The Payment Process

PPS Strategically Targets Payment at a Local Level

By Paul Gaspar, PT, DPT, CCS

Payment is quite possibly the number one concern of physical therapists in private practice. Many insurance companies have cut payment by 25 to 40 percent during the last five years. Others have chosen to hire “middleman” discount networks to effectively lower payment and curb the utilization of physical therapists’ services. To top it off, some have used “all contracts” clauses and questionable pricing and product rollout schemes to lower their costs—and this is at a time when several insurance companies have been posting dramatically higher profits and stock prices, as well as record CEO compensation. Is that fair or legal? Most physical therapists would argue it is not fair, but whether it is legal is a much more difficult question. The legality of specific payment contracts and conditions has to be determined on a case-by-case basis and largely depends on state laws and regulations for most payers. That is one of the main reasons the Private Practice Section (PPS) started a legal fund to support their PPS members at the local level. And it seems to be paying off in a big way.

California physical therapists have been frequent recipients of PPS legal grants, several of which have been used to win the legal status of the Physician-Owned Physical Therapist Services (POPTS) two years in a row. In cases where California physical therapists were no longer able to achieve their goals in the POPTS battle, they returned the remaining legal funds back to PPS so that they could be used where the outcome would be more satisfying to PPS members.

Since direct access and POPTS issues have been largely decided in California, fair payment has been the advocacy focus. California physical therapists continue to be crushed by predatory pricing, middleman networks, and questionable payer tactics. PPS has been relying on its physical therapist members in California to keep them informed about physical therapists’ rights or contracts being infringed. Recently, PPS funded a legal action against a payer’s alleged retribution against PPS members for their fair payment advocacy. The legal action resulted in a positive financial settlement for the PPS members.

PPS remains in close contact with their members in California because many consider it ground zero for payment reform. California’s PPS members are among the most proactive PPS members in the country, often pushing back forcefully if they feel they have been wronged by payers. Many in California are identifying potential actions regarding allegedly illegal contract offers, breaches of contracts, and unfair pricing schemes.

If your goal is to get paid more fairly by insurance companies, don’t sit back and expect others to do the work for you. PPS cannot be in all places at all times. If you think you are being treated unfairly, relay your concerns to your local colleagues, your local private practice group, your attorney, and/or PPS. It would not be a bad idea to consider contacting a PPS member in California either, because if there is a payer problem it is likely that California physical therapists have experienced it, or are doing so currently. After doing so, if it is clear that there may be a viable legal concern, please consider contacting the PPS Board and applying for a legal aid grant. We hope physical therapists in other states will take advantage of this unique opportunity offered only to PPS members.

Paul D. Gaspar, PT, DPT, CCS, is a Private Practice Section (PPS) member and owner of Gaspar Physical Therapy since 1994. He has served on the board of the California Physical Therapy Association, three terms as a PT PAC Trustee, and currently serves as President of the Independent Physical Therapists of California.