"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Monday, April 30, 2012

Volunteers Needed for Florida Physical Therapists' Committee

Florida Physical Therapists in Private Practice (FLPTPP) Call for Volunteers

Wednesday, April 25, 2012

Claims Denials Over Missing MD Signatures May Not Stand Up

Physical therapists should consult their Local Coverage Determination (LCD) for Therapy Services for their state (here is Florida's) as well as the national Medicare Benefit Policy Manual for Physical Therapy as they interpret this legal opinion, posted by The Report for Medicare Compliance.
"Medicare has elevated the importance of physician signatures and certifications, but sometimes its reach exceeds its grasp, lawyers say.

If the lack of a signature or certification is used as a reason to deny payment, providers may have grounds to fight back — especially if Medicare administrative contractors (MACs) or auditors are relying on manual provisions that go beyond the statute or regulations.

For example, physician signatures are not required on every page of office notes, although MACs may argue otherwise, says Minneapolis attorney David Glaser, with Fredrikson & Byron.

In 1995 CMS explicitly said that physicians don’t have to sign every page of office notes, he says. And if physician signatures are missing from any other piece of documentation, MACs and the comprehensive error rate testing (CERT) contractor must accept an attestation from the author of the medical-record entry, according to the Medicare Program Integrity Manual.

A standard CERT letter states that “in order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.”

"Claims are denied all the time for the lack of a signature,” Glaser says. “I am not recommending physicians don’t sign charts because they would be asking for trouble. But if you haven’t signed them don’t let them deny your claims because you can do the attestation.”

One carrier denied a physician’s detailed, two-page evaluation and management note because the physician forgot to sign, but he appealed it and won, Glaser says. It is considered Medicare gospel that physician orders must be signed. After all, that’s what the Program Integrity Manual says.

But Glaser contends that’s not always the case and providers shouldn’t assume they are out of luck if a claim is denied because there’s no signature on an order. For one thing, Medicare regulations obviously set forth specific requirements for each service and they don’t all require signed orders. While home health certifications must be written and signed, independent diagnostic testing facility orders must be written but there is no signature requirement, Glaser says.

And while the Program Integrity Manual insists orders must be signed, it’s a manual — not a regulation, he says.

CMS has made it clear that Program Integrity Manuals  lack the force of law.

In several cases, the government filed briefs arguing that if manuals conflict with governing statutes or regulations, a person relies on them “at his peril.”

Glaser says manuals can set a lower standard of care but not a higher standard of care than the regulations."
Physical therapists, especially busy private practice physical therapists, can sleep easier now knowing that ONE missing signature wont invalidate their entire claim. Medicare appeals are expensive but, in some cases, worth it.

Tuesday, April 24, 2012

Medicare Advantage Plan Wastes 8 Billion Dollars

A new Office of the Inspector General (OIG) report recommends ending the Medicare Advantage bonus program, saying it will waste the $8.3 billion earmarked over the next ten years.

According to the Associated Press
"Medicare Advantage is a popular private insurance alternative to the traditional health care program for seniors. More than 3,000 private plans serve nearly 12 million beneficiaries, about one-fourth of Medicare recipients. They offer lower out-of-pocket costs, usually in exchange for some limitations on choice."
Patients may find that they are excluded from seeing their physical therapist in private practice, as one common limitation on their choice.

According to the New York Times...
"In the 2010 health care law, Congress cut Medicare payments to managed care plans, known as Medicare Advantage, and authorized $8.3 billion in bonus payments to those that provide high-quality care. OIG investigators found that most of the money paid under the demonstration program went to “average-performing plans” rated lower than the benchmarks set by Congress."
Rather than paying bonuses to profitable insurance companies why not put that money into providers, like physicians and physical therapists, with modern tools for imroving quality of care like improved access to hospitals' Electronic Medical Records?

Saturday, April 21, 2012

Low Back Pain guidelines published by Orthopaedic Section of APTA

Just published are the Low Back Pain Clinical Practice Guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association.

The guidelines are VERY comprehensive and cover a broad amount of information, from pathology to psychosocial factors to some of the basic special tests you learned in PT school.

What you will NOT find...
  • No pelvic landmarks
  • No trigger points
  • No palpation for tenderness (only in the case of a spinal compression fracture)
I hope this doesn't slay too many sacred cows but if you have any doubt, or if you'd just like to read a great work by some research AND clinical physical therapists then I highly recommend these new guidelines.

Tuesday, April 17, 2012

20 States Limit Drug CoPayments to Protect Patients

According to this FierceHealthPayer article
"Insurers increasingly are facing potential legislation that could prevent them from shifting larger portions of prescription drug costs onto their members.  
At least 20 states have introduced bills to limit insurers charging higher copays for specialty drugs for chronic illnesses."
Why aren't physical therapists doing more to fight this trend in rising physical therapy co-pays?

So far, only KentuckySouth Dakota and New York have created national headlines for their efforts to protect patients from higher copays.

States proposing copay legislation on drug/medication copays are these:
  • New York was the first state to pass a law in 2012, essentially prohibiting insurers from charging higher copays to patients.
  • Vermont has a one-year moratorium on copays that's in effect until July 1, 2012.
  • Maine limits insurers from charging more than $3,500 a year for fourth-tier drug copays.
  • Louisiana and Texas bar insurers from raising out-of-pocket drug costs in the middle of a contract year.
  • Connecticut, Rhode Island and Delaware are considering similar bills in 2012.
Insurance companies previously used "drug price tiers" that shifted low price generic drugs onto the first tier to encourage patients to use these drugs before choosing expensive, brand name drugs. But, insurers have...
"...altered their benefit structures to shift specialty drug costs onto their chronically ill members, causing patients to pay an extra 30 percent to 50 percent for medications..."
When an isurance company changes a drug tier or changes a physical therapy copay, the company purchasing insurance for its employees is expected to give notice to the employees.
"Any time an employer makes a change, we expect that the employer is communicating with their employees, and we follow up with documentation that spells out very clearly the changes made." said Brad Kieffer, Health Net communications director in The Lund Report.
But, busy people often don't pay attention to seemingly minor changes in employer-sponsored benefits, especially when they're still healthy.

The employee may not notice the change until they need healthcare and they show up at their doctor, pharmacist of physical therapist who says to them, "Your copay is $50 per vist".

Then, its too late.

We need to act now - follow the successful lead of Kentucky, South Dakota and New York and encorage your state-level professional organization to propose copayment legislation in 2013.

Partner with the pharmacy associations in your state and propose a combined Drug/PT Copay act that protects patients from rising copayments.

Make comments to this blog and let us know how your actions are working.

Friday, April 13, 2012

27 New Medicare Accountable Care Organizations Open April 1st, 2012


A new program that will help physicians, hospitals, and other health care providers work together to improve care for people with Medicare is off to a strong start, the Centers for Medicare & Medicaid Services (CMS) announced today.

Under the new Medicare Shared Savings Program (Shared Savings Program), 27 Accountable Care Organizations (ACOs) have entered into agreements with CMS, taking responsibility for the quality of care furnished to people with Medicare in return for the opportunity to share in savings realized through improved care. The Shared Savings Program and other initiatives related to Accountable Care Organizations are made possible by the Affordable Care Act, the health care law of 2010. Participation in an ACO is purely voluntary for providers and beneficiaries and people with Medicare retain their current ability to seek treatment from any provider they wish.

The first 27 Shared Savings Program ACOs will serve an estimated 375,000 beneficiaries in 18 States. This brings the total number of organizations participating Medicare shared savings initiatives on April 1 to 65, including the 32 Pioneer Model ACOs that were announced last December, and six Physician Group Practice Transition Demonstration organizations that started in January 2011. In all, as of April 1, more than 1.1 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.
"We are encouraged by this strong start and confident that by the end of this year, we will have a robust program in place, benefitting millions of seniors and people with disabilities across the country," said CMS Acting Administrator Marilyn Tavenner.
Anyone who has multiple doctors may have experienced the frustration of fragmented and disconnected care: lost or unavailable medical charts, trouble scheduling an appointment or talking to a doctor, duplicated medical procedures, or having to share the same information over and over with different doctors.

Accountable Care Organizations are designed to lift this burden from patients, while improving care and reducing costs. The Shared Savings Program was created by the Affordable Care Act after a number of efforts in the private sector showed that improving care can lead to lower costs. The selected ACOs include more than 10,000 physicians, 10 hospitals, and 13 smaller physician-driven organizations in both urban and rural areas. Their models for coordinating care and improving quality vary in response to the needs of the beneficiaries in the areas they are serving. CMS is reviewing more than 150 applications from ACOs seeking to enter the program in July.

To ensure that savings are achieved through improving and providing care that is appropriate, safe, and timely, an ACO must meet strict quality standards. For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and the patient and caregiver experience of care.

CMS also announced today that five ACOs are participating in the Advance Payment ACO Model beginning April 1. This model will provide advance payment of expected shared savings to rural and physician-based ACOs participating in the Shared Savings Program that would benefit from additional start-up resources. These resources will help build the necessary care coordination infrastructure necessary to improve patient outcomes and reduce costs, such as new staff or information technology systems. CMS is reviewing more than 50 applications for Advance Payments that start in July.

  1. Accountable Care Organization/Collaborative Health Systems Partnerships
  2. Accountable Care Coalition of Caldwell County, LLC Lenoir, NC
  3. Accountable Care Coalition of Coastal Georgia Ormond, FL (Serving beneficiaries in GA and SC)
  4. Accountable Care Coalition of Eastern North Carolina, LLC New Bern, NC
  5. Accountable Care Coalition of Greater Athens Georgia Athens, GA
  6. Accountable Care Coalition of Mount Kisco, LLC Mount Kisco, NY
  7. Accountable Care Coalition of the Mississippi Gulf Coast, LLC Clearwater, FL (Serving beneficiaries in the Mississippi Gulf Coast area)
  8. Accountable Care Coalition of the North Country, LLC Canton, NY
  9. Accountable Care Coalition of Southeast Wisconsin, LLC Milwaukee, WI
  10. Accountable Care Coalition of Texas, Inc. Houston, TX
  11. AHS ACO, LLC Morristown, NJ (Serving beneficiaries in NJ and PA) AppleCare Medical ACO, LLC Buena Park, CA
  12. Arizona Connected Care, LLC Tucson, AZ
  13. Chinese Community Accountable Care Organization New York, NY
  14. CIPA Western New York IPA, doing business as Catholic Medical Partners Buffalo, NY
  15. Coastal Carolina Quality Care, Inc. New Bern, NC
  16. Crystal Run Healthcare ACO, LLC Middletown, NY (Serving beneficiaries in NY and PA)
  17. Florida Physicians Trust, LLC Winter Park, FL
  18. Hackensack Physician-Hospital Alliance ACO, LLC Hackensack, NJ (Serving beneficiaries in NJ and NY)
  19. Jackson Purchase Medical Associates, PSC Paducah, KY
  20. Jordan Community ACO Plymouth, MA
  21. North Country ACO Littleton, NH (Serving beneficiaries in NH and VT)
  22. Optimus Healthcare Partners, LLC Summit, NJ
  23. Physicians of Cape Cod ACO
  24. Premier ACO Physician Network Lakewood, CA
  25. Primary Partners, LLC Clermont, FL
  26. RGV ACO Health Providers, LLC Donna, TX
  27. West Florida ACO, LLC Trinity, FL
Get the CMS fact sheet

Thursday, April 12, 2012

Governor Scott signs Physical Therapist/PTA Temporary License Bill into Law

Physical Therapists and Physical Therapists Assistants graduating from Florida based PT and PTA programs will be able to obtain temporary licensure thanks to Governor Rick Scott signing HB 799 into law on Friday, April 6, 2012.

With Governor’s Scott’s signature HB 799 will become law effective June 1.
HB 799 was a major priority of the Florida Physical Therapy Association (FPTA) along with the state’s 11 Physical Therapy and 15 Physical Therapy Assistant schools.

Passage of the legislation can be attributed to the hard work of our PT and PTA students, faculty, and FPTA leadership and legislative counsel.

As a recap, HB 799 and its companion SB 1228 were heard in a total of six committees of reference and passed every single committee without objection. On final passage in the Florida House of Representatives HB 799 passed 114-0 and then passed 36-0 in the Florida Senate.

While process barriers were ever present during the 2012 session, the legislation steamed on toward final passage. However, it wasn’t until the final day, March 9 at 11:22 p.m. that HB 799 achieved final passage and was enrolled. On Friday, March 23, the Florida House of Representatives procedurally released HB 799 from its purview to be considered by Florida Governor Rick Scott.

As mentioned previously, Governor Scott signed the bill into law Friday, April 6. FPTA’s strategy was textbook advocacy for taking an idea and making it a law.

Thank you to the following legislative sponsors:
  • Rep. Tom Goodson, R-Titusville
  • Senator Bill Montford, D-Tallahassee

Tuesday, April 10, 2012

Skilled Physical Therapy Tied to Medicare Improvement Standard

Many physical therapists still believe that Medicare will not pay for therapy that does not lead to a change in functional status.

This is NOT true.
The Medicare Improvement Standard...

"...has a particularly devastating effect on patients with chronic conditions such as

  • Multiple Sclerosis
  • Alzheimer's disease
  • ALS
  • Parkinson's disease
  • paralysis."
According to the Center for Medicare Advocacy:
"People with chronic conditions and long-term illnesses are often denied Medicare coverage because their medical condition will not supposedly:
  • Improve on functional status scores
  • They need maintenance services only
  • They have plateaued
  • They are chronic and stable
These reasons are referred to as the Medicare "Improvement Standard."  
Medicare is often the only insurance for this population, so, unfortunately, Medicare coverage denials can result in the loss of necessary health care.
This short podcast (7:11) from the Center for Medicare Advocacy may help you understand some of the issues these patients face in trying to get their necessary healthcare.

Unfortunately, due the the complex nature of Medicare documentation many physical therapists must waste valuable time learning how to document "skilled physical therapy" rather than actually treating patients.

I have found that patients often encounter barriers from their own physical therapists who may be uncertain or afraid to append the -KX modifier when care beyond the $1,880 is clearly necessary.

If patient progress is slow, marked by significant setbacks or difficult to measure the physical therapist may refuse to continue treating the patient.

Even though the patients' Medicare benefit allows physical therapy for these conditions.

The physical therapists' reluctance is due to fear of a Medicare Audit.

The Center for Medicare Advocacy has pressed a class action lawsuit against Kathleen Sebelius that may force Medicare to acknowledge its illegal "Improvement Standard" so that physical therapists may gain some clarification on our documentation requirements.

Please share tips on how YOU document exceptions to the $1,880 physical therapy cap.

Thursday, April 5, 2012

Don't Spend Big Bucks on a New EMR... until you read this!

This new article, published in Advance for Physical Therapists April 3rd, 2012, shows you the future of Electronic Medical Records (EMR) in physical therapists' clinics.

We cover EVERYTHING physical therapists want in a new, electronic documentation and billing system.

In the article we discuss the following:
  • Physical therapists documentation
  • Productivity and profitability
  • SOAP notes
  • Medicare Audits
  • Personal Health Records (PHR)
  • Electronic Health Records (EHR)
  • Mobile or handheld computing
  • Psychosocial factors
  • Quality metrics
BEFORE you spend lots of money on a new computer system or new software you should READ THIS FIRST!

Wednesday, April 4, 2012

South Dakota Passes Patient Protection Law Limiting Physical Therapy Copayments

From the American Physical Therapy Assoication (APTA) Press Release:

Last week, South Dakota became the latest state to improve consumer protections from excessively high physical therapy copays when Gov Dennis Daugaard signed House Bill 1183, legislation promoted by the South Dakota Chapter.
HB 1183 limits the amount a health insurer may charge a patient for an out-of-pocket copayment or coinsurance amount when he or she visits a physical therapist or occupational therapist.

After the bill takes effect July 1, those copayment and coinsurance amounts cannot be higher than those charged when a patient visits a primary care physician or practitioner.

Health insurers often categorize physical therapy as a "specialty" service, and typically require higher copays than primary care services—sometimes as high as $60 or more for a single visit.
"Legislators saw that this bill was all about patient access and affordability," said Ronald Van Dyke, PT, OCS, president of the South Dakota Chapter.  
"They wanted to make sure the people of South Dakota could access the physical therapy and occupational therapy care they need at a fair cost."
Hopefully, other states will follow the lead of South Dakota, Kentucky and New York in 2013 - now is the time to start preparing your legislative agenda for next year.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

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