Physical therapy services are performed by someone licensed in the physical therapy profession. This can either be a licensed physical therapist (either a Bachelor, Master, or Doctor of Physical Therapy) or a licensed Physical Therapist Assistant (Associate degree).
Aspects of our profession that are performed in the clinic are as follows:
therapeutic exercise: exercises performed in order to help a patient improve function, strength, endurance, range of motion and/or reduce pain
Neuromuscular re-education: training movement patterns, balance, coordination, kinesthetic sense (where the body is at in space during movement), posture, and proprioception (where the body is at during one moment in time)
Manual therapy: using ones hands or tools to perform massage, joint mobilization (moving individual or groups of joints), traction, passive ROM (using hands to move a joint through its range) in order to improve pain, range of motion, swelling or other restrictions
These are the most common interventions used in my clinic. Other interventions used are modalities (which may or may not have evidence to support the intervention and may or may not be covered by an insurance plan). Some are as follows:
Ultrasound
Electrical stimulation
Heat/cold
Mechanical Traction
Iontophoresis
Laser therapy/light therapy
This is still a grey area for many Physical Therapists (PTs). Although the rules are very straightforward, some clinicians never read the rules that insurance companies impose to the clinicians. When a clinician is treating a patient and is in-network with the insurance company, the PT is accepting the rules imposed by insurance companies. Medicare will pay for medically necessary services.
It is up to the PT to establish this necessity in the documentation. The PT the. Needs to have a physician or other allowable non-physician provider (think nurse practitioner) sign off on the initial documentation, which establishes the PTs plan of action/treatment/care. This plan of action must establish a few details and is valid for up to 90 days.
Let’s talk numbers. Our spending on outpatient therapy services (occupational therapy, speech therapy, physical therapy) is more than many countries spend to run the entire country. This is a very large number and insurance companies, both public and private, are trying to cut down on the total expenditures over time.
It makes sense, because expenses have increased by 6% year to year for the previous years.
It may come as a shock to many patients, but “outpatient” benefits can be used in an inpatient setting 🤫.
If you were in a nursing home, they may have used your outpatient benefits to pay for part of your rehab. This may not be the best use of your funds as seen Here and Here.
Surprisingly hospital outpatients use fewer funds than I suspected. It has been documented that many physicians are pressured to keep a patient “in-house”. This means that physicians are not “supposed to” refer a patient out of the hospital network. This keeps all of the money within the hospital to find profits. This was highlighted in a previous news Article
In a way, I’m not surprised that private practices see such a large amount of the Medicare pie, as it’s been noted how many are abusing the system for large payouts. Such as this company that settled for $7M for performing abusive practices. These practices are very common to see in the field of PT.
Patients with Medicare are only to be billed for non-group services (which by the way pay at a much lower rate), when they are actually seen one-one.
Also, patients are only to be seen by licensed professionals. This means that technicians (techs) or aides are not allowed to guide a patient through their exercise program, at least if the company plans to bill for these services. Don’t believe me…here’s another Example.
So I guess that I am not surprised by how much money is spent in outpatient settings.
Many patients don’t understand that sessions are typically billed by the “15 minute rule”. This essentially means that for every 15 minutes, or at times the better half of 15 minutes (8 minutes), that the patient will see a charge on their explanation of benefits or receipt for services.
For example, a patient may see 3 separate charges for a session if the patient was seen in the clinic for 45 minutes. It can get messy if this is not explained to the patient.
The amount of money that Medicare reimbursed is different for different areas of the country. This is based on how much the cost of performing business is within a certain locale.
Those that have Medicare have to pay 20% of accepted/fee schedule amount.
This is where things can get confusing. For instance, I’ve seen an average visit (1 hr) be charged from $360-$1200 to the insurance company. This is a huge range in charges, which is also a problem with our healthcare system because it makes it difficult for patients to understand the actual charge.
Out of the charge for an hour, Medicare will allow close to $100 depending on how that hour was broken up into charges. The other $260-1100 is written off as an “adjusted” amount based off of insurance “savings”. (This savings number is also arbitrary to make it look like you get a great deal from having insurance).
Of the $100 that is allowable, the patient is responsible for 20% of that charge. The patient can choose to have another entity, a Medicare supplement or secondary, pay the other 20%. Of course the patient has to pay a monthly premium, unless on state aid, for that other 20%.
This is a way for business to start gaming the system. They will start to shorten session lengths so that they don’t lose as much money per session. There are three separate components that go into what is allowable by Medicare. They cut one of the three components by 50%.
Companies are then shortening sessions to the least allowable to maximize charges, such as shortening sessions to 25 or 40 minutes in order to maximize their reimbursement per session. They will then keep the patient coming in for more sessions per week in order to maximize payment.
Sometimes it’s what’s best for the patient, but many times it’s only what’s best for the company.
Those companies that charge more, or are in the upper tier of chargers in our profession. For instance, in our state their was a company that was audited and asked to pay back over $600K to Medicare due to inappropriate charges.
The article can be found Here
Dr. Vince Gutierrez, PT 