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