Keep your money in your pocket—avoid fines for noncompliance

Reenie Kavalar, PT

Welcome to Health Insurance Portability and Accountability Act of 1996 (HIPAA) 101. Since then a number of new HIPAA regulations have been instituted. This is a set of rules that has to be followed by doctors, hospitals, and health care providers to help ensure that all medical records, medical billing, and patient accounts meet certain standards with regard to documentation, handling, and privacy. This set of rules has changed the practice standards for physical therapists and will continue to do so as we enter 2015. HIPAA rules are broken down into Privacy, Security, Transactions, Identifiers, and Enforcement Rules.

I will focus on the Enforcement Rules, as outlined in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of Jan 2009, as they will directly affect us. The most recent modification to HIPAA and HITECH both went into effect in early March 2013 (HIPAA Omnibus Rule) with all changes required to be in place by September 2013. It can be argued that the HIPAA Omnibus Rule is neither a tweak nor sweeping reform. Far too much law is included in the HIPAA Omnibus Rule for it to be characterized as the former. It also cannot be characterized as the latter. However, the HITECH Act was sweeping and, for the most part, the Omnibus Rule is simply HITECH-izing the HIPPA rules. In order to give you information that can be condensed into a usable format, I will highlight a few points:

  1. HI-TECH Act mandated changes are now codified in final rules.
  2. Most recent HIPAA provisions directly apply to Business Associates (BA’s) of recent Covered Entities (CEs).
  3. Business Associate was re-defined.
  4. The Breach Notification method for conducting a breach analysis was revised.
  5. Consumer-oriented rights impact CEs, such as the right to electronic copy of medical record, sale, marketing, and fundraising restrictions, and the right to restrict disclosures.

With the United States Department of Health and Human Services (HHS) Office for Civil Rights expected to begin random audits in 2015, covered entities should take another look at the expanded penalties for privacy and security violations under the updated HIPAA Omnibus Rule. Of particular concern is the issue of audited or investigated organizations having done little or nothing to become HIPAA compliant, such as failing to be able to produce policies and procedures that govern a compliance program or not being aware of the need for compliance. The increased fines under the Omnibus Rule cover four areas of neglect: did not know ($100 to $50,000), reasonable cause ($1,000 to $50,000), willful neglect corrected ($10,000 to $50,000), and willful neglect not corrected ($50,000). However, fines can be assessed for multiple violations under any of these categories with a maximum fine of up to $1.5 million per violation per year.

In a presentation given by Gartner Security and Risk Management with Wes Rishel and Paul Proctor, a focus was placed on educating individuals on the broad nature of the regulation and how enterprises have wiggle room. Gartner reported that practices should not use HIPAA as a checklist but use this regulation as a starting point to determine what they can and cannot do. Once organizations understand how little HIPAA actually requires, they can do a better job of assessing what data really needs to be protected and go about protecting it.

According to Proctor, organizations should focus their efforts on performing a thorough HIPAA Risk Assessment, which clearly shows how security controls that have been put in place reduce the threat of scenarios deemed most likely to occur. Above all else, organizations need to provide details that demonstrate that thought and care have gone into their security programs in order to protect HIPAA related data. “Documenting your decisions is in the [HITECH final] rule,” he says. “You can not just make it up on the fly.” For our practice to comply with recent rules and regulations and keep our money in our pocket, make sure you are staying up to date with changes affecting your bottom line. For more information, you can access www.apta.org/hipaa.

The Dos and Don’ts of Wellness Programs for Your Medicare Patients

Keep your money in your pocket—avoid fines for noncompliance

Mitchel Kaye, PT and Joyce Klee, PT

With millions of aging Baby Boomers eager to remain vibrant and healthy for as long as possible, fitness and wellness programs for Medicare recipients have become one of the nation’s hottest trends. Not only do such programs meet an important need in a population that considers 65 the new 45, but they also have been proven to reduce health care costs associated with both chronic conditions and the common aches and pains of aging.

Physical therapists (PTs) in private practice are tapping into this demand with innovative and increasingly popular services such as wellness and prevention programs. For many PTs, however, the challenge lies not in promoting wellness, but in knowing how and when to transition Medicare patients who have been receiving medical care into a practice’s wellness program. Knowing when and how to make this shift can mean the difference between a successful transition and failure to capture that client. The following are key factors to consider when transitioning Medicare patients to wellness programs.

What is the difference between Medicare treatment and a wellness program?
The single most important step to make when transitioning patients from Medicare into a wellness program is to ensure a clear delineation between the clinical physical therapy programs offered by a practice and its wellness programs. That distinction begins with a clear definition. Physical therapy uses interventions designed to return patients to a meaningful functional level caused by injuries, age, illness, or birth defects. Wellness, on the other hand, promotes or maintains physical fitness and mobility, but does not treat or correct a medical condition.

When transitioning from physical therapy to wellness, it is important to ensure that patients recognize those differences and what it means to them. A patient needs to understand the transition from treatment with a licensed physical therapist to a wellness program where he or she may not be supervised or evaluated by a therapist; however, they will receive other benefits such as: education and assistance in using exercise equipment, the ability to participate in group exercise and other support from a trainer or other appropriate staff at the practice.

It is helpful to patients (and to your practice in avoiding confusion down the road) to provide written materials about the transition and what they can expect going forward through participating in your wellness program.

What criteria are used when converting a patient from treatment to wellness?
The transition decision must follow regulatory guidelines, as well as your own knowledge of a patient’s health status. The Center for Medicare and Medicaid Services (CMS) is quite clear that once a patient has completed therapy and is no longer medically in need of care, he or she must be discharged from treatment. At that point, the patient’s therapy services will not be reimbursed by Medicare and may be a candidate for a wellness program.

There are wide ranges of patients who no longer require Medicare-covered therapy that could benefit from wellness and fitness programs. Examples include:

  • Individuals who need to improve or maintain general strength, conditioning, and flexibility.
  • A patient who has reached the physical therapy goals and is motivated and interested in pursuing exercise on their own.
  • A patient who has reached a plateau in physical therapy and further visits cannot be justified.
  • A patient whose insurance benefits are exhausted before reaching the desired level of physical improvement, but who is ready and willing to continue with independent exercise on a cash basis.

What if a patient needs additional care, but the Medicare cap is met?
When considering a wellness option for patients, it is important to keep in mind that Medicare pays for medically necessary care. When a patient reaches the Medicare cap ($1,920), therapy does not need to be discontinued if additional care is warranted. By adding a KX modifier to the claim, you are indicating that therapy is medically necessary and the patient can continue treatment. Physical therapists often become concerned, however, as patients near the $3,700 Medicare threshold, because this requires a manual review of charts and puts the therapist at risk for the cost of treatment if the claim is denied.

Despite the many benefits of wellness programs for seniors, it is critical to keep in mind that they are not a workaround for the therapy cap. CMS watches for claims trends, especially when they see patients being discharged when they approach the cap, and then restarted when there is a new benefit period. It is a red flag to CMS examiners when a patient requires treatment one day but does not require it the next day when the cap is reached.

How does one determine when a patient reaches the point where he or she could be converted into a wellness program?
While Medicare is very clear, most states yet codified their rules for when a physical therapy practice transitions from being a provider of therapy to a source for wellness programs. Therefore, internal written policies must be in place identifying when and how to convert a patient from one service to another to protect your practice. Such policies will vary by your practice parameters and goals, but at a minimum should include guidance on patients appropriate for wellness, such as those with ongoing functional needs, as well as instructions and guidance on how to broach the subject of ongoing wellness programs with patients. The policies should be communicated to staff, monitored, and updated frequently, so if decisions are questioned, there is a written document to substantiate them. You should also document in the patient record the rationale for moving the patient to a wellness program. Be sure to continuously monitor professional associations, your state licensing board, and other regulators to determine if additional policy changes are needed.

What ethical issues should be considered? Recently there was a case where a practice discharged patients from Medicare before the cap was met, referred them to their own gym, but continued billing Medicare for services. While this case received considerable attention, for most therapists misunderstanding the regulations is more likely than willful misconduct. For example, when a patient meets the therapy cap, a well-intentioned therapist may simply tell the patient that treatment can be continued using much of the same equipment, but under a wellness program. Many ethical dilemmas can be avoided by not making decisions based on the economic interest of the practice or convenience. It is also important that wellness programs be offered in a manner that highlights the benefits to patients, but also stresses that participation is their choice with no negative consequences if they should decline. Assure the patient that even if he or she opts not to participate, you will continue to provide care should they need physical therapy treatment again in the future.

Make sure patients understand when they transition to wellness they are no longer patients of the physical therapists with one-to-one therapy. Wellness programs are provided by trained staff who will assist them, but they will not provide therapy. Again, written materials are helpful in outlining the differences between physical therapy and wellness programs.

What type of documentation should be recorded, by whom, and how often for the participants in a wellness program?
As a professional courtesy, the physician who referred the patient to therapy should be informed if you plan to recommend an ongoing wellness program. Be sure to check with the physician for updates on any physical conditions that could affect the patient’s participation in the wellness plan. In addition, the patient’s therapist should provide wellness staff a referral sheet that outlines recommendations for the patient’s exercise program, activities, or equipment to avoid, and precautions. If appropriate, a copy of the most recent exercise log from physical therapy should also be provided to the wellness staff. The wellness instructor should also document in the chart any significant medical issues that the client may have, so that information is available to any staff member who interacts with the client. Staff should check in with clients after months 1, 3, and 6 and at year-end to discuss their progress, give advice on their exercise program, and consider establishing new goals. Staff should also observe clients on an ongoing basis to ensure they are using equipment correctly and in a safe manner.

Doing well with wellness
While more needs to be done to provide therapists with clear guidelines for transitioning patients to wellness, the uncertainty should not lead to analysis paralysis. Patients have much to gain from wellness, and practices can improve their bottom lines, gain important sources of revenue, and expand their referral base. The keys are to obtain as much knowledge as you can about existing regulations, be clear with your patients about the transition from physical therapy to wellness, and ensure your wellness instructors provide the same level of commitment and quality as therapists on the physical therapy side of the practice. When these steps are taken, you and your patients will do well with wellness.

The Pros and Cons of Wellness

As with any program, there are issues to consider with wellness programs for your Medicare population . For example, building new programs may require capital expenditures for equipment as well as ongoing maintenance costs. In addition, depending on the education, credentialing, and skill level of staff hired, staffing costs may increase. However, the potential benefits of such programs often far outweigh such concerns. A well-thought out wellness program can:

  • Provide an excellent exercise option for patients who would otherwise do nothing after discharge.
  • Expand revenue-building opportunities by generating a revenue stream from cash-paying patients.
  • Create opportunities for positive communications with referral sources, which builds awareness and appreciation within your local medical community.
  • Facilitate continued contact with patients, enabling better monitoring of health and well-being status and further goodwill among patients.
  • Enhance community reputation and brand as the “go-to” provider for the entire spectrum of wellness and function.
  • Bring new potential clients to your practice as patients and family members of those in the wellness program become more familiar with your program.

Mitchel Kaye, PT, is a PPS member and director of quality assurance at PTPN. He can be reached at mkaye@ptpn.com.

Joyce Klee, PT, is a PPS member and co-owner of Clinton Physical Therapy Center in Clinton, TN. She can be reached at jskkjl@aol.com.

Smooth Flow


Managing the payment cycle well is a key component of a successful practice.

By Charles R Felder, PT, DPT, SCS, MBA

Payers are getting more aggressive about delaying, denying, reducing, and even refusing payment while requiring more administrative burdens. They have shifted much of their cost to the provider.

This allows them to keep the payments low, keep the premium money in hand longer, and earn higher profits.

We have to be more aggressive about our approach to the payers. They may seem to be in control, but you have the relationship with the patient, and the patient has the relationship with the payer. Use the patient to assist in getting the payer to act responsibly.

Change Makers


Work toward creating a healthier society by promoting wellness.

By Jean Darling, PT, LAT

As changes take place in the health care system, the science of medicine and the art of healing continue to strike a balance. Our profession needs to participate by taking on the role of wellness professionals. We must be innovative in our approach to wellness as we position ourselves for the future of health care. We have all the tools necessary to succeed, and we need to practice them by being the conductors of healthy lifestyles in our communities.

At the World Economic Forum this year, the focus was on a new and rather upbeat topic: the need for countries to invest in health to achieve long-term economic growth. “The time is right to elevate the conversation on health,” said Robert Greenhill, the managing director and chief business office of the forum. “This year, there is a sense that the global economy is out of intensive care and embarking on rehabilitation. As we ask how, metaphorically, to improve the economy’s health, literally improving the population’s health is a good place to start.”

Aging Population


Creating and growing a successful geriatric physical therapy practice.

By Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST

The decision to open a physical therapy practice with a primary focus on geriatrics cannot be made based only on market research, brainstorming, or simply to replicate another successful niche practice model. A geriatric practice that is created and successfully grown is built on a combination of practical knowledge and focus.

Geriatric rehabilitation requires patience and know-how that are somewhat different than what is required of other outpatient physical therapy practices. Helping someone who is elderly and debilitated stick with what can be a long process of functional rehabilitation takes a great deal of clinical and motivational skill. It also requires a different perspective and knowledge of the business of outpatient rehabilitation.

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