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  • 2015-02-February

The Catch 22 of Health Care Reform

Can private practices meet obligations under compliance and reporting requirements and still turn a profit?

By Dan Alloway

Everyone is asking this question. The new normal for physical therapists is that every time Medicare adds another rule you are forced to spend yet more time coding, checking boxes, and defending your methods of care. If that is not bad enough, the pace of these new rules seems to be accelerating.

Let’s begin with the obvious problem: Increasingly, therapists’ attention and time are dedicated to writing books for payers instead of restoring the patient’s functional deficit(s). This tilts the practice economics dangerously into the negative. Practice costs are steadily increasing as payers chip away at reimbursements, while therapist production per treatment hour is declining because of the arduous and complex documentation requirements. Meanwhile, the payers are using their computers to see if you are following those requirements. They are checking your coding and how your patients are progressing. They are tracking your outcomes. You find yourself a Catch 22—you cannot spend less time treating your patients, but you still have to find a way to document all those treatments. It probably seems like the only answer is to work at night and on the weekends, which is what you are doing.

But there is a better way out of that box: technology. Use the technology available to you. At this point, the common response is is “We are using technology!” Or “We are documenting on computers!” Yes, you are using a computer, but you are using it as a “virtual typewriter” instead of using it as an analytical tool that is capable of substantially reducing documentation time? If computers can fly airplanes and drones, we can certainly, automate G-codes, physician quality reporting system (PQRS) coding, and treatment documentation that will allow you to return to patient care, which can never be automated.

These technologies are not available everywhere, but with a little research you can find systems that will reduce therapist touch time for G-code and PQRS reporting to 30 seconds and compose your notes in the blink of an eye.

So, if this prescription for success is obvious, why is the theme of this month’s Impact magazine: “Can private practices meet obligations under compliance and reporting requirements and still turn a profit?” Why isn’t this month’s theme, “Technology and the golden era of outpatient rehabilitation?” Why have we not made that jump? There are two answers to that question.

First, technology is difficult and expensive. Many EMR companies do not have the financial strength required to play at this level. The development and testing time are extensive.

Second, a concern that technology encroaches on the therapist’s clinical judgment exists—such as “physical therapy documentation should be hard. If it were easy, anyone could do it.”

Sadly, these types of comments are coming from some of the leaders in our industry. They do not seem to understand that we need to automate the mechanics of documentation, so that therapists can cure their patients. They don’t understand that technology does not threaten clinical judgment, it enhances it.

Computers accumulate and analyze data and then organizes that data, saving a physical therapist hours of work. Forward-thinking doctors in hospitals, such as the Mayo Clinic, are all over this new approach. They understand that there is no way to fulfill their mission without maximizing the use of technology. They understand that technology is used to identify and organize evidence. They also understand that technology is used to present medical professionals with evidence-based scenarios, enabling significantly more complex analyses than are possible any other way.

As outpatient rehabilitation embraces technology instead of dropdowns with checklists, we will alleviate the burdens of complex payer reporting requirements and usher in a new era of technology-driven, evidence-based capabilities—enabling significant gains in both treatment efficiency and patient outcomes.

Dan Alloway is vice president of Development Systems4PT. He can be reached at DCA@Systems4PT.com.

Expert Advice

Creating more profitable private physical therapy practices.

By Steve Takle, BA (Hons), MA

While there are most likely as many motivations for entering the physical therapy industry as there are therapists, the majority are inspired to complete their training to provide care for others. Whether this comes from an interest in the science and technology behind modern physical therapy practices or simply an altruistic intent to do good, it seems that most privately-owned physical therapy businesses are therapy first and business second.

However, that does not mean that “business” is a dirty word. It just means that practice owners tend to be therapists, rather than entrepreneurs. It is a mindset that is practically the default of nearly all academic institutions, where the business element of owning or managing a private practice is largely disregarded.

It is this mindset that physical therapists take into their professional career. As a result, many private practices lack the tools, knowledge, and ability to maximize the potential of their businesses. Paths to this information can be costly, time consuming, and off-putting with hard-nosed business advice, which seems a world away from providing the care that inspired a person to become a physical therapist in the first place.

It was precisely with this in mind that the first COPA Practice Growth was held in London, England, in 2013. The exhibition and conference was specifically designed to offer chiropractors, osteopaths, and physical therapists industry-specific business advice and insight, along with the latest rehabilitation research and products in the sector. The event was an instant hit with the European profession and doubled in size for 2014 to become Europe’s largest medical rehabilitation exposition. This year the event will be held March 4 and 5 at the Javits Center in New York.

COPA Practice Growth is designed for the private practice owner and is a business services expo specifically created to help successfully grow the practice and skills of the practitioner. The event aims to enable you and your business to grow, providing rehabilitation practitioners with expert advice, guidance and inspiration from experienced, successful sources. You will gain the knowledge you need to propel yourself and your practice to the next level.

These seminar sessions cover the most important developments facing rehabilitation therapy, with speakers ranging from leaders in medical to business experts and professionals—confirmed to speak are Henry Hoffman, Co-founder of Saebo and Dr. William Pawluck, electromagnetic field expert.

COPA Practice Growth is committed to providing advice and education to aid your professional development. Attending the exhibition and conference will contribute toward your continuing education units.

COPA Practice Growth will coincide with Neurological Rehabilitation Therapy & Technology, Elite Sports Therapy & Medical Rehabiltation; and Animal Rehabilitation Expositions.

To register for a free ticket to the expo, visit www.copaexpo.com

Steve Takle, BA, MA, is a freelance copywriter and editorial consultant in Bristol, England. He can be reached at hello@stevetakle.com.

Finding a Better Way

Ideas

Innovation is key to creating a successful physical therapy clinic.

By Jerry Henderson, PT

“Without tradition, art is a flock of sheep without a shepherd. Without innovation, it is a corpse.” —Winston Churchill

IN CASE YOU HAVE NOT NOTICED, THE CENTERS FOR MEDICARE AND MEDICAID Services (CMS), the nation’s largest payer, have been busy. They are releasing aggressive health care reform programs at a breathtaking pace. Equally astounding are the regulatory hoops that rehabilitation practices must jump through to remain CMS compliant: continued therapy caps, manual medical reviews, functional limitation reporting, and multiple procedure payment reduction (MPPR). The list goes on.

As predicted, other commercial payers are beginning to follow suit, compounding the burden and risk. Noncompliance is not an option, but few therapists can see patients and keep an eye on every regulatory nuance without working around the clock.

Something’s gotta give.

All of the best innovations, like the discovery of electricity or the first rocket to the moon, share one thing in common: They were born out of a need to find a better way. As physical therapists, the future of our profession depends on finding a better way.

Innovate or Die

In health care, the status quo is no longer an option. The United States spends more on health care than Japan, Germany, France, China, the United Kingdom, Italy, Canada, Brazil, Spain, and Australia combined. This does not necessarily translate to better quality in return.

When the terms “Health Care Reform” and “Outcomes” started becoming popular buzzwords in the mid-90s, I predicted that reimbursement would soon be closely tied to patient outcomes.

It took much longer than I thought, but I was right. Functional limitation reporting and PQRS programs from Medicare are just the tip of the iceberg. Changes are happening continually and at an accelerating pace. Pay for performance is on the horizon.

Maintaining professional independence depends on your ability to comply with the new regulatory environment. In my view, this means fully innovating your processes, systems, and— most importantly—people.

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Innovation Tips

Trash the Policy Manual
At my first position as a staff physical therapist at a large hospital, I was asked to review the Policy and Procedure Manual for our department on my first day at work. It was full of, uh, stuff—including detailed step-by-step instructions on how to search for bombs in case of a terrorist threat.

After reviewing the manual, my supervisor asked if I had any questions. I politely told her that I was not qualified for my new position. She, of course, asked, “Why?” I answered that I was not brave enough to enlist for bomb-searching duties in the hospital.

Her response led me to believe she had not read the manual herself, so I showed her. She asked me to stay on anyway, and said that I could follow my cowardly instincts in case of a bomb threat without fear of losing my job.

You probably have an equally impressive policy and procedure manual in a three ring binder sitting somewhere in your office. You may not have opened it in years. You probably created the manual because of regulatory requirements, but you probably do not use it in your day-to-day operations.

Ditch your policy and procedure manual. Replace it with an operations guide, which articulates your practice’s critical administrative activities. Create checklists based on this guide that set expectations about specific tasks to be completed on a daily, weekly, and monthly basis.

This is different than a system that optimizes therapist workflow. This simple checklist maps out the key routine administrative tasks necessary to running a healthy compliant practice.

Think daily and weekly routine—not protocol for every situation under the sun.

Automate, Automate, Automate
Even with a good operations guide in place, it is still almost impossible to keep up with regulatory requirements without a system that automates as much of your workflow as possible.

An automated system cannot think for you, but it can provide helpful guidance. For example, establishing and documenting medical necessity requires the decision making of a trained physical therapist. A well-designed workflow software should embed processes that automatically track and alert physical therapists to tasks that they must complete to be compliant.

An automated workflow system must also be totally integrated, meaning all of the information from your clinical documentation, claims, and patient accounts lives in one place. This system integration is important because it makes sure that clinical documentation supports claims.

Integration is not enough. Your automated system must also provide instant access to the information. How can you tell if you have enough access? If you find yourself calling, emailing, walking to the front desk or billing office to access information routinely, you don’t have a good system.

Workflow automation takes the guesswork out of Medicare compliance and frees your therapists up to provide great care. They should not waste their time understanding the intricacies of the 8-minute rule and national correct coding initiative edits.

Invest in Clinical Leadership
The most refined processes and best workflow automation are useless without great clinical leadership. My tenure at Clinicient has afforded me a unique opportunity to observe the management of hundreds of physical, occupational, and speech therapy practices all over the country. These practices range from small to large and represent a wide variety of clinical specialties. The one thing that distinguishes successful, innovation-friendly practices is the quality of their clinical leadership.

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Great clinical leaders must be clinicians. The most brilliant nonclinical business strategist or accomplished business manager cannot get a group of clinicians to adopt new processes or systems. Clinical leaders must translate the “big picture” to clinical staff, which is nearly impossible to do without being a clinician yourself.

Great clinical leaders must also communicate with transparency. They should never try to shield staff from all of the “dirty details” about the decision-making process that led up to changing a system or process. Instead, their communication should be grounded in experience and at least some scientific rationale.

Great clinical leaders also know what they do not know. When it comes to introducing new processes and systems, they will seek out the advice of other business and management professionals. They will hire a knowledgeable compliance consultant when needed. They will make sure they hire the best people for their billing office and front desk. They know it is worth it to pay a little more to build a staff that can embrace innovative ideas.

Innovate for Practice Independence
I knew that I wanted to be a physical therapist at the age of 14. But after I finally became one, I was not able to provide the care my patients deserved because documentation, compliance, and general bureaucracy ate up all of my time.

In hindsight, this frustration was a blessing, because it gave me the inspiration I needed to innovate. You do not have to start your own company to help colleagues find a better way. You just have to be willing to do things differently. Investing in fresh processes, workflow automation, and good people is the first step.

Jerry Henderson, PT, is vice president of Therapist Success at Clinicient. He can be reached at jhenderson@clinicient.com.

It Is a Sign

BMPBYJ

Strengthen your image through billboard advertising.

By Deb Gulbrandson, PT, DPT

A number of years ago, my practice had to face the reality that it really had no physician referral sources left. Even though I had been the director of the local hospital and had good relationships with many physicians when I started my private practice in 1989, things gradually changed. Every orthopedic practice in our area became a physician-owned physical therapy service (POPTS), many family practice and internal medicine doctors went to work for the hospitals, and the private equity corporate physical therapy chains moved into our hometown. We could not match their schmoozing strategies in either time or money.

Although we had a great reputation, years of experience and commitment in the community, and patients who informed their doctors they wanted to see us for physical therapy, how could we let newcomers to our area know about us? Our clinic is “hidden” in a professional building, somewhat off the beaten path. One of our strategies became the billboard campaign. Using the adage that “One picture is worth a thousand words,” our aim was to be visible on a quarterly basis at various spots along an eight-mile stretch of highway. According to the county demographics, over 60,000 cars travel that road daily.

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Initially, we started with professional stock photos, which we purchased through an advertising agency. I gave the agency the concept and the pictures we wanted to use. Their staff then created the billboard artwork. I chose scenes that depicted everyday life, or experiences to which our potential patients could relate.

Emotion is a powerful attention grabber and we started with humor, using the “Got Pain?” campaign. We have since moved on to highlight what makes us different. As the only private practice around, we want people to know that the owners are onsite, willing to do what it takes to help patients.

When choosing the look of our billboard, we have learned open space is not a bad thing, especially when your reader is traveling at 45 miles an hour. We have eliminated our address and phone number, assuming all they really need is our name. They can look us up on the Internet for more information. We are also in the process of choosing a specific font and color scheme for branding purposes.

We have always brought our dog, Bailey, to work with us. She is a natural “therapy dog” and often stands by a patient who is feeling down that day. Another of our distinctions is true one-on-one therapy but in fact, sometimes our patients receive two-on-one therapy with Bailey helping out. Bailey made the billboard campaign last month.

Of course, the big question is, does it work? What is our return on investment? We track how patients hear about us. Over 70 percent are either word of mouth or as previous patients. Every so often someone actually does mention the billboard. However, many people comment that they saw our new billboard and love the photos. It tells me they notice. It is another way of keeping our company “top of mind” when someone needs therapy.

I’m convinced that there is no one way to market our services. It is the repetition and variety of places and spaces that resonate with people. And it allows us to use our creativity to show what makes us exceptional. Just wait until you see what is next!

Telerehabilitation

telehealth

Considerations for utilizing telehealth in physical therapy private practice.

By Paul J. Welk, PT, JD
February 2015

“Telehealth,” sometimes referred to in the physical therapy setting as “telerehabilitation,” is defined in the physical therapy context as “providing physical therapy via electronic communication where the physical therapist or physical therapist assistant and the patient are not in the same location.”1 Telehealth has become a frequent topic of discussion in physical therapy as providers seek to adapt and broaden the services provided to patients. In recognition of the importance of addressing telehealth issues, at its 2014 House of Delegates, the American Physical Therapy Association (APTA) passed RC 8-14, which provides in part that “it is the position of the APTA that telehealth is an appropriate model of service delivery for the profession of physical therapy when provided in a manner consistent with association positions, standards, guidelines, policies, procedures, Standards of Practice for Physical Therapy, Code of Ethics for the Physical Therapist, Standards of Ethical Conduct for the Physical Therapist Assistant, the Guide to Physical Therapist Practice, and APTA Telehealth Definitions and Guidelines; as well as federal, state, and local regulations.”2

Four key issues exist for private practices should they wish to explore implementing telehealth services.

1. State Law and Regulation. Only a limited number of states have telehealth legislation and regulation that specifically address physical therapy practice.3 These states include, among others, Alaska and Washington. By way of example as to how telehealth is regulated in the physical therapy context, Washington allows the use of telehealth in the practice of physical therapy by both physical therapists and physical therapy assistants. Among other requirements, the Washington regulations mandate that the physical therapist or physical therapy assistant identify in the record that physical therapy occurred via telehealth.4 Alaska allows for the provision of physical therapy via telehealth to patients who are located at distant sites in the state, which are not in close proximity to a physical therapist. The regulations further provide that the physical therapist must be present in the state while performing telehealth and provides that telehealth may be conducted for one-on-one consultations, including initial evaluations.5

The somewhat obvious conclusion drawn from the above information is that the majority of jurisdictions do not have specific laws or regulations governing telerehabilitation. Regardless of whether a jurisdiction has extensive regulation on telerehabilitation or none at all, providing telerehabilitation inconsistent with applicable statutes or regulations puts the licensed physical therapist at risk of regulatory action. For this reason, it is important for any practice that desires to start a telehealth program, to review applicable state laws and regulations, including applicable licensure laws, as well as any guidance available from the jurisdiction’s licensure board. In addition to understanding what qualifies as telehealth under state law and regulation, it is important to understand what may be permissible without falling within the regulatory realm of telehealth. For example, state law and regulation may expressly permit a non-face-to-face discussion between physical therapists regarding the care of one therapist’s patient.

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2. HIPAA and Privacy Compliance. To provide telehealth services in compliance with applicable state and federal privacy standards, physical therapy practices will need to consider a number of issues related to technology, privacy and security.6 These considerations may include developing policies for the provision of telehealth services and engaging appropriate professionals to assure that the platform for providing such services complies with HIPAA and other legal requirements. Practices must also assure that there are secure communication channels through which to provide the telehealth services and that, where appropriate, confidentiality and/or business associate agreements are entered into with relevant service providers. Private practitioners need only to read the daily newspaper to see the risks associated with a breach of the privacy of patients’ and customers’ personal information.

3. Professional Liability and Insurance. Prior to providing any telehealth services, practices and their providers should assure that they have adequate professional liability insurance to cover such services. Failure to secure adequate professional liability insurance coverage puts the practice and the provider at risk. Given that telehealth is a somewhat emerging issue across the national landscape, professional liability insurance products may have not yet adapted to cover telerehabilitation services. In addition to professional liability issues, practices may also wish to consider whether securing cyber liability insurance or other similar coverage is appropriate. Cyber liability is the risk posed by conducting business over the internet, over other networks, or using electronic storage technology. By way of example, a private practice may be subject to a cyber liability claim asserted by a patient whose personal information has been breached.7

4. Reimbursement. Governmental payers have differing views on the reimbursement of telehealth services. Medicare does not pay for telehealth provided by physical therapists.8 However, in the Medicaid context, 44 states reimburse for live videos and 10 states reimburse for remote patient monitoring provided by certain health care providers. Specific to telerehabilitation, the Arizona, Minnesota, and New Mexico Medicaid programs reimburse physical therapists for telehealth.9 When seeking reimbursement from private insurance companies for telehealth services, it is important to review the practice’s payer contracts to determine if telehealth services provided by physical therapists are a covered benefit. It is also important to determine the appropriate coding required by private insurers to ensure that there is a mutual agreement on the codes that may be used for services. Failure to confirm that reimbursement is available or to properly submit appropriate billing codes for telerehabilitation may result in costly audits and other related issues.

In summary, telehealth provides both unique opportunities and unique challenges to private practice physical therapists. As physical therapy providers enter into this area of practice, they must be cognizant of the issues that need to be considered to maintain compliance. 

REFERENCES

1. WAC 246-915-187 (2014).

2. See APTA 2014 House of Delegates Meeting Minutes available at www.apta.org/HOD. Accessed November 16, 2014.

3. www.apta.org/telehealth/legislationregulation Accessed November 3, 2014.

4. WAC 246-915-187 (Accessed November 3, 2014).

5. 12 Alaska Admin. Code 54.530 (Accessed November 3, 2014).

6. See www.hhs.gov/ocr/privacy/ Accessed November 20, 2014) for extensive resources related to HIPAA compliance.

7. www.filetransferglossary.com/cyber-liability Accessed November 15, 2014.

8. www.apta.org/telehealth/billingcoding. Accessed November 3, 2014.

9. www.fsbpt.org/Portals/0/Content%20Manager/PDFs/Forum/Forum-Spring2014-The_integration_of_Telehealth.pdf Accessed November 16, 2014.

Paul Welk, PT, JD, is a PPS member and an attorney with Tucker Arensberg, P.C., where he frequently advises physical therapy private practices in the areas of corporate and health care law. He can be reached at pwelk@tuckerlaw.com.

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