Direct Access for PT

[MSHARO]

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Of course I know the difference between a what a primary care physician does and a PT. Do you? Are you a physical therapist? Are you a physician? I am not sure in all honesty. And didn't I say diagnose PT related conditions (i.e. movement problems)? This is where YOU need to read the literature. There is lots of articles written about diagnosis and PT. And please don't lecture me on reading literature. I haven't kept up with all of the specific PT literature because I am in medical school right now and have been a little busy studying this medical school stuff. Have you been to medical school? I am also not working as a PT anymore. I really only have time to keep up on the literature that really interests me or is involved in the research I am working on.

And maybe if you were a PT...your training sucked. Or if you are involved in teaching PT's, you suck as a teacher... Can I pick up on the clues that it may not be mechanical low back pain versus acute prostatitis? Probably. But then again, how often does you average patient go to their GP because their back has been sore working in the yard and get a prostate exam? And did I ever advocate doing pelvic exams or prostate exams? Do you really think that someone is going to come to a PT for dysmennorhea or dysuria? And do I as a PT ask questions about this to sort through the DDx? Of course!!! Then since I have such minimal training, my pea brain refers them to a physician. Come on....use your freaking head!

Obviously you haven't seen enough ankle sprains, hamstring strains, low back pain etc to know when something can be treated conservatively. As an athletic trainer who has worked both in collegiate sports and professional sports, I was usually the first one to see them. Do you think that even with these athletes we x-ray'd every single one? Come on!!! Learn to do a physical exam!!! You sound like the idiots who order an MRI everytime you think someone has an ACL tear. LEARN TO DO A PHYSICAL EXAM!!! And please enlighten me...how do most GP's treat a majority of musculoskeletal conditions successfully?

I am not trying to bash GP's, because they do have to know such a wide breadth of information from cancer, to HTN, to low back pain. But that doesn't mean they are musculoskeletal or movement experts. Certainly no more than a PT. In training, do you think that GP's get more time treating HTN, DM, etc., or musculoskeletal conditions? I was very fortunate to have very good relationships with several of the GP's across the street from my clinic. They would often send their patients across the street to see me if they weren't sure what was going on. So, obviously they thought my clinical skills for detecting musculoskeletal conditions. But then again....maybe they were just idiots like me.

 

[adamdowannabe]

My retort was in reference to the comment about PA's not practicing medicine, it had nothing to do with PT's and medicine, because PT's aren't licensed to practice medicine, where as PA's are........hence my comment about being licensed to do so by the states medical board.....or if I forgot to mention it, I had meant to.

I'm curious how much education PT's have in osteosarcoma or osteomyelitis, what about someone with bone pain caused by myeloma? Would a PT be able to recognize any of that, when it presents so vaguely?

This is merely a question...I am not aware of what a PT does and does not get educated in.

 

[MSHARO]

We had a 2 hour lecture by one of the orthopods on bone cancers and another one on bone infections. Not sure how much we talked about mult. myeloma...can't remember...has been a few years. Did we go into the histology of it...no.

Do PA's practice under a physician's license or under their own license? I know that PA's are not even licensed in several states, and aren't they still registered in some states? So obviously they are not licensed to practice medicine everywhere, and even so, not without the supervision of a physician who is legally responsible for their work.

And once again...I never stated that a PT should practice medicine. But if in the practice of physical therapy, I come across a medical problem (which I should be looking for if I am a competant PT), I should be able to pick this up and refer out as it is OUT OF THE SCOPE OF MY PRACTICE AS A PT. Even without direct access this happened all the time when I practiced. I certainly didn't treat HTN if I found it for example, but I refered them back to their doctor about it. Just as if I found a patient that I though had a fracture or an ACL tear, I didn't order the x-ray's or perform the surgery, as THAT IS OUT OF THE SCOPE OF PRACTICE OF A PT. Now, is treating an ankle sprain within the scope of practice of a PT...last time I checked I thoug it was....That doesn't seem like practicing medicine to me? It sounds like practicing PT and making sure it is not a medical problem along the way. Another example....if you go to a health fair and a PN, LPN or someone draws your blood and checks your BP and you find out you have high cholesterol or HTN and refers to a physician, is that practicing medicine or is it screening? I guess in your mind it would be....

 

[deleted6669]

"Do PA's practice under a physician's license or under their own license? I know that PA's are not even licensed in several states, and aren't they still registered in some states? So obviously they are not licensed to practice medicine everywhere"

pa's practice in all 50 states, guam, the virgin islands, samoa, etc
49 states allow pa's to have their own dea #s( everywhere except indiana). supervision is a very loose concept. in my state it means 10% of my charts as chosen by me are reviewed within 1 month. there is no requirement that an md see any of my pts in person. in fact I could fax 10 charts a month to a "supervising doc" I had never met in person and this would fulfill the legal requirement.in fact I volunteer at a free clinic occasionally (and have done so for years) and have never met my sp of record there.

I have great respect for p.t.'s and use their services frequently, however I usually try standard therapies 1st and if the pt is not improving in 1-2 weeks I send them to p.t.
my only concern about direct access is that someone could self refer with something like avascular necrosis of the hip which they think is a thigh strain from playing tennis and go down the wrong treatment path for a long time before getting the correct dx
I do not know what training p.t.'s have in differentiating true "medical "conditions from musculoskeletal conditions with similar sx.
if this is a major part of your educational process then I would be totally ok with direct access otherwise limited direct access for a specific set of obviously musculoskeletal conditions seems more appropriate.

 

[PT/MD]

I thought with all the debate about PT's fighting for direct access just for the money everyone would find this report interesting.

OIG Finds Improper Physical Therapy Billing by Physicians Costs Medicare Millions
In a long-delayed report issued this week, the Office of Inspector General (OIG) of the Department of Health and Human Services found that 91% of physical therapy services billed by physicians in the first 6 months of 2002 failed to meet program requirements, resulting in improper Medicare payments of $136 million. The Inspector General found that the total payments for physical therapy claims from physicians skyrocketed from $353 million in 2002 to $509 million in 2004, and that the number of physicians billing the program for more than $1 million in physical therapy more than doubled in that 2-year period.

Full report Link
OIG Report

Now who is it that we should be concerned about when it comes to overbilling and fraud? I know physican owned PT physical therapy is a slightly different issue but if you are worried about PT over utilization with direct access look what is happening now with the current setup. Now I am not saying all PT's are perfect but 91%, come on! Physical therapy treatment should be administered and controlled by physical therapists and should not be subject to a referral requirement. Let physical therapy be controlled by therapists, it's only a matter of time.

 

[lawguil]

I thought with all the debate about PT's fighting for direct access just for the money everyone would find this report interesting.

OIG Finds Improper Physical Therapy Billing by Physicians Costs Medicare Millions
In a long-delayed report issued this week, the Office of Inspector General (OIG) of the Department of Health and Human Services found that 91% of physical therapy services billed by physicians in the first 6 months of 2002 failed to meet program requirements, resulting in improper Medicare payments of $136 million. The Inspector General found that the total payments for physical therapy claims from physicians skyrocketed from $353 million in 2002 to $509 million in 2004, and that the number of physicians billing the program for more than $1 million in physical therapy more than doubled in that 2-year period.

Full report Link
OIG Report

Now who is it that we should be concerned about when it comes to over billing and fraud? I know physician owned PT physical therapy is a slightly different issue but if you are worried about PT over utilization with direct access look what is happening now with the current setup. Now I am not saying all PT's are perfect but 91%, come on! Physical therapy treatment should be administered and controlled by physical therapists and should not be subject to a referral requirement. Let physical therapy be controlled by therapists, it's only a matter of time.

Why don't you tell us what the OIG report actually said?
This is what the OIG report says,

1. Found that documentation of services that was performed in physician offices did not meet CMS required documentation
2. Documentation did not meet CMS guidelines for plan of care
3. And physical medicine and rehabilitation services performed in MD/DO offices did not meet CMS criteria for being medically necessary!

Everybody knows that nothing meets CMS guidelines and these particular findings have nothing to do with over billing and there is no "control" you can compare it to! Does Ms. Norwalk intend to order an investigation of billing from physical therapists in the same fashion or compare costs of physical therapy services provided in a PT owned office for a similar caseload. You aren't going to see the ATPA PAC's lobbying for this type of investigation because it would show that these same services provided in a PT office would be far more costly with the same results.

The issue with this data isn't about whether physicians are over billing, but about proper documentation of services provided in a physician office. It's about documenting the patients condition so that it meets CMS criteria for care that is medically necessary, and ensuring that the provider is documenting a plan of care that meets CMS guidelines. I'm sure that many PT's have mastered this fickled process of making sure they use the language that is necessary in the notes to meet the guidelines!

The other issue that is entertained in this report (as the ATPA PAC's adamantly lobbied for) was an investigation of the qualifications of the practitioners that provided the services and "incident to" billing. They found in their study that a wide spectrum of individuals provided these services including chiropractors, podiatrists, massage therapists, PTA's, PT's, and PT-aids. I do agree that persons implementing these services should be licensed and/or certified to provide physical medicine and rehabilitation services and have been appropriately educated. What I found interesting about this report was that licensed physical therapists and PTA's provided care in a physician owned office may also be responsible for inappropriate care, improper documentation, and improper plan of care.

"....physical therapist and Physical therapist assistants appear to have rendered the services of 18 of the 54 reviewed cases."

What is interesting was that ATC's were never mentioned as practitioners in any of the report that I reviewed and therefore one can reasonably assume that ATC's were not responsible for improper documentation, or providing care that isn't necessary according to CMS, but PT's, PTA's, chiropractors, physicians, podiatrists and PT-Aids as well as other non-licensed "providers" are mentioned. ****my intention is not to bring up an ATC vs. PT debate, just mentioned it because of the APTA's aggressive efforts to eliminate any and all competition in the health related movement sciences.

Further, this study does not prove anything with respect the safety or cost effectiveness of direct access for physical therapists!

 

[PT/MD]

First I would like clarify something, Billing medicare for services that are not appropriate or don't fall within medicare guidelines (or are not able to be justified by appropriate documentation) = overbilling. If they are billed to Medicare under the pretense that they are justified (which is what you do when a signed claim is sent in) this = fraud.

Next, my goal is not to continue the PT and ATC debate. I have worked with many ATC's and PT/ATC's that were excellent. I problem I have is with referral for profit rehab practices. They can use aides, PT's, PTA's or ATC's. The problem is the same. Thinking that these employees will not be pressured to overutilize services is naive. Now I am sure someone will have some great practice where everyone respected each other and worked to get the patient better without regard for $$ but this is not the norm and it likely you just didn't see it. I have seen it too many times. These are profit centers (and apparently fraud centers) for the physicians and nothing more. They could have the same relationship by renting space to an independent rehab center and working together.

The reason this is a big problem is the referral requirement (direct access issue). If a physican controls if a patient can see you or not and owns a rehab center where they make money off patient getting treated, where do you think they will send the patient? It will not matter if the other rehab clinic has better equipment/services or better therapists/ATC's. Money is a powerful motivator and like it or not the U.S healthcare system is big business. With direct access patients would be able to choose where they go for therapy without absolute control by the physician. With regard to the safety and cost effectiveness of direct access. It is already legal in 48 states which means 48 state legislatures have decided to is safe to allow their citizens to be treated and I see alot of patients already that pay on a cash basis. The only thing lacking is insurance reimbursement. With respect to cost effectivness I know there are some studies out there that I will try to locate but it is surely better than a physician owned rehab centers.
Don't argue the PT vs ATC debate back because we won't get anywhere. My guess is you are an ATC and really I think you should be worried about physician billing for rehab services as well. Your profession is being used to generate large sums for these physicians. It may also be that the APTA's push toward not allowing ATC's to be reimbursed for Medicare services was aimed at these physicians and not a ATC's themselves. Just a theory.

 

[lawguil]

First I would like clarify something, Billing medicare for services that are not appropriate or don't fall within medicare guidelines (or are not able to be justified by appropriate documentation) = overbilling. If they are billed to Medicare under the pretense that they are justified (which is what you do when a signed claim is sent in) this = fraud.

Next, my goal is not to continue the PT and ATC debate. I have worked with many ATC's and PT/ATC's that were excellent. I problem I have is with referral for profit rehab practices. They can use aides, PT's, PTA's or ATC's. The problem is the same. Thinking that these employees will not be pressured to overutilize services is naive. Now I am sure someone will have some great practice where everyone respected each other and worked to get the patient better without regard for $$ but this is not the norm and it likely you just didn't see it. I have seen it too many times. These are profit centers (and apparently fraud centers) for the physicians and nothing more. They could have the same relationship by renting space to an independent rehab center and working together.

The reason this is a big problem is the referral requirement (direct access issue). If a physican controls if a patient can see you or not and owns a rehab center where they make money off patient getting treated, where do you think they will send the patient? It will not matter if the other rehab clinic has better equipment/services or better therapists/ATC's. Money is a powerful motivator and like it or not the U.S healthcare system is big business. With direct access patients would be able to choose where they go for therapy without absolute control by the physician. With regard to the safety and cost effectiveness of direct access. It is already legal in 48 states which means 48 state legislatures have decided to is safe to allow their citizens to be treated and I see alot of patients already that pay on a cash basis. The only thing lacking is insurance reimbursement. With respect to cost effectivness I know there are some studies out there that I will try to locate but it is surely better than a physician owned rehab centers.
Don't argue the PT vs ATC debate back because we won't get anywhere. My guess is you are an ATC and really I think you should be worried about physician billing for rehab services as well. Your profession is being used to generate large sums for these physicians. It may also be that the APTA's push toward not allowing ATC's to be reimbursed for Medicare services was aimed at these physicians and not a ATC's themselves. Just a theory.

I clearly understand the conflict of interest that you are talking (physicians referring to themselves) about and agree with much of what you are saying.

I still struggle with the idea about direct access for PT's! Maybe I am wrong, but I still havn't heard a convincing arguement!

 

[lawguil]

I thought with all the debate about PT's fighting for direct access just for the money everyone would find this report interesting.

OIG Finds Improper Physical Therapy Billing by Physicians Costs Medicare Millions
In a long-delayed report issued this week, the Office of Inspector General (OIG) of the Department of Health and Human Services found that 91% of physical therapy services billed by physicians in the first 6 months of 2002 failed to meet program requirements, resulting in improper Medicare payments of $136 million. The Inspector General found that the total payments for physical therapy claims from physicians skyrocketed from $353 million in 2002 to $509 million in 2004, and that the number of physicians billing the program for more than $1 million in physical therapy more than doubled in that 2-year period.

Full report Link
OIG Report

Now who is it that we should be concerned about when it comes to overbilling and fraud? I know physican owned PT physical therapy is a slightly different issue but if you are worried about PT over utilization with direct access look what is happening now with the current setup. Now I am not saying all PT's are perfect but 91%, come on! Physical therapy treatment should be administered and controlled by physical therapists and should not be subject to a referral requirement. Let physical therapy be controlled by therapists, it's only a matter of time.

First I would like clarify something, Billing medicare for services that are not appropriate or don't fall within medicare guidelines (or are not able to be justified by appropriate documentation) = overbilling. If they are billed to Medicare under the pretense that they are justified (which is what you do when a signed claim is sent in) this = fraud.

Below is a link to a report by the OIG dated March or 2005, about a year before the report that you cited that shows that over 99% of a hundred sample claims from physical therapists did not meet CMS guidelines because the therapist did not maintain proper documentation, they did not meet the plan of care requirements or someone other than the billing therapist performed the services! Of the one hundred cases reviewed, therapists received $57,253 for services that should not have been billed to medicare.
http://www.oig.hhs.gov/oas/reports/region6/60300085.pdf

(MD/PT said) Now who is it that we should be concerned about when it comes to overbilling and fraud? I know physican owned PT physical therapy is a slightly different issue but if you are worried about PT over utilization with direct access look what is happening now with the current setup. Now I am not saying all PT's are perfect but 91%, come on! Physical therapy treatment should be administered and controlled by physical therapists and should not be subject to a referral requirement.

By this standard, we should be very concerned about overbilling and fraud when it comes to PT providing rehabilitation services. Physicians who billed for Physical medicine and rehabilitation only had 91% of their claims that didn’t meet CMS guidelines according to the OIG compared to PT’s who were over 99%.

Just last year, the Medicare Payment Advisory Commission (MedPAC) noted that based upon 2002 payment data, the most cost-effective place for Medicare beneficiaries to obtain physical therapy was in the physician’s office, which supports the long-standing practice of providing “therapy-incident to.”
http://www.medpac.gov/publications/other_reports/Dec05_Medicare_Basics_OPT.pdf

Average $581.00
Physician $405.00
Hospital OPD $429.00
PT in Private Practice $653.00
OT in Private Practice $594.00
Skilled Nursing Facility $868.00

Significantly, these findings were substantiated by the May 2006 OIG report which notes that despite the fact that a very small number of physicians are responsible for a significant number of claims, the average cost per beneficiary for therapy services provided in the physician’s office has actually declined since 2002, to $305 per beneficiary making it even more cost effective to provide physical medicine and rehabilitation in the physician office.
http://www.oig.hhs.gov/oei/reports/oei-09-02-00200.pdf

MedPAC supports the continued supervision of physical therapy by physicians, as discussed in a December 30, 2004 study on “the feasibility and advisability of allowing Medicare fee-for-service beneficiaries to have “direct access” to outpatient physical therapy (PT) services and comprehensive rehabilitation facility services.” The report determined that physician supervision and referral remain in the best interest of Medicare beneficiaries.
http://www.medpac.gov/publications/congressional_reports/Dec04_PTaccess.pdf

Direct access for PT’s just doesn’t seem to add up!

 

[guetzow]

One only has to read his latests posts on (DPT Practice Thread) to see that Direct Access is about SCOPE, not the Ruse of money issues (Reimbursement, cost efficiency.....whatever). This horse is about scope. RNs 'know alot' about meds and second guess docs, RTs 'know alot' about ventilators and second guess pulmonologist... but they "Don't" practice medicine. Deciding whether or not a fracture is acute enough 'to send to an FP' ('Keep them out of the loop', as Toran writes..), ordering imaging and deciding if a fracture pattern is stable, and whether or not to send to an Orthopod, are not within the purview of the Therapist. I think it's great that people want to learn how to read xrays (Just like RNs have drug books), but "learning how to read xrays does not change your scope". Really now... people who are obviously not satisfied in their chosen field need to go back to school. In this case, "Med" school.

 

[Farbar]

Good points. I will have to say that as a PT and a 4th year medical student, the idea of direct access is not a good one. It is not because PT's are not smart or capable, but rather, the current system is set up to give MD's the ultimate responsibility. That is why they pay 1,000,000 per year in malpractice as opposed to 100. Someone must be in charge and it should be the most highly trained in a broad range of areas. Most MD's no very little about PT; and they should'nt. That is the PT's area of expertise. But don't tell me a DPT has the skill in radiology to diagnose anything. All physicians spend years studying radiographs and always with backup from there attending. Even after that, it is sent to the radiologist for confirmation. One semester course in x-ray's does not prepare you to be a radiologist. Those guys do 4 years after medical school to learn. I agree with previous posts; If you want to be a doctor than go to medical school.

Farbar

 

[50960]

Nobody pays 1 mil for malpractice??? The coverage may be for 1 mil, or 3 or 5 but the cost is much lower...unless you are OB!!. Why do people try to prove how important they are by how much malpractice insurance they pay anyhow....that is really counter-intuitive........sigh 😳

 

[Farbar]

Nobody pays 1 mil for malpractice??? The coverage may be for 1 mil, or 3 or 5 but the cost is much lower...unless you are OB!!. Why do people try to prove how important they are by how much malpractice insurance they pay anyhow....that is really counter-intuitive........sigh 😳

Well, you really jumped on that one. My point was the relative cost. I have payed PT malpractice for years and it is way less than MD malpractice. You are the one who is trying to make herself important. By the way, FP has to pay the same cost's as OB because they deliver babies. Learn your fact's.

Farbar

 

[truthseeker]

Well, you really jumped on that one. My point was the relative cost. I have payed PT malpractice for years and it is way less than MD malpractice. You are the one who is trying to make herself important. By the way, FP has to pay the same cost's as OB because they deliver babies. Learn your fact's.

Farbar

That's a nice, civil reply. " am not . . . are too . . . am not . . . are too"