Do you currently offer rehabilitation services or physical therapy to patients in your practice but are unhappy with the return?
Are you unsure about who can perform rehab services in your state? Is your practice in compliance with state and federal regulations? And how do rehab services integrate with a cash- based practice?
If you are thinking about adding rehab to your clinic or are having problems making it profitable, this quiz just might have the answers to your questions.
Know the difference
Many doctors make the mistake of using physical therapy interchangeably with rehab in their notes—and sometimes in their marketing. Be aware that they are not the same. Strictly speaking, physical therapy consists of passive modalities such as heat and electrical stimulation, and exercises performed by a physical therapist.
Rehab therapy may consist of the same modalities and exercises, but it is not necessarily performed by a physical therapist. This distinction has relevance to marketing and compliance and billing issues.
In most states, a chiropractor can perform rehab therapy; it’s within the scope of practice. In some states this is limited to the spine. An important exception is Medicare, which will only pay for rehab or physical therapy services performed by or under the direct supervision of a licensed physical therapist or physical therapy assistant.
These rules have important ramifications for billing and documentation. If a chiropractor is billing for services performed personally, then it should be billed with the chiropractor as the provider and specified as rehab and not physical therapy.
Who is doing what?
Another issue is billing for rehab services performed by athletic trainers, massage therapists, and other non- physical therapist providers under the direct or indirect supervision of a chiropractor. Medicare strictly enforces the rules relating to who can perform physical therapy and applies them to the person who is actually performing the therapy (regardless of who is supervising).
Private payers have been increasingly asking who exactly is performing the therapy and they are denying claims for therapy performed by non-physical therapists, but billed under a directly or indirectly supervising chiropractor. In one case, a practice was asked to provide the license number of the person performing the service. To make matters worse, this principle has been applied both to pre-payment audits leading to denials and to post-payment audits leading to requests for returns of payments made.
You may be wondering if this also applies to therapy performed under the supervision of an MD. The answer is “yes” in most cases, because massage therapists and trainers are not licensed to perform physical therapy. Medicare will pay for such “incident to” services under an MD, but only when performed by a licensed nurse practitioner, physical therapist, or certified nurse specialist. Of course, doing it this way would be extremely unprofitable.
Making the sale
The person doing the therapy has important implications for marketing. The physical therapy lobby is strong and they have succeeded in getting laws passed in many states forbidding the advertising of physical therapy and even physiotherapy services, except those performed by licensed physical therapists. They are highly protective of their turf.
There are cases in which chiropractors have advertised physical therapy services and have had complaints lodged by competitors to their boards. In several cases, this occurred even though the chiropractor had a physical therapist working in the practice. This is less of a problem in big cities, but should be considered by those in a rural or suburban practice. Following the rules will generally provide you with immunity from such frivolous complaints.
The road to integration
There are three main paths to integrating rehab in your practice. First, you can hire a PT but not have an MD in the practice (DC-PT practice). Second, you can have both PTs and MDs in the practice (DC-MD-PT practice). Or third, you can do it yourself or hire another DC to do rehab and bill care as chiropractic for those states where it is in the scope of your license.
Hiring the PT without having an MD has the advantage of being less expensive, but there are some disadvantages to the DC-PT setup. The main drawback is that you will not be able to do rehab with Medicare patients. This negates one of the biggest advantages of having a MD on board. Only an MD can write a prescription for physical therapy for Medicare patients. This opens up another world of patients you have not been able to see profitably as a chiropractor.
There are some cases where chiropractors have been able to make a DC-PT practice work by having a close relationship with a family doctor or orthopedic surgeon who would work closely with them, and write the Medicare PT prescriptions, but you will definitely lose complete control once the patient leaves the office. There may also be some legal issues with such a referral arrangement.
It is thus recommended to hire an MD and a PT for maximum profitability and flexibility. An exception to this would be if you only want to see PI patients in a state where the reimbursement is the same for services performed by a chiropractor they are for MDs or PTs for PI patients. And opening your practice to different types of clients is a good hedge against decreased reimbursements by the various third-party payers.
Providing physical therapy and medical services reimbursed by Medicare and private insurance, such as trigger point and joint injections, can open the door to adding cash-based physical medicine services. These might include platelet enriched plasma injections, stem cell therapy, IV therapy, laser therapy, and spinal decompression. If you are not doing rehabilitation and physical therapy in your office but are thinking about adding some cash- based services, now is the time to consider the possibilities.
Marc H. Sencer, MD, is the president of MDs for DCs, which provides intensive one-on-one training, medical staffing, and ongoing practice management support to chiropractic integrated practices. He can be contacted at 800-916-1462 or through mdsfordcs.com.