professional judgments.”  Principle 6C goes on to affirm; “Physical therapists shall evaluate the strength of evidence and applicability of content presented during professional development activities before integrating the content or techniques into practice.”

            Despite differences in academic training, specialties, treatment settings, payer plans, or therapist or practice preferences, all physical therapists must keep the patient/client’s best interest in mind when making clinical decisions.

Myth 4:  “Physical Therapists work from prescriptions.”

Truth:  All fifty states allow for physical therapists to evaluate patients without physician referrals. However, the APTA estimates that 70% of people believe (falsely so) that a therapist must receive a “referral” or “prescription” from a physician before evaluating a patient/client.  It is important to understand that the term “prescription” is not synonymous with “referral.” Technically speaking, physical therapists do not require a “prescription.”

            It is typically a health care plan coverage rule that determines whether a physical therapist must have a referral before treating a patient. Medicare requires a physician referral for example. The non-requirement for a referral is one of the reasons [along with physician trust and confidence in therapists] that a majority of referrals are written with some variation of “evaluate and treat as per discretion”. This means the therapist produces a “physical therapist diagnosis”, designs the PT plan of care (POC) and determines frequency and duration. In all cases, these data must be provided to the referring physician in addition to re-evaluations, modifications in POC, home exercise program (HEP) , functional goals and discharge plans.

 Myth 5:  “No pain, no gain.”

Truth:  The two most common reasons that patients seek or physicians refer to physical therapy are pain and dysfunction. It is unacceptable to believe that a physical therapist’s goal is to increase pain. It is doubtful that a patient would return for treatment especially if scheduled 2-3 times weekly or for the doctor to continue referring therapy if therapy causes more pain. APTA estimates that 71% of people who have never participated in a physical therapy program possess a “No pain, no gain” belief. This percentage markedly drops when actual patients/clients are surveyed.  It is my professional opinion that the “no pain, no gain” myth emanated from the sports medicine arena and athletes who may generally have a higher activity and pain tolerance than non-athletes.

 Yes, there may be some exercise, stretching or manual therapy-induced discomfort with therapy, but like most episodes of post-exercise stiffness, soreness and mild pain; there are no adverse effects.

Myth 6: Physical therapists are not qualified to provide professional opinions

about injury causality."

Truth:  Physical therapists (PTs) are qualified by virtue of education, training, continued education, clinical practice and consulting experiences to provide sound professional opinions grounded in data regarding causality. The more critical question is; Can PTs provide legal opinions regarding causality?” Responses to this question will be directed by statutes, insurance plan rules/regulations and the context of causality issues.

Physical therapists are obligated as part of a comprehensive evaluation to determine injury mechanisms. These professional opinions may or may not be admissible within health plans, e.g. workers’ compensation, but therapists by way of education, training, experience and professional responsibilities routinely address causality and injury mechanisms especially, in orthopedic conditions.  These data are necessary in order to design and execute both a safe and effective rehabilitation program.

Many physical therapists routinely provide injury mechanism opinions in the context of ergonomic analysis, development of functional job descriptions, ADA “reasonable compliance” data, OSHA abatement activities especially directed at cumulative trauma disorders or CTDs, FCEs or functional capacity evaluations, and in addressing human-environment matching under a return-to-work program. PTs are musculoskeletal experts trained in biomechanics, kinesiology, human movement, and anatomy. PTs and OTs/occupational therapists are universally recognized as THE functional experts who operate within the medical model of healthcare.      

Myth 7: “PTs are technicians and do not have practice autonomy.”

Reality:  Physical therapy is an autonomous profession and physical therapists operate as independent practitioners. Physical therapists can practice as first contact providers and perform their own initial evaluations, make “Physical Therapy” diagnoses, design and execute plans of care. Therapists graduate from accredited institutions, sit for licensure exams, are obligated to take continuing education courses.  And, as previously stated; physical therapists in all fifty states can by statute (state practice acts) evaluate patients without physician referral.

Myth 8:  “Certifications held by physical therapists guarantee that patients are receiving evidence-based treatment from the best providers.”

Reality:  Certifications come in many flavors and each and every one must be analyzed on its own merits or lack thereof. Certifications really only tell us who is doing something, but not necessarily how well they are doing it. This is not unlike other credentials such as one’s choice of school, specialty, treatment setting or patient population.

Myth 9:  “Physical therapists are only trained to treat trauma and injury.”

Reality:  While physical therapists are trained, educated and skilled in treating injury especially musculoskeletal conditions, this is only one component of this profession’s capabilities. Therapists receive comprehensive education both classroom and field-based that spans virtually every body system. Therapists are equipped to treat and manage injury and diseases at any level of irritability from acute to subacute as well as chronic. Although some physical therapists specialize e.g. hand therapy, sports medicine, work injury, all receive disease and injury specific training/education. Therapists manage patients with cardiac, endocrine, neurological, digestive, circulatory, integumentary and pulmonary conditions.   

Myth 10:  “Therapists cannot perform medical screenings.”

Reality: Standards of care and evaluation/treatment guidelines require therapists to perform medical screenings of patients. This requirement has become stronger with “Direct Access” or the ability to evaluate and/or treat without physician referral in all fifty states. In fact, many referring physicians appreciate that therapists conduct medical screenings and this is reflected by the fact that approximately fifty-percent of all PT referrals have some version of “Evaluate and treat as per discretion”. This recognizes the autonomous status of physical therapy and reliance on sound clinical judgement. Boissonault and Bass opine that “Medical Screening Examination: Not Optional for Physical Therapists”.  It is critical to understand that therapists do not make visceral disease diagnoses, but rather communicate clinical findings or patient history that are causes of concern. These findings may result in further physician investigation. This assures better care for patients and enhanced risk management for providers.

 

© 2016 DPLUSWC DAVID CLIFTON PT All Rights Reserved

 

Sources:  

American Physical Therapy Association (APTA). Guide to Physical Therapist Practice, Alexandria: VA, 2001; 81(1):9-744,  

APTA. Infographics 7 myths about physical therapy, Alexandria: VA, www.apta.org, accessed 4/17/2016 

APTA, Diagnosis by Physical Therapists, House of Delegates P06-12-10-09, Alexandria: VA, updated 08/12/12, nationalgovernance@apta.org, accessed 4/17/2016  

Boissonnault W., Goodman C., Physical Therapists as Diagnosticians: Drawing the Line on Diagnosing Pathology, Journal of Orthopedic & Sports Physical Therapy 36(6); 351-353 

Boissonnault W, Primary Care for the Physical Therapist: Examination and Triage, 2nd ed., St Louis: MO, Elsevier, 2011 

Boissonnault W. and Snyder, Differential Diagnosis for Physical Therapy: Screening for Referrals, 5th ed., St Louis MO, Elsevier, 2013 

Boissonnault W. and Bass C, Medical Screening Examination: Not Optional for Physical Therapists, Journal Sports Physical Therapy, 14(6); 241-242, Dec. 1991 

Guccione AA. Physical therapy diagnosis and the relationship between impairments and function. Phys Ther. 71(7):967-969, 1991 

Jette A., Diagnosis and Classification by Physical Therapists: A Special Communication, Phys Ther. 69(11); 87-89., 1989

Rose SJ, Physical Therapy Diagnosis: Role and Function, Phys Ther 69(7); 535-537, 1989

Sahrmann SA: Diagnosis by the physical therapist-A prerequisite for treatment: A Special Communication. Phys Ther 68:1703-1706, 1988

World Confederation for Physical Therapy, Policy Statement: Description of physical therapy, www.wcpt.org, accessed 2/19/2013

World Confederation for Physical Therapy. Policy Statement: Direct access and patient/client self-referral to physical therapy. London, UK: WPT: 2011, {12}, www.wcpt.org, accessed 2/19/2013

World Confederation for Physical Therapy. Policy Statement: Autonomy, London, UK: WCPT 2011, www.wcpt.org. Accessed 2/19/2013

10 Transformative Trends Impacting Disability Management

10 Transformative Trends Impacting Disability Management

WELCOME to D+WC’s website and our inaugural “CLIFT Notes” blog.

This blog is the first installment of many to follow that promise new insights into disability prevention, disability management, disability forensics and physical rehabilitation. We launch this blog during one of the most epoch periods in health care history. We live in a time when a confluence of powerful forces are challenging traditional health care delivery and finance systems.