What Is Your Game Plan?

Creating a successful team in your private practice.

By Jean Darling, PT, LAT

Imagine The 1992 United States men’s Olympic basketball team, nicknamed the “Dream Team;” it was the first American Olympic team to feature active National Basketball Association (NBA) players. Described by American journalists as the greatest sports team ever assembled and called by the Naismith Memorial Basketball Hall of Fame “The greatest collection of basketball talent on the planet.” This team defeated its opponents by an average of almost 44 points en route to the gold medal. What if you could assemble your Dream Team, what would it look like? If you have your top picks when it comes to basketball players would LeBron James and Stephen Curry be in your starting line up? That sounds like a great start up plan but what if your team can only practice once a week, due to being spread out geographically?

This is a problem that mid- to large-sized physical therapy companies may be presented with, but having a stellar executive team is the key to success. What makes a winning team within a company? Certainly an all for one and one for all mentality comes into play, but we must consider the overall mission statement that a business has. If a business has the following three core qualities, it can assemble a winning team of its own.

1) Hard Workers
A business needs to employ people who realize that good things come to people who put out good effort. This is a trait that will become the backbone for your business and keep you afloat in the event of a crisis or even just a down period. Hard work must be given out willingly, too, without asking constantly, “What’s in it for me?” Consistent, strong effort rarely goes unnoticed, but someone who always wants a little something extra for themselves and is looking out for only “number one” might not be the best fit as a team player.

2) Bring in Your Unique You!
Now that you have a backbone established, you can begin rounding out the team and honing in on the particular strengths each member has to offer. Diversity is what makes a business strong—not everyone can or should be the same. Embrace that. Otherwise we would have 50 CEOs in the same corporation and that would be a real disaster. Celebrate what skill sets your team members have that made them stand out from the crowd when you decided to hire them, from great writing skills to stellar negotiation tactics and focus on assignment deadlines.

3) Problems? Communication Assemble!
You have the backbone and sharp characteristics of your team players established now but even with all of these strengths going into play, there is always a challenge to address or a crisis to be prepared for and face head-on. Do not do it alone or it will overwhelm you. Know how to communicate with your team members—all of them. Whether you communicate best via email, in person, or within an organized meeting, keep communication lines open and be available to new ideas and options suggested in the process.

Last, How do you reward these individuals within your management team?
An obvious answer is to get to know your new employee well! Are they motivated by cash, bonus, or stock options in accordance with how well the company does this year? It would be an excellent fit to find someone who enjoys a modest salary and is happy with a challenging job, and those individuals do exist. Some are happy with family time and a fun culture, while others may be attracted to being part of innovation or a world changing effort.

Do not forget, once the new members of your team are on board, it is time for the truly hard part: putting your trust in them. Your gut will fight you every step of the way. You will assume your instructions are clear and misunderstandings are their fault. You will assume when you disagree that you are right and they are wrong. But you will sometimes be wrong. The key to successful executive relationships is changing what your gut tells you. Remember how you interviewed for trust? That is important because once you hire an executive team, you must let them take their responsibilities and run with them. That means agreeing with them about what their roles are, what deliverables they are responsible for and on what timeframe.

Entrepreneurship and business creation is about going for the things that are much bigger than what you could do alone. Your job is not to reach the goal; it is to build a team that will reach the goal. If you really want to reach your goals, you will need to bring on others to help. Creating a good executive team means knowing what you need them to do, finding good candidates, promoting from within, and giving them what they need to do their jobs. If you choose well, they will be successful and make you successful as well. Now you can build your Dream Team of 2016!

Jean Darling, PT, LAT, is an Impact editorial board member and vice president of Advanced Physical Therapy & Sports Medicine. She can be reached at jean@advancedptsm.com.

Dip into the Pool

Guidelines to providing excellent aquatic care

By Kelly McFarland, PT, DPT

Risk. Thrill. Heartache. Sleepless nights. Profit.

Perhaps like many of you, I come from a family of entrepreneurs. My father started his own business. As did my mother, and my brother, and my sister, and myself. We are passionate about what we do. This makes for some interesting kitchen table discussions about customer service, leadership, return on investment (ROI), return on equity (ROE), and net operating income (NOI).

Business may run in my veins, but so does another substance.


I opened my physical therapy practice with the goal of helping people heal the best way—my way—with personalized plans and individual care. I knew going into private practice would be my best shot at accomplishing this. Because of personal experience and the positive outcomes that I have witnessed, I believe in aquatic therapy as an adjunct to a patient’s care. Water soothes, relaxes, promotes movement, compresses, and—when used correctly—heals. From the beginning, I wanted to make water my “niche.” I researched many options and eventually chose to invest in a therapy pool with an underwater treadmill, resistance jets, and underwater video monitoring system. With a pool and a place to put it, I was ready to roll.

Twelve years, three clinics, and 18 employees later, aquatic therapy remains a focal point of our practice. Its mere existence in our practice draws clients to us and its effectiveness brings them—and their friends—back. Water has helped brand us as a premier clinic; expanding into new markets, and serving people with diverse conditions. Along the way we have learned a few things about how to create and maintain a high-quality aquatics program.

One Patient at a Time

Treating multiple patients in the therapy pool at the same time is possible, but at Premier, we like to specialize in individualized care as a best practice. We found patients tend to feel apprehensive when they are being treated in the pool in a small group setting. Some are not comfortable exposing their bodies “publically” in a swimsuit. They want privacy. Others may be rehabbing from a joint replacement surgery and are unsure of their body’s functionality, while others are ready for speed training. They want personalized attention. When a therapist is juggling multiple patients it cuts down the quality of care, at least in the patient’s mind. With a single-patient policy and 45-minute sessions, the maximum capacity each day for our pools is 12 patients. We average 8-12 patients per day.

Invest in the Best Product on the Market

I heard a respected attorney once answer this question from a young, soon-to-be law student. “I’m choosing between two schools. One will pay my way but the other is in the top 10. Where should I go?” His answer: “Always choose the better school. It will pay off in spades.”

I opened my first clinic in 2003 with the crowning feature being a therapy pool with underwater treadmill, resistance jets, and video monitoring system. Since the day we opened, we have strived to provide premium service, special attention, and a more personalized approach, much like a “private school” version of physical therapy. People notice that we are different. Having water helps us “niche” our practice and stand out, but having the best water and using its tools creatively conveys to our patients our dedication to innovation and quality care. Many patients seek us out simply for our aquatic tools.

Create Personalized Programs

Our patients receive individual care created specifically for their situation. Some programming inevitably overlaps, but we progress patients based on their needs for each visit.


Judy suffered from scoliosis since she was a child, undergoing various amounts of pain medication and physical therapy through the years. As she progressed through middle age, the pain and neuropathy increased dramatically. She lost function. At age 55, Judy chose lumbar spinal fusion surgery, from T9 to sacrum, totaling nearly half of her back.

Judy was presented to our clinic two and a half months postsurgery. She was unable to sit during the initial evaluation due to her pain level and limited mobility. After an initial evaluation, we moved her immediately into the pool.

We instituted a Core/Lumbar Stabilization program where we were able to focus on muscle reeducation and establishing the proper firing patterns from the core stabilizers. We also incorporated functional movements such as squats, step ups, and walking.

Judy began the walking program without the use of the resistance jets, holding the handrails 100 percent of the time. She progressed quickly. Soon she was able to walk pain-free in the pool. We increased the treadmill speed, duration of the walk, and added resistance jets.

Judy now walks pain-free on land and has increased her stride length and range of motion. She also drives, sits for longer periods of time and walks—pain free—up stairs. She feels her “spirit has been lifted” as she has regained her functional mobility that she thought might be forever lost.

Educate Others about the Value of Water

Because of some therapists’ perceptions that patients are simply “floating around in the water,” aquatic therapy sometimes gets dismissed as a nonaggressive modality. With the underwater treadmill, resistance jets, and monitoring equipment, this is not true. Many research studies show its effectiveness for advanced recovery time, return to running, exercise advancements, weight loss, and rehabilitation.

Doctors W. Matthews Silvers and Dennis Dolny conducted several conclusive hydrotherapy research experiments at the University of Idaho. In the first study, it was found that training on an underwater treadmill can create a metabolic and cardiovascular environment as stressful as traditional land-based treadmills but with reduced joint stress. In follow-up studies, positive results were also verified with factors such as maximal oxygen consumption, heart rate, ventilation, blood lactate, leg stride rate and length, and perception of effort. Each study confirmed the effectiveness and equivalent responses with aquatic fitness vs. land-based treadmills.1

Offering a low-pain and less-feared method of exercise, physical therapy can greatly enhance patients’ quality of life. In the water, there is no fear of falling. Research from the University of Utah shows that older adults who consistently exercise on an underwater treadmill improve flexibility and even sleep patterns. 2 As we educate patients, caregivers, and practitioners about the benefits of aquatic exercise, we become the “facility of choice” in the region and a valuable asset to their overall health.

Business ownership may be many things, but it is always interesting. My goal in opening a physical therapy practice was to provide the highest standard of therapy with compassion to each patient, focusing on return to function, education, and wellness. Creating and maintaining an innovative aquatics program helped me accomplish this and in so doing, brand our practice as “creative,” “premier,” and “innovative.”

Run a quick check to see what is running through your veins. I bet you’ll find some platelets, plasma, and—if you’re lucky—a little water.

Kelly McFarland, PT, DPT, is a member of the American Physical therapy Association and serves as a guest lecturer for the Texas Physical Therapy Association, HydroWorx. She founded Premier Rehab Physical Therapy in 2003. She can be reached at premierrehab@sbcglobal.net.

Hope and Opportunity

By Stacy M. Menz, PT, DPT, PCS

As I read through Sturdy’s article this month, appropriately titled, “Hope and Opportunity,” I was struck by exactly that, the hope and opportunity that our profession has. The article discusses how when we contract with employers directly to provide services to their employees, we are not only getting their employees back to work, but also we are preventing lost time from work—creating a savings on the company’s bottom line. Through these actions, we are demonstrating our value as a profession.

What I found even more compelling was that therapists are contracting with companies in ways that are innovative. One therapist is working with the ballet, while another works with a tech company. If you are in pediatrics like me, you can contract with school systems (this is the kiddo version of work). The opportunities are there if we as a profession look for them and continue to promote our own value.

Even more exciting is how we have moved beyond just getting employees back to work, we are also preventing injuries and thereby preventing days missed. And as employers ourselves, who cannot get behind the idea of keeping our employees working! What are some of the innovative ideas you and your company have supported employers by keeping their staff healthy? I can only speak from a pediatric perspective, but I know that we have begun using motor groups in the pre-schools where we work, which has cut down on the number of referrals for physical therapy overall; it has also empowered the teachers and staff on how to support their kiddos. It would be great to hear your ideas on our discussion board www.ppsapta.org.

On a different topic, we are going to start running a new column occasionally called “What’s on my Desk?” I know as a business owner, and as a person, I am always looking for new and interesting ideas for things to listen to, read, and explore. So, I am sharing four of the things that I am into at the moment. I would love to hear from other members of the private practice section with regards to what’s on your desk (or iphone, or computer, or ipad). If you want to share, please write it up and send it into me, and we will include it in one of our issues.


Mixed Emotions

By Terry C. Brown, PT, DPT

It is the weekend after returning home from the American Physical Therapy Association (APTA) NEXT conference and the House of Delegates (HOD); I have mixed emotions as to what occurred. I am a veteran of the HOD after spending 13 years as a Kentucky delegate and six years as the Private Practice Section alternate delegate. I realize this may seem paramount to a prison sentence to some of you, but I have always found it to be a fascinating process that can elicit some profound discussion, or it can be an exercise in futility. This year’s HOD was a bit of both.

Looking at it from my water bottle being half full, let’s start with the positive.

  • An excellent discussion regarding the physical therapist’s role in prevention, wellness, fitness, health promotion, and management of disease and disability will help place the profession in its rightful place at the forefront of this important movement.
  • A most substantive discussion was had on the feasibility of obtaining primary care practitioner status. The pros and cons of this status were discussed openly and debated with intelligence. Issues regarding ordering imaging and prescribing meds were argued in ways so that I found myself being swayed in both directions. In the end, the decision was made that we are indeed an integral part of the primary care team and the experts in movement disorders, and this is where our efforts should focus.
  • Good discussion also occurred on the use of health information technology and electronic medical records, which will help move APTA forward in this important area.

These types of rich debates are what make the HOD a necessary and effective body for our profession.

Now, for the other side, with my water bottle “half empty,” I bemoan the things that we as the governing body of this profession cannot seem to get over. Again, we spent an entire morning discussing the vote, or no vote, or half a vote on the physical therapist assistant (PTA): if the PTA should or should not be a chapter delegate and if the PTA should be able to be elected to the APTA board of directors. Let me preface this report by saying that I have nothing against PTAs and employ two highly qualified and stellar PTAs who enhance our practice. This is more about who sets the professional standards and directs the future rules and regulations of our profession. This act should always remain in the hands of the physical therapist. However, we as the HOD cannot say enough, or discuss enough, or rehash enough, as this subject has come back every year for the majority of my 19 HOD years.

Finally, the HOD voted to continue to not allow the section’s delegates a vote. While we have a voice in the HOD by the right to submit a Reference Committee (RC) and to speak in debates of all RC, we are not given a vote in either the House itself or in the election of APTA leaders. The HOD soundly defeated an RC submitted by the Health Policy and Administration (HPA) section—the catalyst supported by all sections.

So there you have it, my bird’s-eye view from the back of the room on the 2015 House of Delegates.


PQRS Opportunity


Last chance to stave off a penalty reduction in reimbursement.

By Nancy J. Beckley, MS, MBA, CHC

This compliance topic is in response to requests by many private practice members to understand the Physician Quality Reporting System (PQRS) and to effectively report to stave off future payment reductions. The focus is on claims-based reporting. American Physical Therapy Association (APTA) members are encouraged to visit www.apta.org/PQRS for a wealth of information about the PQRS program including reporting requirements.

Q: My Medicare reimbursement this year is being reduced for each code that I bill. When I called my Medicare Administrative Contractor to inquire about this reduction, I was told that it was related to nonparticipation in the PQRS program in 2013. Is there any way that I can stop this payment cut?

A: Late in 2014, the Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality sent letters to eligible professionals who did not participate in the 2013 PQRS program indicating the criteria to avoid the 2015 PQRS payment adjustment. The letter further explained: “CMS will reduce all Medicare Physician Fee Schedule (MPFS) payments for services rendered January 1, 2015 through December 31, 2015 and billed using this Tax Identification Number/National Provider Identifier (TIN/NPI) combination by 1.5 percent.”

CMS alerted providers to the reality of payment reductions for nonperformance throughout 2013 and, in fact, implemented a provision that if one code for one patient was successfully reported a provider could stave off the 2013 1.5 percent reduction to Medicare reimbursements.

Q: Is participation in PQRS voluntary? If it is voluntary why is there a penalty for not participating? Can you clarify the rules regarding participation?

A: Participation is voluntary; however, the penalties are now in effect and are increasing. Some providers elected, for a variety of reasons, to not participate in 2013 and 2014, weighing the loss of Medicare reimbursement against the cost of participation. The 1.5 percent payment reduction this year is based on 2013 performance. Providers not participating, or not successfully participating, in 2014 will receive a 2 percent payment reduction in 2016. If an eligible provider does not successfully participate in 2015, a 2 percent payment reduction will be applied in 2017. During the early years of PQRS (originally called Physician Quality Reporting Initiative [PQRI]), a bonus was offered for those who successfully participated.

Q: Is there still time to participate in PQRS in 2015 and if so how does a private practice get started?

A: There is a last chance opportunity to begin participation in PQRS this year in order to prevent the 2 percent penalty in 2017. Time is short and participation will need to be monitored closely for accuracy. Each individual provider will need to report all 6 claims measures on 50 percent or more of all of eligible Medicare patients for the 2015 calendar year. Given a late start it is likely that measures will need to be reported for 100 percent of Medicare patients. The APTA has resources to assist a provider new to PQRS at www.apta.org/PQRS.

Providers can start by using claims-based reporting, which is free. There is also an option to report via registry. Several therapy-based registries exist, including those that are associated with specific electronic medical record (EMR) programs. The 2015 listing of registries through which therapy providers may report can be found at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2015_Qualified_Registries.pdf.

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Q: What are the reporting requirements for PQRS claims-based reporting?

A: Measures required for physical therapy claims-based reporting in 2015 are noted in the table below. Additionally APTA has provided content on both claims-based reporting and registry reporting that should be used as a guide when initiating PQRS reporting to ensure compliance. APTA also provides helpful data collection sheets for each measure.

Q: If a clinic is getting a late start to PQRS, how can they ensure that they are meeting the reporting requirements?

A: Providers should visit the QualityNet website to register for an account. QualityNet also provides a Help Desk for providers. QualityNet can be accessed at: www.qualitynet.org/portal/server.pt/community/pqri_home/212.

Q: I plan to leave my current private practice at the end of June and in this practice we are not participating in PQRS. I am going to another private practice in the same town that does participate in PQRS, and they are concerned because I did not previously participate that I might affect their results and ultimately their reimbursement. My new practice wants to ensure that they do not receive a payment reduction for my therapy billings.

A: There is good news for your new practice. Participation in PQRS is tied to both the individual provider (physical therapist) number and the practice TIN. So your participation at your previous practice linked your NPI number with that practice’s TIN. When you move to your new practice your participation will be measured for that practice, and will not take into consideration participation (or nonparticipation) with your previous practice.

Q: Can you explain the difference between PQRS and functional limitation reporting (FLR)? Are they using the same G codes?

A: The PQRS program as well as functional limitation reporting both use “G codes,” which often is the source of confusion among providers. (Not all PQRS reporting is represented with a “G code,” but all functional limitation category selections for current function, goal function, and discharge function are “G codes”). PQRS Quality Data Codes (QDCs) coding is unique to each measure and the measure specifications for use of the codes is contained in each measure’s description.

Functional limitation reporting, often referred to as claims-based outcome reporting, is required for all providers billing the Medicare Part B program for therapy services. Only providers enrolled in Medicare as a “supplier,” such as a physical therapist in private practice, can participate in the PQRS program at this time in large part due to the ability to report based on individual therapist NPI numbers. Therapists working in hospitals, skilled facilities, rehab agencies, Comprehensive Outpatient Rehabilitation Facilities (CORFs), and home health agencies do not bill under their provider number, but rather the facility number and bill using the UB04 claim form. Private practices (a Medicare “supplier”) bill using their own provider number even if benefits have been assigned to a group practice on the CMS 1500 claim form. 


Nancy J. Beckley, MS, MBA, CHC, is certified in health care compliance by the Compliance Certification Board and is a frequent speaker and author on outpatient therapy compliance topics. She advises practices on compliance plan development and audit response. Questions and comments can be directed to nancy@nancybeckley.com.

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