By bringing innovative programs to your community, your business will continue to thrive.
By Lynn Steffes, PT, DPT
As I travel the country and have the honor of working with private practices nationwide, I hear what I refer to as “the six million dollar question:” In this ever-changing health care climate will private practices survive? I respond with a resounding “Yes!” But not without a few caveats:
Private practices must:
- Exercise the agility that is inherent to being a small business.
- Be lean and study their expenses, while controlling their overhead.
- Build and leverage relationships they have in their communities and with their patients.
- Explore opportunities to collaborate with each other to create economies of scale.
- Celebrate the cost effectiveness of their setting in a cost-conscious personal and health care economy.
- Innovate new programs to bring highly valued services to our patients, our communities, and our health care system!
The first five solutions are often already on the “radar screen of private practice owners.
So how do practices begin to embrace and meet the challenges of number 6?
We must identify the emerging trends and greatest burning needs for our population and build cost-effective (see 4) services through our practices to serve the needs of our patients and our communities (see 3). Perhaps the most burning need in health care is brain fitness!
The enhancement of cognitive health through fitness and wellness may be one of our nation’s most important priorities in the next decade. Age is the greatest risk factor for cognitive impairment and as the Baby Boomer generation passes age 65, the number of people living with cognitive impairment is expected to jump dramatically. In fact, more than 10,000 Baby Boomers are turning 65 each day. After 65, the risk of being struck by the disease doubles every five years, so almost half of people suffer from this disease by 85. What this single disease may do in the next few decades boggles the mind, resulting in nearly 10 million Baby Boomers who will die with or from Alzheimer’s and Dementia (AD). “The National Institute of Health’s research funding for AD research already low in comparison to other major diseases, some have called this one of the biggest predictable humanitarian catastrophes in the history of America.”
Cognitive impairment is a very costly disease, for patients, families and the U.S. government who anticipates spending billions on care. “The projected rise in Alzheimer’s incidence will become an enormous balloon payment for the nation—a payment that will exceed $1 trillion dollars by 2050,” warns Robert Egge, vice president for public policy for the Alzheimer’s Association. “It is clear our government must make a smart commitment in order make these costs unnecessary.”
Since research has demonstrated that prescribed exercise has the single greatest opportunity to make a difference, I believe that this is an obvious calling for our profession. Both education and exercise are key components of building an effective cognitive fitness program. As physical therapists, we know that these skills are cornerstones of our skill set. Physical therapists are highly engaged with the primary target for this service: the Silver Generation. Individuals—ages 50 to 70—whose top concerns include their future cognition as it pertains to the aging process. Strong evidence exists that the current boomer generation is concerned about cognitive health and fears Alzheimer’s disease.
“Nigel Smith, director of strategy at AARP, framed the conversation by sharing that 80 percent of the 38,000 adults over 50 surveyed in the 2010 AARP Member Opinion Survey indicated “Staying Mentally Sharp” as their top ranked interest and concern—above other important concerns such as Social Security and Medicare.”
In addition, these Baby Boomers also happen to have the highest disposable income for cash based programs. They are known as “….the wealthiest generation in history…”.
I strongly believe that this prevention and wellness strategy belongs in the physical therapy market space. This is where people can come for confidential assessment, exercise planning, and education based on the latest research available. A clinic-based program enables physical therapy clinics to implement a cost-effective and holistic approach.
I initiated development on a program named BrainyEX to honor both of my parents and my family members who have been on the difficult journey of Alzheimer’s disease and vascular dementia for over a decade; a journey that had little hopeful guidance and is both heart wrenching and frightening to travel.
The first BrainyEx pilot was highly successful in empowering participants to not only feel capable of impacting their cognitive health but showing significant changes in their lifestyle including exercise, dietary changes, sleep & stress management. The initial results were measured by Lumosity and in-clinic cognitive testing—all improved.
PT Plus in Elm Grove, Wisconsin, was our small pilot sight. Amy Snyder, MPT, DPT, and owner PT Plus, Milwaukee says, “Our practice has hosted a focus group and the pilot cognitive fitness program. Our client’s interest and enthusiasm to learn more about cognitive fitness has astounded me. I believe that brain health and wellness has been under served by the health care system. No one asks the questions or provides interventions until a problem occurs. As physical therapists we have a wonderful opportunity to reach out to or communities and empower them to make health choices that will keep both their body and mind well for years to come.”
We hope your clinic will explore brain fitness too. It is definitely a key part of answer to the six million dollar question!
Lynn Steffes, PT, DPT, is president and consultant of Steffes & Associates, a national rehabilitation consulting group focused on marketing and program development for private practices nationwide. She is an instructor in five physical therapy programs and has actively presented, consulted, and taught in 40 states. She can be reached at firstname.lastname@example.org.
Mergers, acquisitions, and other exit strategies.
By Iris Kimberg, PT, MS, OTR
Orchestrating the sale of your practice is not unlike the process of starting or growing your practice. It requires intense focus on your end goal, coordination among many professionals working on your behalf, and a firm belief in your ability to navigate the course as it unfolds. Since the sale will impact your professional and private life after the sale, you must structure it to meet your end goal.
Fifteen years after I sold my own therapy practice and 15 days after I helped a physical therapist sell his practice to an employee so he could move back to Australia, I am still in awe of how a therapy entity can be sold. After all, we cannot guarantee that a patient will walk through our doors, we cannot guarantee that a physician will make another referral, or that a therapist will stay at work. Yet, if a practice is built to last and if value is integrated into every aspect of a practice, it is an asset that commands whatever price the marketplace will bear. Anything that increases the volume or the security of future revenue will increase the value of your practice. What makes your practice valuable to you should also make it valuable to a buyer.
In the past, practice owners approaching the age of 60-plus and thinking of retiring were the most likely private practice sellers. Today there is a new face for practice sellers. These include therapists of any age who have grown their practices as far as they can and want “out;” therapists who are selling from a position of strength (for example, their practice is booming, and they want to capitalize on that); therapists who are selling from a position of weakness or desperation; and therapists who need to sell for myriad reasons, death in family, breakup, or dissolution of partnership.
Make sure you understand why you are selling so that you are clear to potential buyers. Be sure about your goal in selling and be flexible about how you might reach that goal. If the goal in selling is to secure enough money to retire: Don’t count on it, although many therapists look to recoup their initial investment and be compensated for many years of hard work and endured risk. Others want to end the burden of ownership, but continue working as a highly compensated employee. Typically, the ways to reach your overall goal of selling include an outright sale (stock or asset purchase), a structured buy in/buyout plan, or a merger with a local competitor.
To achieve your goal, you will need to assemble a team to navigate the course, yet I cannot emphasize enough how vital a role and voice you should have in the process. While everyone’s focus tends to be on the asking price, and, later on, the gap that is often between the asking price and the offered price, many other facets to any practice deal exist. Life after your practice sale needs to begin well before the ink is dry and the deal is done. How you structure the deal will impact how your life will be after the deal.
Your accountant will play a vital role in your practice sale. The strength and quality of your financial statements is a direct reflection of your practice and should include profit/loss statements/balance sheets from the past three to five years with information backed by filed tax returns. Your accountant should help you break down your clinical costs so that gross profit percentages can be determined. Prospective buyers will want an accurate aging report (AR), and projections for the current year.
Your accountant may or may not be equipped to help you with your practice valuation; if he is not, seek out a professional who is. Your accountant should discuss with you and your attorney the consequences from a tax perspective on structuring your deal as an asset or a stock sale. This is crucial and will directly impact your tax liability. Unfortunately, what is advantageous for a seller from a tax perspective may not be advantageous from the buyer’s perspective; fair negotiations are important.
There must be an open and ongoing dialogue between your attorney and accountant for structuring the purchase agreement. Your attorney should make sure you have a good nondisclosure agreement in place before you release any details to potential buyers. Your attorney should help you evaluate any letter of intent from a potential buyer, and review, revise, and sometimes create the purchase agreement. Your attorney should help craft an employment agreement (if that is part of your deal) and evaluate any non-compete clause you will undoubtedly have to sign. Sometimes lucrative employment contracts offset a less than optimal purchase price. Other times a poorly negotiated employment agreement may not compensate you adequately, especially when you may be working less or differently during the non-compete transition period.
Be realistic, be flexible, be clear about what you want for yourself, and what you want your role to be post sale. Most therapists think their practice is worth more than it actually is, so be prepared for some initial disappointment. If you plan on staying on only for a “reasonable transition period,” then who you sell to is less important. If you want to stay on post-sale as an employee, then you need a high degree of compatibility between you and the new owners. The negotiation of your employment agreement (terms, salary, etc.) becomes almost as important as the negotiation of the purchase agreement. Your non-compete clause must be reasonable in order for it to be enforceable. Carve out any nuances that you believe are important. You must always be allowed to earn a living, but there are a finite number of nonclinical, academic, or management positions in our field. Do not wait to begin exploring what is next until the day you walk out the door.
The emotional component to a practice sale is rarely addressed or discussed. Regardless of the purchase price and the joy you may envision after a sale, most owners post-sale have some degree of identity crisis. You are probably more attached to your work identity than you realize. Answering “yes” to the question: “Can this practice exist without you?” is easy. Answering “How will you exist without your practice?” may be harder. Even though you may be selling of your own accord and on your own terms, you are likely to feel a sense of loss. Who we were versus who we are today comes into play. One therapist described it best: “It is like I lost my wallet. Suddenly, I don’t have a job title, a desk, or a name plate!” Re-inventing yourself post-sale, much like growing and selling your practice, is a process. Capitalizing and leveraging the skills you have amassed over the years will assist your successful transition.
Iris Kimberg, PT, MS, OTR, is a PPS member, private practice consultant, and owner of NYtherapyguide.com. She is also on faculty at Columbia University and can be reached at email@example.com.
The right technology helps physical therapists report and document patient care accurately and efficiently.
By David McMullan, PT
Earlier this year, legislators passed HR 4302, “Protecting Access to Medicare Act of 2014,” which once again temporarily addressed the flawed Sustainable Growth Rate (SGR) formula for Medicare Physician Fee Schedule. This latest legislation brings the physical therapy industry closer to a new payment model that will offer significantly more value to patients while mitigating Medicare and insurance fraud and abuse.
Historically, the physical therapy industry has operated on a fee-for-service billing model. Because the process is subjective, there has been room for interpretation. Ongoing treatment and procedure codes are based on time, and do not consider patient improvement or how time is spent with the patient. As a result, overbilling and inaccurate coding—either intentional or accidental—are common in the physical therapy industry.
To remedy the flawed program in 2007, Medicare introduced the Physician Quality Reporting System (PQRS) to gather quantitative data on the quality of the care being provided to patients. PQRS uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals. While well intended, this voluntary program has low participation, particularly in the area of outpatient rehabilitation. Despite the bonus potential and/or penalties tied to reporting, the majority of physical therapists opt out of this program because of its onerous reporting requirements.
In 2013, Functional Limitation Reporting (FLR) was introduced, shifting the emphasis from providers to patients and patient outcomes. Similar to PQRS, FLR is a quality-reporting initiative that gathers data on patient status and outcome. While PQRS is focused on risk, the emphasis of FLR is on function (i.e., how a patient’s functional limitations have changed as a result of the therapy that they received). Unlike PQRS, FLR is mandatory; therefore, if a physical therapist does not report, he or she will not be paid.
While elements of PQRS will remain, it is apparent that the claims-based reporting option is going away and will not be an option in 2015. However, FLR appears to be the stepping-stone to the industry’s new payment model, which will focus on patient outcomes and not the amount of time physical therapists spend with each patient.
In 2016, a new payment model is expected to be introduced, which will have new evaluation codes and a more simplified coding system. Coding will follow a patient’s current medical status, how severe or involved the patient is, and the amount and intensity of treatment that is required to move a patient from their current level of function to their optimal level of function. It is anticipated that the evaluation component of this new model will mirror the physician model that utilizes evaluation management (EM) coding. Using this model, physicians bill different value codes for an evaluation based on the complexity of the patient condition and evaluation procedures required. For example, if the physical therapist performs a battery of tests and the treatment is very involved, coding is billed at a much higher-level evaluation code. However if the patient’s condition and assessment were straightforward, requiring only limited assessment tests that are problem focused, physical therapists would bill at a lower evaluation code.
The EM coding model has been around and worked in the physician world for some time. While most people realize that the current physical therapy payment model must change, providers fear that they may be paid less. While providers certainly will not be paid more under this new model for giving good care, being efficient, and obtaining good outcomes for their patients, they should not be negatively impacted by the change. In contrast, however, for those blatantly abusing the system, the new payment model will make fraud related to overbilling difficult. Providers will need to show how involved they were with the treatment, patient status from start to discharge, and demonstrate the value of care that they are providing patients—otherwise they will not be paid.
The Role of Documentation Technology
Providers may have trepidation about the new payment model, particularly if they are taking liberties when billing. For these providers the impact of these billing standards will be significant, and lead to a 15 to 20 percent decrease in revenues. Having the right tools in place will help physical therapists accurately report.
Gathering data is essential to the success of this new payment model. For the outpatient rehabilitation market, providers need a standardized outcome tool to benchmark against. Such a tool most likely will be a combination of something the patient completes, an overall sense of improvement/satisfaction with the care they were provided, and something more quantifiable on the provider’s side, such as where the patient started, how they improved, how many visits the improvement required, and the cost involved.
From a technology perspective, capturing the appropriate documentation and data elements will be essential to a provider’s success. Documentation technology will play a pivotal role in a provider’s ability to record and report the functional status of a patient at the outset of care, throughout the care model, and at the end of care.
When considering documentation technology, look for a solution that offers alerts. Providers are required to report at specific intervals—at the onset of care and then every 10 visits—or they will not be paid. In addition to alerting the physical therapist to report on FLR, the documentation system should also alert the scheduler at the front desk to the impending deadline so that they can put an additional reminder on the physical therapist’s schedule. Visual alerts and dashboard make reporting on a timely basis easier for physical therapists.
The ideal system should also assist providers with documentation. Similar to a clinical decision-support system, it should guide clinicians to the appropriate coding and billing selections. For example, built-in logic can guide providers along the way, ensuring test measures have been completed and offer code recommendations based on the type of visit and other pre-determined justifications. The system should provide clinicians with the power and guidance to bill appropriately given the amount of time spent treating patients and the intensity of the service provided in combination with current medical condition and functional status of the patient already documented within the system. The use of algorithms and logic will make documentation easier for clinicians, thus enabling them to spend more time on treating patients and less on reporting.
As the industry continues to move toward a new payment model, clinicians will likely see an expansion of the current FLR requirements. The ability to report accurately ensures claims are processed and paid efficiently. Documentation technology with built-in logic will keep you on top of these changes.
David McMullan, PT, is vice president of Product Management for SourceMedical. David has more than 20 years of outpatient rehabilitation health care experience. He can be reached at David.McMullan@sourcemed.net.
Using contemporary technology to improve clinical assessment.
By Brian Hoke, PT, DPT, SCS, CGFI
Andrew Altman, PT, MPT, ATC
David Volkringer, PT, MPT, and
Katie Johnson, PT, DPT
What is the common element in the following events: a soccer player lands a jump, a pitcher throws a ball, a long distance runner makes contact with the ground, and a golfer makes impact with the ball on the tee? They all take place in less than one second, and the movement that occurs cannot be accurately assessed with the unaided eye. The integration of video technology solves this clinical dilemma by capturing the motion and allowing the clinician to replay the motion at a much slower rate to analyze posture, joint positions, and symmetry.
Video technology has evolved greatly from the days of the first tape-based systems. Some will recall the VHS and Sony Beta technology of yesteryear, with its large recording units and cameras. The cost of the equipment was high and slow motion playback was often “fuzzy” with poor definition. Fast forward to modern technology for video capture and playback, and the user is provided with several video options that are more compact, affordable, and produce a much higher definition playback for slow motion clinical analysis.
In our physical therapy practice, we use video capture
- to analyze landing patterns that reveal a higher risk of anterior cruciate ligament (ACL) injuries
- to analyze the throwing motion in baseball
- to analyze the swing path and body positions during the golf swing
- to analyze gait patterns for walking and running
ACL Injury Risk Evaluation
In the United States alone, there are more than 200,000 ACL injuries annually. Of these, approximately 65 percent will undergo reconstructive surgery. This has consequentially created an increase in the numbers of rehabilitative cases seen in the physical therapy outpatient setting. As a result, there has been much attention toward designing a physical therapy training program that will not only result in predictably good outcomes, but also one that is able to test and predict the level of injury and or re-injury.
There have been many efforts toward determining various risk factors that lead to ACL injuries, and high valgus moments, especially with anterior tibial forces, have been determined to result in strain and increase the risk of rupture of the ACL1,2,3,4. A Drop Jump Test objectively measures the athlete’s ability to control lower limb axial alignment in the frontal plane.
To perform the video analysis, the patient jumps off a box on to the ground and then immediately jumps in to a maximum vertical jump. The camera captures the jump in four specific phases; just as the toes are touching the ground (pre-landing), the landing (deepest position), the take-off in to the maximum jump, and the maximum jump.
The knee valgus angle can also be measured to objectively document the higher risk athlete who demonstrates greater valgus angle on landing.
Clinically, we have found that the video analysis of the drop jump test is a standardized, time-efficient measurement tool that can be performed easily in a physical therapy office.
Biomechanical Throwing Analysis
High-speed video analysis can be a valuable tool to assess a baseball player’s faulty mechanics as they perform the movement of throwing.
A portable system is necessary to video at a baseball field, which can be analyzed and reviewed at your physical therapy practice with the player, coach, and parents. To perform a good quality video analysis for a baseball pitcher:
- The player should wear clothing that affords good exposure of the throwing arm, trunk, and legs. Have the player shirtless or in tight clothing so that all land marks and joints can be identified. Sliding shorts or bike shorts are useful to video the lower trunk and hips.
- Mark necessary landmarks with small retroreflective markers such as ScotchLite® Adhesive Tape. You can also use a permanent felt-tip marker.
- Film three to five pitches from three different views: second base view (behind pitcher), home plate view (front view), and open side (left handed pitcher would be from first base and a right handed pitcher would be from third base.)
During analysis, identify the biomechanical faults observed in the thrower’s motion to decrease the athlete’s risk of injury and/or improve a thrower’s performance and development of maximal pitch velocity. After reviewing your analysis with the athlete and other key individuals, such as parents, coaches, and sports agents, it is not uncommon for them to recommend the analysis to other players and coaches.
Gait Analysis for Walking and Running
During walking the foot is only on the ground for six tenths of a second, and when we run stance phase is as short as 2/10 of a second.
Integrating video into the evaluative process enables the clinician to observe the gait pattern in a frame-by-frame manner and find the exact moment in gait where the subject reaches maximal pronation. At this point we are able to use an angle tool to compare the difference between the left and right subtalar joints. As a result of the analysis, the plan of care may include strengthening for the lower limb decelerators, a footwear recommendation, or orthotic therapy. A marked difference between the left and right sides may also lead the clinician to look further up the kinetic chain to determine if there is a reason behind the difference, such as a limb length discrepancy, pelvic asymmetry, or scoliosis.
Vertical displacement of the center of mass is another predictor of running efficiency. Decreasing vertical displacement improves performance by using less energy to go up and down and spend more we have for moving forward. We use the video software to find the lowest and highest points during the subject’s gait cycle and use the calibrated line segment tool to determine the distance that the runner travelled up and down.
Video capture and playback software enables the clinician to slow down movements that are too fast for the naked eye to see and educate the athlete regarding their biomechanical faults or movement inefficiencies and identify excessive or inadequate motion that can be altered to improve performance or reduce the potential for injury.
Golf Swing Analysis
Down-The-Line Golf Swing Video Capture
Face-On Golf Swing Video Capture
Video analysis of golfers’ swings is a common practice by teaching golf professionals and on sports coverage of televised professional golf events. For the clinician, a brief analysis of a golfer’s swing can assist in detecting faults that can increase the risk of injury and also impair a golfer’s performance.
The video analysis of a golfer’s swing is typically done from two views: “face on” and “down the line.” The “face-on” view (Figure A) is done by filming facing the player as they swing. This provides useful information regarding proper weight transfer during the swing as well as lateral sway of the hips and pelvis during the swing. The second view is “down the line” (Figure B) filmed by standing behind the player facing their target. This view is extremely helpful in analyzing the golfer’s posture, swing plane, and rotation of the hip and pelvis.
What You Need to Get Started
Knee extension of trail leg leading to Reverse Pivot swing fault
Takeaway and swing path
To begin video analysis, you will need a camcorder, preferably with the ability to record in high definition, a tripod to keep the camera steady while filming, and a computer with a memory card reader or USB cable to connect the camera to load the video for analysis. For the analysis itself, you may choose from many user-friendly software packages. Some of the more commonly used programs available for purchase are Dartfish, Sports Motion Analysis, and Coach’s Eye. There are also very useful public domain programs for the clinician, such as V1 Home and Kinovea.
Capturing and printing the video frames that reveal the most useful information can be helpful and providing video images to the patient is a marketing opportunity. People love to see themselves on the video since it is a perspective that they cannot otherwise obtain, and they will often share this information with other athletes and coaches. When the patient has been referred by a physician or coach for the video analysis, make sure the referral source also gets a copy of the video images, as well as a concise summary of the significant findings.
The integration of video analysis into clinical practice can open the door to more accurate analysis of functional movements, particularly in the high velocity movements of common sports. The information obtained can assist the clinician in identifying factors that increase the risk of injury, cause the body to move into abnormal patterns of compensation, and impair optimal sports performance. From this information, corrective measures can be developed, and subsequent analysis can further assess the effectiveness of treatment interventions. In addition to providing an extremely valuable clinical tool for the clinician, this novel service can also be a new source of revenue for the clinical practice. This is particularly true in the absence of injury, where the goal is injury risk reduction and improved performance. If people in your community value this service, it can provide significant cash-based revenues.
The following are examples of four common swing faults that can be demonstrated on the video and linked to specific problems that can be addressed by a physical therapist:
Reverse Pivot: If a golfer allows the trail leg to move into knee extension during the backswing (Figure C) and subsequently fails to make proper weight transfer to their lead foot in the downswing, they will hit “off their back foot.” This can often be corrected with core stabilization of the lower trunk musculature, lower extremity postural stabilization exercises in a flexed knee position, and better proprioceptive awareness and balance ability.
Improper Swing Path: If the golfer swings the club outside the ideal swing path on the backswing, they will repeat the path on the downswing imparting a left to right sidespin to the subsequent ball flight (“slicing”). When this is observed in the video analysis, it may reflect a lack of thoracic rotation or inadequate shoulder external rotation range of the trailing shoulder.
Loss of Golf Posture: In an ideal golf swing, the golfer maintains a consistent spine angle from takeaway to impact with the ball. This creates consistency in bringing the club head back to a “square” position as the club is brought through the impact zone. When the loss of golf posture occurs, the golfer fails to maintain a stable spine angle (Figure B) during the swing, becoming more upright during the golf swing. This can be related to inadequate strength and stability in the hip and pelvis and can frequently be corrected with core stabilization exercises for the gluteals and lower abdominal musculature.
Shortened Swing Arc: A golfer’s swing arc is related to the power developed and ultimately the distance that the ball travels. When the golfer fails to bring the club back fully in the backswing there is a loss of power and distance. The video analysis provides an easy tool to observe the length of the arc of a golfer’s swing (Figure D). Tightness in the posterior shoulder of the lead arm, loss of hip internal rotation of the trail leg, and limitation of trunk rotation can all lead to a shorter backswing.
Brian Hoke, PT, DPT, SCS, CGFI, is a PPS member, co-owner of Atlantic Physical Therapy, PC, in Virginia Beach, VA, and a Titleist Certified GolfFitness Instructor. He can be reached at firstname.lastname@example.org.
Andrew Altman, PT, MPT, ATC, is co-owner of Atlantic Physical Therapy, PC. He can be reached at email@example.com.
David Volkringer, PT, MPT, OCS, is a physical therapist with Atlantic Physical Therapy, PC. He can be reached at firstname.lastname@example.org.
Katie Johnson, PT, DPT, is a physical therapist with Atlantic Physical Therapy, PC, and a former Division 1 soccer athlete. She can be reached at email@example.com.
1. Boden BP, Dean GS, Feagin JA Jr, Garrett WE Jr. Mechanisms of anterior cruciate ligament injury. Orthopedics 2000; 23: 573-8.
2. Boden BP, Torg JS, Knowles SB, Hewett TE. Video analysis of anterior cruciate ligament injury: abnormalities in hip and ankle kinematics. Am J Sports Med. 2009;37(2):252-259.
3. Ford KR, Myer GD, Hewett TE. Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exerc. 2003;35(10):1745-1750.
4. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am. J. Sports Med. 2005; 33: 492-501.
5. Zebis MK, Andersen LL, Bencke J, et al. Identification of athletes at future risk of anterior cruciate ligament ruptures by neuromuscular screening. Am. J. Sports Med. 2009; 37: 1967-73.
By Mary R. Daulong, PT, CHC, CHP
Q: Does Medicare require all outpatient therapists, billing Part B, to be enrolled in Medicare and to have a Medicare Provider Transaction Access Number (PTAN)?
A: Yes, I believe that Medicare mandates that a physical therapist be enrolled in the Federal Program when billing Part B Medicare. The rationale for my “yes” is based on the following regulations:
Therapist refers only to a qualified physical therapist, occupational therapist, or speech-language pathologist. TPP refers to therapists in private practice (qualified physical therapists, occupational therapists, and speech-language pathologists).
To qualify to bill Medicare directly as a therapist, each individual must be enrolled as a private practitioner and employed in one of the following practice types: an unincorporated solo practice, unincorporated partnership, unincorporated group practice, physician/NPP group or groups that are not professional corporations if allowed by state and local law. Physician/NPP group practices may employ TPP if state and local law permits this employee relationship.1
For purposes of this provision, a physician/NPP group, practice is defined as one or more physicians/NPPs enrolled with Medicare who may bill as one entity. For further details on issues concerning enrollment, see the provider enrollment Website at www.cms.hhs.gov/MedicareProviderSupEnroll and Pub. 100-08, Medicare Program Integrity Manual, chapter15, section 18.104.22.168.
This CMS Program Integrity Manual specifies the resources and procedures Medicare fee-for-service contractors must use to establish and maintain provider and supplier enrollment in the Medicare program. These procedures apply to carriers, fiscal intermediaries, Medicare administrative contractors, and the National Supplier Clearinghouse (NSC), unless contract specifications state otherwise.
No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each provider and supplier enroll with the appropriate Medicare fee-for-service contractor.2
Q: Is it true that Medicare is using a Fraud Prevention System (FPS) to identify aberrant billing by providers and suppliers? If so, how do I know what they consider aberrant?
A: Yes, Medicare introduced this system about three years ago, and it has been very successful. The system allows Medicare to identify atypical or aberrant billing behavior. This predictive analytic technology is used to identify the highest risk claims for fraud, waste, and abuse in real time; and it stopped, prevented, or identified $115 million in payments, resulting in an estimated $3 for every $1 spent in its very first year.
A few examples of aberrant billing that would could be identified by the FPS for therapists are:
- Redundant coding (e.g., using the same code sets for each date of service and/or for all patients regardless of their diagnosis)
- Excessive use of the therapy cap exceptions (exceeding the peer average with no evidence of co-morbidities or complexities to justify the coding behavior)
- Billing up to the therapy cap and never attesting to a therapy cap exception need
- Abnormally high units of service under one National Provider Idenitifier (NPI)
- Abnormally high billing with Advanced Beneficiary Notices (ABNs) noting “not medically necessary or statutorily non-covered services”
- Disregard of Local Coverage Determination requirements and/or restrictions
Q: I know one of the seven recommended elements of a Compliance Program is monitoring and auditing. What should I be monitoring and auditing?
A: You are very prudent to be concerned about the “monitoring and auditing” element of a Compliance Program as this is how you prove its effectiveness. Compliance Programs are dynamic and require regular monitoring to determine if a policy, procedure, or process is current and reflects present day regulations. Many practitioners use a question process which, while revealing, can be less than comprehensive. Questions such as:
- Is there a risk of internal fraud or theft?
- Is there a risk of a protected health information (PHI) breach?
- Is there a risk of hiring a person who is excluded from providing services to federal beneficiaries?
- Is there a risk of exposing an employee to Bloodborne Pathogens?
- Is there a risk of filling inaccurate or fraudulent claims?
- Is there a risk of non-compliance with federal and/or state supervisory requirements?
- Is there a risk of a patient abandonment claim?
- Is there a risk of patient and/or staff harm due to a fire in the facility?
A risk assessment is a more thorough method to monitor effectiveness. The risk assessment is often divided into regulatory categories so it can be managed in separate time frames. These categories, typically, have many subsections which identify specific requirements or risk areas associated with the regulations; the detail of this method assists in the monitoring or auditing process. An example of some regulatory categories would be:
- Fraud & Abuse
- Office of the Inspector General List of Excluded Individuals & Entities
- Payor Regulations
- Human Resources/Labor Law
Health Insurance Portability and Accountability Act (HIPAA)/Health Information Technology for Economic and Clinical Health Act (HITECH)
- Occupational Safety and Health Administration
- Americans with Disabilities Act
- State Practice Act
- Town, City & Municipality Ordinances
In addition, I recommend using a compliance calendar to provide guidance regarding the timing of required activities mandated by payers, agencies, and other regulators. The use of a compliance tracking system is, also very helpful in verifying the status of functions completed, as well as corrective action plans.
Q: What is the difference between a HIPAA security incident and a HIPAA security breach?
A: HIPAA security standards define a “security incident” as an attempted or successful access, use, disclosure, modification, or destruction of information on a system without appropriate authorization. The incident need not involve “protected health information” to qualify as a security incident, as many security incidents occur because they compromise the security of the system and are attempts to bypass security controls.
Some examples of security incidents that would be germane and/or of potential risk are:
- Shared passwords
- Unlocked screens and/or extended log-off times
- Worm, virus, and/or malware infections
- Access and/or attempts to access applications or the Internet without authorization
- Social browsing (employees/students without E-PHI access rights)
- Unauthorized software downloads (e.g., screen savers)
- Saving data to the local drive verses the server
- Unprotected laptops used in or in transit to remote sites
On the other hand, a “security breach” is any impermissible use or disclosure of PHI that is presumed to be a breach, with a subsequent requirement to provide a breach notification, unless the covered entity or business associate, as applicable, demonstrates that there is a low probability that the PHI has been compromised. Importantly, the covered entity or business associate, as applicable, has the burden of demonstrating that all notifications were provided or that an impermissible use or disclosure did not constitute a breach, and they must maintain documentation sufficient to meet that burden of proof.
In determining whether notice of a breach is required, a covered entity or business associate must consider at least the following factors:
- The nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification
- The unauthorized person who used the PHI or to whom the disclosure was made
- Whether the PHI was actually acquired or viewed
- The extent to which the risk to the PHI has been mitigated
Q: What audits that should be performed to comply with HIPAA/HITECH/Affordable Care Act Security Regulations?
A: Some of the typical security audits that you should conduct to be proactive are:
- Network or Local Drive Audits (e.g., patches and ports)
- Baseline Security Analyzer Audits (e.g., Security Update Status)
- Back Up Logs or Reports (verify reproducibility)
- Electronic Medical Records Access Audits
- Practice Management Program Access Audits
- Web Access Audits
- Company and Personal Device Password Compliance
- Remote User Security Measures (e.g., firewalls, antivirus software).
Mary R. Daulong, PT , CHC, CHP, is a PPS member and the owner of Business & Clinical Management Services, Inc., a consulting firm specializing in outpatient therapy compliance, including documentation, coding and billing, enrollment and credentialing, and Health Insurance Portability and Accountability Act and Occupational Safety and Health Administration regulation education. She is also the author of both The Private Practice Compliance Manual and The Third-Party Biller Compliance Manual. She can be reached at firstname.lastname@example.org.
1. CMS Benefits Policy Manual, Chapter 15 Section 230.4, Services Furnished by a Therapist in Private Practice (TPP),(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14).
2. CMS Program Integrity Manual, Chapter 15 Section 15.1, Introduction to Provider Enrollment, (Rev. 347, Issued: 07-15-10, Effective: 07-30-10, Implementation: 07-30-10).