Physical Therapists Cannot Opt-Out of Medicare

From First Coast Service Options e-news (June 18th, 2012): Private contracts between beneficiaries and physicians or practitioners.

Title 42, Part 405 of the Code of Federal Regulations outlines the guidelines and requirements for physicians and/or non-physician practitioners who wish to enter into private contracts (opt out).

These regulations permit a physician or practitioner to opt out of Medicare and enter into private contracts with Medicare beneficiaries, if specific requirements of these instructions are met.

Definition of physician or practitioner
For purposes of this provision, the term “physician” is limited to doctors of medicine and doctors of osteopathy who are legally authorized to practice medicine and surgery by the state in which such function or action is performed; no other physicians may opt out.

Also, for purposes of this provision, the term “practitioner” means any of the following to the extent that they are legally authorized to practice by the State and otherwise meet Medicare requirements:

• Physician assistant
• Nurse practitioner
• Clinical nurse specialist
• Certified registered nurse anesthetist
• Certified nurse midwife
• Clinical psychologist
• Clinical social worker
• Registered dietitian
• Nutrition professional

The opt-out law does not define “physician” to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract.

Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not within the opt-out law’s definition of either a “physician” or “practitioner.”

Physical Therapy Services Billed by Physicians in Florida Have a High Error Rate

Services billed by physician specialties represented 70% of the dollars incorrectly paid for physical therapy services in the November 2011 Comprehensive Error Rate Testing (CERT) Report.

Additionally, past medical review experience has identified high claim error rates when therapy services are billed by physicians.

The most common reasons for an error to be assigned are the following:

• insufficient documentation
• failure to meet Medicare’s documentation requirements specific to physical therapy services
• failure to meet medical necessity guidelines.

Therefore, based on high error rates validated through CERT findings and FCSO’s data analysis, a prepayment medical review edit for physical therapy claims billed by physicians in Florida will be implemented on March 19, 2012.

This prepayment edit will require submission of medical records to support physical therapy services billed by physicians.

More information can be found at the First Coast Service Options web site.

We discussed Medicare Audits here and the high CERT error rate for Chiropractors here.

Virginia Chiropractors can't make a Physical Therapy Diagnosis

You can read this discussion about Virginia chiropractors practicing physical therapy that was 'born' on the Physical Therapist Manager Yahoo Groups and can be read here . You will need to sign in to Yahoo Groups to contribute to the discussion.

It's too bad 'physical therapy privileges' can be awarded to
chiropractors who probably can't do a physical therapy evaluation on a
patient prior to performing treatment.

This letter from the acting Virginia Attorney General states that chiropractors can 'practice physical therapy' when performing techniques and modalities.

Here is last paragraph of letter posted on site:

“Based on the above, I am of the opinion that the statutory changes enacted
by the General Assembly in 2000 were not intended to change, and did nothing
to change, the scope of practice of chiropractors, and I am further of the
opinion that chiropractors may lawfully provide physical therapy modalities
as part of a treatment program for patients and, therefore, practice
physical therapy.

With kindest regards, I am
Very truly yours,

Randolph A. Beales

Acting Attorney General”

I wonder if the Virginia state practice act required a 'physical therapy
diagnosis' prior to any profession administering physical therapy
treatments if that would slow the chiropractors down.

The 'physical therapy diagnosis' would require specific measurement of
impairments in ROM, strength and other physical patient
characteristics and also measurement of functional limitations
(perhaps with the OPTIMAL).

The physical therapist would then hypothesize the 'physical therapy
diagnosis' - the link between the impairments and the functional
limitations.

The physical therapist would then treat the patient using any
combination of techniques - exercise, manipulation, education,
whatever it takes.

The physical therapist would then re-measure the patient
characteristics (ROM, strength, OPTIMAL) to see if any improvement
occurred.

If improvement did occur, the physical therapist could attribute the
benefit to the treatment and render a 'discharge physical therapy
diagnosis'.

I've developed a decision-making process called SIMPLE Physical Therapy Diagnosis with 'how-to' videos, data-collection templates and extensive references at www.SimpleScore.com .

If most physical therapists followed this decision-making process I
bet most chiropractors would hesitate mightily before advertising
their services as anything akin to physical therapy.

The problem is that most physical therapists don't follow this
decision-making process prior to administering physical therapy on a
patient and most chiropractors know this.

If chiropractors thought that physical therapy diagnosis was 'over
their heads' then we would be safe from professional infringement.

Physical Therapy Diagnosis is the only sustainable competitive position that physical therapists have in the rehabilitative marketplace.

The only way to protect that position is by practicing Physical Therapy Diagnosis.

Legislative solutions wont work because economic forces drive legislation. Deeper pockets will prevail.

Physical therapists can beat chiropractors not with better laws but by being better physical therapists.