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Feature
Commentary
Navigating the Challenges of Being a Healthcare
Provider:
What Are the Risks for Physical Therapists?
Helene
M. Fearon,
PT and Stephen M. Levine, PT,
DPT, MSHA
Becoming a physical therapist
of advanced clinical or business
skill is a goal that many
have accomplished through
arduous planning, long hours,
and personal sacrifice. After
all the work involved, it
is unlikely most want to
risk it all by thinking and
plotting how to best defraud
the federal government or
a third party payer - in
fact, the vast majority of
physical therapists demonstrate
a high amount of professional
satisfaction, and go to work
each day thinking about the
positive impact they can
have on their patients and
the communities they serve.
But, this is not accomplished
without the struggles that
anyone would experience in
an environment that encourages
an increased scrutiny from
healthcare regulators and
third party insurance review
organizations. Unfortunately,
over the past decade, providers,
including physical therapists,
are working harder and spending
longer hours in the clinic
overwhelmed with paperwork
to meet the increasingly
burdensome regulatory requirements.
All of this is done while
juggling the management of
your practice, which is inevitably
facing negative impacts on
growth due to lower third
party reimbursement, higher
patient co-pays, and a depressed
economy.
On one hand, physical therapists who work in private
practice environments often
cite the reason for their preference
in providing care in this setting
is that it allows them to be
creatively in charge of providing
the highest level of clinical
care to their patients and
clients with their own unique
touch and style. But then,
there is always that pause
and the inevitable footnote
addressing the reality of needing
to keep up with the things
that must get done during each
day, every month, and always
at the end of the calendar
year to stay out of an auditor's
crosshairs. Alternatively,
therapists who work in other
settings, both outpatient and
inpatient, often get lulled
into the sense that the organization
in which they practice insulates
them from the reality of today's
volatile healthcare environment,
and falsely believe it minimizes
or eliminates their risk related
to knowing and adhering to
practice act requirements and
third party regulation. In
all settings, physical therapists
universally feel they simply
do not have to efficiently
and effectively stay current with
all the rules and regulations
related to being a healthcare
provider in 2010.
However, the consequences for not paying close
attention and developing strategies
to adhere to the rules of a
third party payment environment
have become too big to ignore,
particularly in light of passage
of the Patient Protection and
Accountable Care Act, known
most commonly as "healthcare
reform". Healthcare in general,
and physical therapy specifically,
remains a target for audit
and investigation in order
to minimize fraud, waste, and
abuse in the healthcare system,
particularly in the Medicare
and Medicaid programs. And
the recently passed healthcare
reform legislation allows for
recovered funds to be used
to assist in paying for the
identified 37 million plus
uninsured Americans who will
be covered in this reform process.
Although there may be few who are intentionally
committing Fraud, which requires
knowingly and willfully doing
something to obtain money under
false or fraudulent pretenses,
there are far more physical
therapists who fall into the
category of abuse when it comes
to their coding, billing and
practice management procedures.
Abuse is defined as "That which
may directly or indirectly result
in unnecessary
costs to the
Medicare or Medicaid program,
improper payment, or payment
for services which
fail to meet professionally
recognized standards of care,
or that are medically unnecessary.
Abuse involves payment for
items or services when there
is no legal entitlement to
that payment and the provider has not knowingly
and/or intentionally misrepresented
facts to obtain payment."
The most common area where physical therapists
may unknowingly tread is a
violation of the civil statute
known as the False Claims
Act (31 U.S.C. §3729(a)), (the Act). A healthcare provider
can be found guilty of submitting
a false claim if he/she:
- Knowingly presents, or causes to be presented, a
false or fraudulent claim for payment or approval;
- Knowingly makes, uses, or causes to be made, a false
record or statement to get a false
or fraudulent claim paid
or approved;
- Conspires to defraud the Government by getting a false claim
paid or approved; or
- Knowingly makes, uses, or causes to be made, a false
record or statement to
conceal, avoid, or decrease
an obligation to pay money or property
of the Government.
The liability under the False Claims Act is three times the loss
to the Government plus penalties
of $5,000 to $10,000 per claim,
and the stakes have become
higher in recent years as government
agencies interpret violation
of the law as an individual
who either knew or should have
known that what they were doing
was incorrect. The concepts
of "knowing" and "knowingly"
are specifically identified
in the Act as someone who:
- Has actual knowledge of the information;
- Acts in deliberate ignorance of truth or falsity of information;
or
- Acts in reckless disregard of the truth or falsity
of the information, and no
specific intent to defraud
is required.
The top five audit flags in physical therapy documentation can
be summarized as follows:
- Lack of accurate reporting of time in relationship to provision
of clinical services
- Lack of support for reported interventions requiring one
to one contact
- Lack of progress documented over episode of care
- Treatment that solely or primarily involves passive care
(including modalities) over
majority of episode of care,
and
- Lack of functional context in the documentation of evaluation,
treatment and discharge.
All of these flags can lead third party payers
to a determination of a lack
of medical necessity, which
can constitute abuse as described
above. Four out of five of
these require review of the
medical record in order to
come to this conclusion, and
review of the medical records,
often after a claim has been
processed and paid, is happening
with far greater frequency
over the past several years,
and will likely continue.
So, why would therapists trained in the McKenzie
method be at an increased risk
for negative consequences of
an audit, even in situations
where they are successful in
treating patients and achieving
significantly improved outcomes?
The answer often lies in the
language that therapists, trained
in the McKenzie approach to
patient care, use to communicate
(and document) their diagnostic
and clinical findings, which
does not easily translate to
justification of medical necessity
as required by most third
party payers.
When reviewing the McKenize classification system
and assessment forms through
the eyes of an auditor, particularly
a Medicare reviewer, it is
clear that the classifications
of dysfunction, derangement,
and postural, while helpful
to the McKenzie therapist,
do not demonstrate a connection
to functional limitations that
are a requirement under the
Medicare benefit for therapy
services. Abbreviations on
assessment forms, such as FIS,
EIS, FIL, EIL, and SGIS offer
no understandable relationship
to measurable functional limitations
through which an auditor will
evaluate progress through a
therapy episode of care.
Therapists trained in the McKenzie Method must
develop or enhance the skill
of communicating an international
classification system and resultant
treatment in a way that is
meaningful to the entity paying
the claim. In order to minimize
the risk of a negative audit
or worse, this skill is as
important to practice management
as clinical skills are in achieving
identified functional outcomes.
If documentation cannot demonstrate
medical necessity as required
under a third party payment
system, then the unsuspecting
(although clinically excellent)
therapist may find themselves
accused of abusive practices,
at best having to pay back
any money provided through
the Medicare or private payment
system, and at worst, having
to defend against accusations
of fraud and abuse!
www.FearonLevine.com
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