Creating Balance

Don’t let the regulations define your bottom line.

By Scott C. Spradling

I found out the hard way in college that for every hour of class time there were at least two hours of study time or homework I needed to complete. After four years of undergraduate and three years of doctoral studies, it is understandable that the last thing a physical therapist wants to do is spend as much time documenting cases as they do treating patients.

Unfortunately, documentation is a reality of the profession today. Physical therapists are challenged at every corner to prove medical necessity (value). Over the past few years, physical therapists have been overwhelmed with doing physician quality reporting system (PQRS) and function limitation reporting (FLR). As any administrator can tell you, the very mention of these words instantly elicits groans from clinicians.

Do we just throw up our hands and admit defeat? No! The very nature of physical therapy is to rise above and work through the pain and the impairments to achieve a better outcome.

The current compliance and reporting requirements do not—nor should they—have a direct impact on the bottom line of a private practice. However, they do require administrators to take a hard look at current processes and procedures, as well as the overall business model.

Payer mix is one of the first things to consider. How many patients require extra or extensive reporting during a day at the clinic? If 50 percent of your practice is Medicare patients and you are going to have a lot of “homework,” you may want to ensure that the profitability of your practice does not hinge on just one or two payers. This allows you to absorb the greater burdens of one payer with another of lesser burden.

Conditions of payment is another important consideration. Which payer and which compliance or reporting requirement actually have a direct effect on reimbursement? Reporting of the FLR G-codes and their severity modifiers directly impacts if a claim will be processed and paid. Anything that prevents or delays a check from a payer affects your bottom line. Conversely, reporting of PQRS has an indirect effect on your bottom line, as failure to comply or failure to meet the benchmark standards will have an impact on your reimbursement, reducing it as much as 6 percent per year. However, if you can make that 6 percent up in the services that you offer and with your payer mix, then that 6 percent becomes much less of a threat.

Processes for documentation and the need for data collection and reporting is the final thing to consider. These requirements ultimately fall to the clinician to document. However, this is an area in which a properly functioning administrative team can add value. Whether you are using an electronic medical record (EMR) or paper charts, arming the clinician with the necessary information they need regarding specific reporting during the visit can prepare them to manage their visit time. For example, a simple highlighted note on their schedule informing them the 9 a.m. patient has Medicare, is on their 10th visit, and will require FLR can be so valuable. First, it reminds them to actually do it, saving the possibility of the claim being rejected. Then it allows them to collect the appropriate clinical findings’ data making documentation slightly easier. I call this whole approach “chart/visit prep.” It makes the clinical and administrative teams work together through a series of checks and balances to ensure the cleanest possible claim gets sent out the first time.

If the profitability of your practice is determined by the current (and near future) compliance and reporting requirements, then you have a much bigger problem on your hands and your business model requires an immediate reboot. The profession of physical therapy is in the spotlight; this time is seen by many as the ah-ha moment in health care for which we have been waiting. However, across the aisle there are many others who still want proof that the profession is valuable. PQRS and FLR utilization management review are all administrative burdens but necessary to prove that physical therapists are the key primary care practitioners in physical medicine.

Scott C. Spradling is a member of the PPS Administrators Council and a certified administrator since 2011. He is the administrator of Movement Systems Physical Therapy in Seattle, Washington, and can be reached at sspradling@movementsystemspt.com.