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  • 2015-11-November

What Is the New Normal?

By Terry C. Brown, PT, DPT

As I sit down to write this letter, we are approaching the Private Practice Section (PPS) Annual Conference and I am looking back at the first year of my tenure as PPS president. The word that strikes me is “change” and it is all around us. Nothing is static. Payment models are changing: ICD-9 is now ICD-10. Practices are consolidating. Insurance companies are merging. Quality research proving the efficacy of physical therapy is being published. New models of practice are emerging that challenge the status quo. Education models are evolving. PPS has a new executive director and a new president.

Change is all around us. Maybe it is time we acknowledge that change is the new normal. I have seen the word transformed used when speaking of our profession’s objectives, but this word implies an end point or a goal to be reached. I believe evolution is what we are seeing, and it is constant. As a profession, we can evolve or we can try to hold the ground that we have had in the past. Evolution will require that we move out of our comfort zone and reach out to achieve new and challenging goals. The growth and progress necessary to achieve our goals is best accomplished together with PPS being the conduit to success.

I am proud of PPS and all of our members who are leading the evolution of our profession. We are at the forefront of many changes and will be fighting to gain access in others. By attending the PPS annual conference you will be exposed to many of the initiatives that are ongoing within the section. If you were unable, to be there then please read the annual report and see for yourself the evolution that is occurring. Change is constant, how we respond to it is critical. PPS is evolving right alongside the industry, and we will continue to advance our members’ ability to provide quality care to their clients.


Make the Referral Process Easy

By Paul Martin, PT, MPT, CBI, M&AMI

If you are a company that makes regular contact with your referring physicians, consider a new strategy. As opposed to simply telling the physician why your services are so much better, or that you deliver higher quality over your competitors, why not lead with some questions? In our experience, physicians hear pretty much the same thing from every provider, and the majority of physicians do not see a considerable difference in quality from one provider to the next.

So why not have your marketing person or practice liaison lead with some great questions with the goal of finding out what could distinguish your practice from the rest of the providers in your market? While there are a number of questions to ask, how about, “What can we do to make the referral process easier for you and your office?” And then listen, respond, and deliver!


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 pmartin@martinhealthcareadvisors.com.

Private Practices and Rehabilitation Agencies, CMS Requirements – Table Data

Private Practice
Rehabilitation Agency
Condition Y/N Comment Y/N Comment
Clinical Record Audits ? Not mandated, but auditing would be considered a proactive fraud and abuse prevention activity Yes Required in the Conditions of Participation (C of P)
Employee Safety & Emergency Education and Training Yes OSHA’s 29 CFR 1910 Yes C of P & OSHA
Infection Control/Bloodborne Pathogens (BBP) Policies/Procedures Yes OSHA/Bloodborne Pathogens Standard Yes C of P & OSHA
Hazard Protection Yes OSHA/Hazard Communication Standard Yes C of P & OSHA
Patient Safety Yes OSHA Yes C of P & OSHA
Environment & Equipment Preventive Maintenance Yes OSHA Yes C of P & OSHA
Personnel Policies ? Proactive for workers compensation (WC) and professional liability risk management and avoidance of “negligent hiring and retention” lawsuits Yes C of P
Patient Care Policies ? Professional ethics, practice acts, and professional liability risk management Yes C of P
Independent Agent/Staffing Yes Contractual terms required Yes C of P
Patient Record Management & Retention Yes Health Insurance Portability and Accountability Act (HIPAA) Yes C of P< & HIPAA
Payment-Billing Variances
Physician Fee Schedule Yes Yes
Billing on CMS 1500 Form Yes Physical Therapist (PT) and Practice’s National Provider Identifier (NPI) No
Billing on CMS UB-04 No Yes RA’s NPI
Billing Frequency Limitations No Daily or To Be Determined Yes Monthly
Coding & Reporting
Use of Correct Coding Initiative (CCI) Edit (59) Yes Yes
Use of Advance Beneficiary Notice (ABN) Yes Yes
Application of Therapy Cap (KX) Yes Yes
Reporting of Functional Limitations Yes Yes
Reporting of Physician Quality Reporting Scale (PQRS) Measures Yes No UB-04 limitation
Enrollment Variances
Enrollment is required for each therapist who treats Medicare patients Yes Claims have to be held until the therapist receives a Medicare Number (PTAN) No Therapists have no individual screening or enrollment requirements
State Agency Survey Required No Yes After the CMS enrollment application has been approved, the state agency or an accrediting organization must perform an in-depth physical plant and provider compliance survey based on the Conditions of Participation for the RA. There are fees for the survey as well as annual fees based on full-time equivalents (FTEs). There are multiple approval and review levels; time from beginning to end varies from 90-160 days
Therapists Application Forms: CMS 855i, 855r & sometimes the CMS 460 Yes No
Practice Application Forms: 855b, CMS 460, EFT 588 Yes Yes 855a & EFT 588
Enrollment/Revalidation Application Fees No Yes ~$500
Revalidation Applications: Practice & therapists Yes Both the practice and the therapists Yes Practice (RA) only
Certified Institutional Provider No Yes Only RA
Enrolled Supplier Yes Both the practice and the therapists Yes
Reassignment requirements (the PT has the option to grant the practice the right to receive payment for his/her services) Yes Both the practice and the therapists No The RA is automatically the billing entity; no reassignment is necessary
Therapist must have an NPI (national provider identification number) for billing purposes Yes Both the practice and the therapists No Only the RA is required to have an NPI and all charges are billed under the RA NPI
Practice/therapist participation (assignment from patient) Yes The therapist/practice may elect to accept patient assignment No RA must accept patient assignments
Site Survey related to Medicare enrollment/revalidation, practice site change, or the addition of a new therapist Yes This is a “proof” of existence survey; it is not an in-depth survey of charts, conditions, or compliance No RA is in the low-risk category but is subject to the State Agency Survey (see above)
Miscellaneous Variances
General supervision of a physical therapist assistant No Onsite supervision is required in the private practice setting Yes Unless state law is more stringent, Physical Therapy Assistants (PTAs) do not have to have onsite supervision
Two Person Duty Requirement No Yes Two individuals present during patient treatment
Facility Administrator No Private practices do not have to designate an administrator but some states do require that they designate a “charge therapist” Yes Yes RA is required to have a full-time administrator; this person needs to be qualified but does not have to be a physical therapist
Services can be provided in the patient’s home, Part B Skilled Nursing Facilities/Nursing Facilities, Assisted Living Facilities (SNF, NFs, ALFs) and Independent Living Facilities Yes Yes
Practice Site Change or Addition No The private practice must submit a practice site relocation, termination, or addition notification, via the 855b or 855i, within 30 days of the change but it is not typically subject to approval Yes When an existing RA intends to move its primary site or if it intends to move any of its approved extension locations to a new practice location or it desires to add a new practice location, it must first notify CMS within 90 days of the expected move or addition and seek approval from Medicare’s Regional Office before it can bill Medicare for covered services from the new address
Thirty-mile radius limitation for additional practice sites No Yes This only applies to RA if it relates to an extension site
Physical therapy or speech therapy (ST) must be provided at each practice site. Occupational Therapy (OT) cannot be the only service provided No Yes
Aquatic therapy provided in a community pool No The agreement with the community pool must indicate separate space but the pool does not need to be closed to the public Yes The pool must be closed to the public
Policies & Procedures Yes As a health care provider, the following are minimally required:
  • OSHA
  • ADA
Yes RA must have policies and procedures in place in order to comply with the Conditions of Participation as well as those mentioned for PTPP

Perfect Balance

Creating value strategies either increases revenue or decreases your expenses.

Dr. Laurence N. Benz, PT, DPT, OCS, MAPP, and Dr. Rob Wainner, PT, PhD, DPT, FAAOMPT, ACC

One of the first principles that we teach in strategy is that value-creating strategies have to either increase your revenue or decrease your expenses. In essence, the value focus must translate at some point to your bottom line. Therefore, if you collect outcomes in your practice, then they should translate to your overall bottom line. However, the way clinical outcomes best translate to your bottom line is not how you might expect.

In our experience, practice owners are often frustrated because they do not see an immediate and direct impact of outcomes on their financial results. Here, I will look at clinical outcomes from a holistic perspective—one that we think will deepen your appreciation for how clinical outcomes play a role in creating a value strategy as well as a source for financial gain.

By an old school definition, we were taught many years ago that outcomes can be measured in terms of clinical (functional) or patient satisfaction, loyalty, and experience. When clinical outcomes are discussed as part of a strategy, most clinicians and clinic owners confine their perspective to third-party systems that collect traditional outcomes and then aggregated and eventually result in summary reports and searchable databases.

We have been encouraged that unless our practices collect functional outcomes, we will not be in the game with payers and our data must be our talking points. In fact, the American Physical Therapy Association (APTA) and specialty firms have made strategic initiatives to enter in the repository and reporting business using proprietary and other means that allow for providers to submit data and for consolidations, analysis, and summary. More recently, the mandated Physician Quality Reporting System (PQRS) caused a real tipping point and an opportunity for these approved registries to combine clinical outcomes with required Centers for Medicare and Medicaid Services (CMS) reporting.

But where are the “goods” to support the focus on clinical outcomes and pay for performance (P4P) initiatives? Are payers moved in a way that matters when we present our outcomes to them in an effort to substantiate our clinical efficacy? There is minimal evidence that any of our third-party produced outcomes have ever been used to obtain anything other than standard form contracts. Has any of this helped produce revenues or gains in one’s financials? Despite the lack of evidence, the pressure and emphasis continues.

For years our practice has systematically collected and reported traditional clinical outcomes using an outcomes database system (there are plenty of acceptable systems out there), as well as non-traditional measures using CARE (Compassion and Relational Empathy questionnaire) along with patient loyalty scores. But are clinical or functional outcomes enough? We do not believe so, simply because there can be assumptions surrounding their conclusions. Adding patient loyalty or a measure like CARE can be great additions simply because they are drivers of intrinsic motivators around areas that physical therapists (PTs) value: empathy, compassion, positivity, listening, and letting the patient tell their story and set their own goals.1 The CARE measure even allows each PT, clinic, or company to see how they rate versus a standardized database of more than 5,000 physios in Scotland!

At the same time, we have used a simple financial metric related to the return we get from our outcomes: “return on quality.” Return on quality (ROQ) is the actual cost of collecting, analyzing, and training incurred from quality initiatives and determine whether our resulting incremental revenues are worth the cost. When looked at from that perspective, an easy conclusion would be they have not. The trouble with looking at ROQ is that it only looks at direct expenses and revenues and does not take into account the most significant factors related to indirect costs in our business: the well-being, productivity, and retention of our therapists.

A natural question would be “how do outcomes affect these significant, indirect cost-related factors?” The simple answer is internal motivation. While the concept is simple, Dan Pink, author of Drive The surprising truth about what motivates us, has done an excellent job helping us identify the essential elements of internal motivation as they relate to meaningful work: autonomy, mastery, and purpose (A.M.P). The question then becomes how to leverage these three elements in an intentional way in order to build internal motivation.2

When considered in the context of A.M.P., one can see where focusing on and measuring outcomes is a nearly perfect fit in a practice like ours, where clinical excellence is a cultural pillar. Our therapists are able to exercise a high degree of autonomy in managing their patients. We also heavily support their pursuit of clinical mastery with certification, residency, and fellowship training in terms of time and tuition. Both of these elements are undergirded by a higher sense of serving and purpose. What we have found is that outcomes are a linking element that helps practically integrate all three elements of A.M.P by providing our therapists a standard to aim for and a mark to measure themselves by. Said differently, by setting a bar you can measure your growth by, as well as compare yourself to others is an essential element to facilitate and sustain internal motivation.

If we dropped our third party outcome tools, what would be the unintended consequences? First, we would lose a significant part of what attracts physical therapists to our company in the first place: a model that incorporates clinical excellence, service excellence, and care and compassion excellence. This in turn would severely affect our ability to provide our therapists with credentialed post-graduate training programs at our current level of scale. Without the ability for our therapists to measure their individual performance and we our corporate performance, we lose accountability and the ability to aim for an evidence-based standard. Taken collectively, the total loss is greater than the sum of the individual parts. The result is that we experience the most damaging loss of all: a significant loss of internal motivation in our therapists.

At the end of the day, we strongly believe our clinical outcomes efforts substantially reduce or eliminate recruiting costs, staffing shortages, and turnover. There are a variety of formulas for determining those indirect costs if one wanted to go to that granular level, but we do not think there is a need to do so. A clinical excellence focused culture leads to higher engagement (an easy and established measure) and increased therapist satisfaction, both of which lead to higher patient satisfaction. By the way, the third party produced analysis is not critically important to us centrally, but it is to our PTs who desire the feedback and comparison to a larger database. Internally, we put more emphasis into our own metric-completion rates (number of new patients with outcome measures/total number of new patients) because it supports the intrinsic motivator of mastery and avoids what we see in the field as “cherry picking” selectively using only certain patients for outcomes.

The value creating strategy around outcomes counter intuitively is not about payers—it is about our knowledgeable workers and their motivation and internal reward systems: mastery and purpose. The strategy of outcome collections is about values—your values as an organization and what you are trying to produce. Show me an organization that does not enhance primary intrinsic motivators for PTs and we will show you an organization with frequent turnover and where extrinsic motivators like money and status are the primary emphasis.

The return on quality from a revenue standpoint is probably impossible to calculate but this reflects one of our core management credos: “at times we do not get what we measure, we get what we emphasize.” If you want a strong clinical culture that is accountable, third party clinical outcomes is a must—it is the modern day equivalent to a reflex hammer and goniometer. But if you want to see how they truly impact your bottom line, you will have to look beyond the obvious.

Dr. Benz is the chief executive officer and partner of Confluent Health that includes multi-state private practice physical therapy clinics, Evidence in Motion, and Fit For Work. He can be reached at Larry@physicaltherapist.com.

Dr. Wainner is Leadership Coach and partner of Confluent Health that includes multi state private practice physical therapy clinics, Evidence in Motion, and Fit For Work.


1. Mercer, S. W. (2004). The consultation and relational empathy (CARE) measure: Development and preliminary validation and reliability of an empathy-based consultation process measure. Family Practice, 21, 699–705.

2. Pink, D. H. (2011). Drive: The surprising truth about what motivates us. Penguin.

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