Florida Physical Therapist Busted by Medicare

On August 15, 2007 Gordon Sato, the Regional Inspector General for Audit Services for the Office of the Inspector General sent a letter to Michael Bovarnick, Physical Therapist in Boca Raton, Florida.

The letter contained a report titled "Review of Florida Physical Therapist's Medicare Claims for Therapy Services provided during 2003".

In the report, the Office of the Inspector General found that Mr. Bovarnick had done the following:

• inappropriately used his provider identification number to bill for services performed or supervised by someone else

• the documentation for some therapy services did not meet Medicare requirements

• some therapy services were miscoded

• a plan of care did not meet Medicare requirements

(read the Office of Inspector General report at this link).

The report went on to say this:

"The physical therapist did not have a thorough understanding of Medicare requirements and did not have effective policies and procedures in place to ensure that he billed Medicare only for services that met Medicare reimbursement requirements."

Finally, the Office of the Inspector General recommended that Mr. Bovarnick, the Physical Therapist, take the following course of action:

"Refund to the Medicare program $411,781 in unallowable payments for therapy services provided in 2003. Develop quality control procedures to ensure that therapy services are provided and documented in accordance with Medicare reimbursement requirements."

Physical therapy compliance experts cite Medical Necessity and Skilled Services documentation as two of the biggest areas of Medicare audit activity in physical therapy in the near future.

Medical Necessity is an area that physical therapists have not typically been taught (at least not when I graduated in 1992 from the University of Florida).

Medical Necessity is akin to Physical Therapy Diagnosis since impairments in range-of-motion (ROM) and strength constitute reversable finding that may be amenable to physical therapy interventions such as Therapeutic Exercise (CPT 97110) and Manual Therapy (CPT 97140).

Physical findings such as strength and ROM deficits that contribute to functional limitations and disabilities are what physical therapists treat.

Moreover, Mr. Bovarnick had this problem...

"The selected physical therapist operated five clinics that were leased and subleased in Florida during 2003. Nine physical therapists, including the selected physical therapist, and 10 physical therapy assistants worked in these clinics during this period."

Mr. Bovarnick not only had to police his own behavior and documentation but he had a staff of twenty physical therapy clinicians to train, motivate and supervise!

An impossible task? No, but a challenging one.

How should a manager approach the task of training, motivating and supervising a staff of physcal therapy clinicians to properly write notes and charts that will reliably withstand a Medicare audit?

1. The physical therapy manager could invent or develop a proprietary Medicare compliance plan.
2. The physical therapy manager could outsource Medicare compliance to consultants.
3. The physical therapy manager could 'fly below the radar' (and leave money on the table - see this blog post Fly Below the Radar for further explanation).
4. The physical therapy manager could make notes and charts easier, quicker and better for patient care by using Physical Therapy Diagnosis as the basis for all clinical decisions and the beginnings of all clinical documentation.
   

Learn more at SimpleScore.com .

PT Manager Let Me Join the Conversation

I get a lot of information, questions and cues from the PT Manager 'list-serve' at Yahoo Groups.



Click to join PTManager

Watching and reading this list was part of my inspiration to take my proprietary Medicare compliance plan to market.

First, I did the following...

• published the plan on my website at www.SimpleScore.com
  
• started this blog
  
• began doing seminars
  
• wrote a 'how-to' workbook that demonstrates how we create 'bulletproof' notes and charts at Medical Arts Rehabilitation, Inc.
  

The Yahoo Groups list serve covers a wide variety of topics, not all pertaining Physical Therapy Diagnosis or to Medicare compliance.

What is clear from reading the list is how many physical therapists are hungry for more information and less uncertainty.

Bottom line, most of us PT's didn't go to school to become doctors or Medicare experts.

We just want to treat our patients.

If you want to join the conversation then go sign up to and check out the PT Manager list serve at Yahoo Groups.

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Doctor-owned Specialty Hospitals

It's not easy to see how physical therapy diagnosis and specialty-hospital physician ownership are related but I'm going to show you how I think they relate to each other.

First, a preamble.

Legislation attempting to limit physician ownership of specialty hospitals has been attached to a bill currently in the US House of Representatives.

This bill would not limit physician ownership of physical therapy.

The rationale for the bill, however, is that restrictions on physician ownership would save Medicare money (presumably from over-utilization). The American Hospital Association is for the bill while the American Medical Association is against the bill.

Here is a position statement by AMA immediate past president William G. Plested III who argues against the bill.

Specialty hospitals concentrate or 'cherry pick' the most profitable patients (eg: elective total knee and hip replacements) and take those patients away from community hospitals that also serve indigent patients in the emergency room.

Cherry picking concentrates the orthopedic (and the physical therapy) caseload so that only the surgeon's patients are seen by the physical therapist.

The physical therapist will have little opportunity to practice physical therapy diagnosis on a wide range of patient types.

Physical therapy diagnosis is based on the measurement of physical impairments and the link between those impairments and the patients' self-reported functional limitations.

Physical therapy diagnosis requires independent decision making by the physical therapist such as goals and interventions.

Post-surgical protocols are more straightforward and usually don't require the physical therapist to exercise the same level of decision making and treatment planning.

Physical therapy diagnosis also requires a discharge diagnosis to confirm or refute the initial diagnosis.

Re-evaluating the patient (and taking new measurements) to make the discharge diagnosis helps the physical therapist learn which interventions work best and which goals are most appropriate.

Physician owned specialty hospitals (and physician owned physical therapy) are, in the long run, detrimental to the development of physical therapists' diagnostic skills because of the 'deadening effect' of the ultra-specialized caseload they see.

Sahrmann wrote the book on diagnosis

Diagnosis and Treatment of Movement System Impairments by Shirley Sahrmann, PhD, PT, FAPTA came out in 2002 and I bought the book, I read the book and I changed how I practiced because of the book.

Now, in 2008, I am slowly re-reading the book.

I am going out of order, chapter by chapter. I read chapter 4 (the hip) first and now I'm back to the Introduction.

Tonight, I've come across a passage that, even though I don't remember hi-lighting in 2002, tremendously changed my life.

If you'll permit, I'll share it with you now...

"A standardized examination format is used to identify the Directional Susceptibility to Movement (DSM) and the factors that contribute to the presence of a dysfunction" (p.4)

When I took her physical therapy continuing education course in 2003 I saw her use her standardized examination format.

Dr. Sahrmann's tests are easy to learn, reproducible and reliable.

My only concern with her approach is that she assesses pain.

Dr. Sahrmann states the following:

"The (Movement Impairment) syndromes are named for the alignment, stress or movement direction that most consistently produces pain." (p. 74)

I wonder if physical therapy can move forward if we continue to assess pain?

Dr. Sahrmann influenced my career because I went on to develop a standardized assessment system that uses repetitive, corrective exercises to influence and improve 'regional musculoskeletal disorders'.

I've detailed the standardized approach at Physical-Therapy-Videos.com .

Nevertheless, Diagnosis and Treatment of Movement System Impairments by Shirley Sahrmann brought me a watershed moment in my career and my professional growth.

I encourage every physical therapist and physical therapist assistant to buy and read a copy of Dr. Sahrmann's book.



Take her course and watch her diagnose her patient right in front of you.

Nothing will give you greater confidence in pursuing physical therapy diagnosis than watching the one who wrote the book.

Diagnosis Definition

Physical Therapy Diagnosis blog describes my evolution as a physical therapist clinic owner and how I developed a Medicare compliance program based on clinical excellence and simple measurements.

Other physical therapists have done work on physical therapy diagnosis , some of which I'm able to share with you here.

Diagnosis Definition
by Lisa Giallonardo

"A diagnosis is a label based on a cluster of signs and symptoms after the collection, organization, and interpretation of information reached through the evaluation process. For the physical therapist, these are generally movement-related impairments or functional limitations. Sometimes, as in the case of the patient with the ankle sprain, the diagnosis is at the pathology level."

Lisa's definition comes from the book Techniques in Musculoskeletal Rehabilitation by William Prentice and Michael Voight.


Most physical therapists (and physical therapist assistants) graduating today are comfortable with the notion of physical therapy diagnosis.

What about the 'old school' physical therapists? I graduated in 1992 from the University of Florida. I was never taught physical therapy diagnosis. I never learned about the disablement model in PT school.

What about you?

Where do you fall on this issue?

Vote in the poll below. Let us know how you feel. What do you think?

Comment on this blog if you feel strongly - either way, on physical therapy diagnosis.

Physical Therapy Technology

Physical Therapy Diagnosis blog uses technology such as blogs, YouTube videos, Google AdWords and AdSense and Web 2.0 in general to drive home the message that Physical Therapy Diagnosis is simple and easy.

Every Physical Therapist should perform Physical Therapy Diagnosis using skills learned in our entry-level program (BS, MS or DPT).

One physical therapist, Mark Schwall, uses technology in general to improve our lives and our businesses at his website at Tech4PT.com .

In Mark's words...

"TECH4PT.com is dedicated to informing and educating Physical Therapists and anybody else with an interest in utilization of technology to improve their personal lives, business productivity and the visibility of their practices through leveraging the power of availability of technology and the Internet ."

Technology is not usually found in physical therapy education curricula. Technology is also usually not in the skill set of the physical therapist - just look at the low acceptance of 'paperless' or electronic medical records in small outpatient physical therapist offices.

I congratulate Mark on his new website.

I also challenge Mark to find meaningful and useful ways to help physical therapists improve our patients lives through the power and the wonder of technology.