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.
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 22.214.171.124.
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 email@example.com.
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).
By Tannus Quatre, PT, MBA
Health care has roots in tradition and authority. Medical providers—experts in the human condition—have long been put on pedestals by those they serve out of respect and reverence for their knowledge.
While there is nothing fundamentally wrong with a relationship built on respect and admiration, some believe that the inherent imbalance of power between the provider and patient has perverted basic market influences such as customer choice, price transparency, and competition.
As consumers bear increasing financial responsibility for their care, a shift is occurring in which consumers are becoming more discriminating with regard to choice of provider. This shift is coming as a shock to many providers entrenched in the health care paradigm of yesterday.
Acknowledging this shift and responding to it with an approach to a market that views consumers not as patients (old paradigm) but rather as customers (new paradigm) will allow providers to continue to evolve our profession in a way that serves new demands as they come our way.
Tannus Quatre, PT, MBA, ATC, CSCS, lives at the intersection of physical therapy and entrepreneurship, spending his time helping physical therapists build and operate successful practices through his company, Vantage Clinical Solutions. He specializes in marketing, finance, and business planning, and authors and speaks regularly for the APTA and PPS. He can be reached at firstname.lastname@example.org.
By Paul Martin, PT, MPT, CBI, M&AMI
I have a strategy that will bring you more than 120 new patients in the upcoming year if you commit to doing it. This strategy builds “real” relationships with physicians. So often, we as physical therapists believe that we can build a relationship with physicians simply by stopping by their office or bringing them lunch. Been there, done that—those strategies are getting old. If you really want to build relationships with physicians you need to create social situations where physicians actually let their guard down and have a little fun.
Commit to a discipline of one social outing with a physician every month over the next 12 months. Take the physician to his or her favorite sporting event, concert, show, golfing, fishing, or to his or her favorite restaurant—anywhere that you can create a relaxing atmosphere and the physician will actually have fun! Consider taking your spouse and inviting the physician’s spouse. Or better yet, take one of your therapists and request that the physician bring a guest. A small group will stimulate interesting conversation. And no, do not talk about how great you are as a physical therapist. Find things in common to give you a reason to get together again, or at the very least stay in contact due to a common interest. This is true relationship building and you will get at least 10 more referrals a month from each physician. That equals 120!!
Paul Martin, PT, MPT, CBI, M&AMI president of Martin Healthcare Advisors, is a nationally recognized expert on health care business development and succession planning. As a consultant, mentor, and speaker, Paul assists business owners with building value in their companies. He has authored “The Ultimate Success Guide,” numerous industry articles and weekly Friday Morning Moments. He can be reached at email@example.com.
Mark A. Anderson, PT, is president and founder of Mountain Land Rehabilitation in Salt Lake City, Utah. He can be reached at firstname.lastname@example.org.
Mountain Land Rehabilitation includes Mountain Land Physical Therapy, Brighton Rehabilitation, Western Rehabilitation Health Network, and Mountain Land Rehabilitation Home Health with 32 outpatient clinic locations, six hospital contracts, 49 skilled nursing facility contracts, two home health agencies and 60 home health contracts, and 950 full- and part-time employees. The practice was founded 29 years ago.
Most influential person who enhanced your professional career and why: The most influential person in my professional career was my grandfather. Growing up next door to him, I spent considerable time with him as he ran his small business. He taught me not to be afraid of taking risks and to work hard. He also taught me the “Golden Rule—to always consider what is best for others as you do business with them.”
Describe the flow of your average day and when or if you still treat patients, perform management tasks, answer emails, and market: My career path has led me out of clinical practice and into various management roles within our organization. As president, my primary role is to develop and implement the organization’s strategies. I am involved in business development, market forecasting, and business relations. I am involved in state and federal government affairs, with focus on health care regulation and legislation.
Describe your essential business philosophy: Promote our vision and core values throughout the organization. I place great value on my partners, our employees, and our patients. Everything we do should assist all stakeholders to achieve their greatest potential.
What have been your best, worst, and toughest decisions? Hiring the right people for the team is the most important decision we make. Finding exceptional people who share our values and are passionate about our profession is paramount in achieving success.
How did you get your start in private practice? In 1984, I opened an outpatient practice in Park City, Utah. I practiced out of an old house with the waiting room in the front room and hydrotherapy in the kitchen. It was a lot of fun.
How do you stay ahead of the competition? I strongly believe in an abundance mentality. Over the years, I have gone to great lengths to work with and collaborate with our competition. From forming therapy networks to establishing study groups, I have never regretted building rapport. I was taught many years ago by my first physical therapist employer that having an exceptional therapist open up an office down the street is actually a positive, not a negative. High quality, ethical competition is good for everyone.
What are the benefits of PPS membership to your practice? I have been going to PPS conferences for as long as I have been practicing. I owe much of my understanding of the business side of physical therapy to my peers in the PPS. I always come away from PPS fall conference with many new pearls of wisdom. I also have gained countless friends and resources within the membership of PPS.
What is your life motto? Make work fun, and it is no longer work. One of our core values is “have fun.” I believe I am the champion of this core value.
What worries you about the future of private practice/what you are optimistic about? I am concerned that payors may lose perspective of the value and worth of physical therapy. Unscrupulous business practices and referral for profit scenarios tarnish our reputation.
I am optimistic for the growing need for physical therapy care for an aging population. We are the cost-effective alternative to promote independence and function within this population.
What new opportunities do you plan to pursue in the next year? We are building expertise in several niche areas. We believe that diversifying from third-party paid services is an important element of our future success. We also are on a quest for standardizing our outcome and electronic medical record data collection to better prepare for case rate reimbursement and affordable care organization collaboration opportunities.