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.

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.

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

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