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Re: PT's against Fraud!
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Re: PT's against Fraud! - February 14, 2002 7:54:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
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T. Baldwin:
Again.....asumptions about what I bill and do. I never said that I billed four units/hour so what's your point. I have been warned????? What does that mean. Do you think you are the only person to discuss this? Do you think you have a monopoly on ethics?
Raleigh.....As for being sensitive........it usually happens when someone is arrogant and insulting.
If you want to let PTs know what correct billing is....then fine. Talk to the people who are billing these units. Speak to the APTA and ask for clarification. Take it up with the clinic owners of some of the "mills" you keep disucssing.
You seem fairly outraged about this issue. So my question is why spend your time beratting first, the treatment team who tried to answer your question. And second, some of the respondents on this board who have very little to do with the problem you are discussing.
So.....what is your purpose.
mcap
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Re: PT's against Fraud! - February 14, 2002 9:55:00 AM
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T. Baldwin, PT
Posts: 15
Joined: February 10, 2002
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Mcap,
I made no assumptions, just simply a FYI statement. Let us compare the professional and direct comments that I have made to the obviously defensive and angry ones you have made. I have spoken to the APTA and some state chapters as well, most of which do not wish to make any sort of strong stand on this matter for fear of stepping on toes, as I have apparently done to yours. The owners of the mills in some cases as I have learned are sitting on our state boards, ethics groups, etc. Stop with the name calling, I didn't "warn" I only provided information, and I obviously do not feel that I am the only ethical person in my field, I am simply pointing out facts to those who may not be informed. Please look up the definition of "berating" and use it properly next time. I simply asked a question to the txteam for clarification purposes and pointed out inaccuracy. Again quit with the name calling. Is it really necessary to call those who post "arrogant and insulting". That is only your opinion and really isn't needed for discussion. I am the new generation of privately owned clinics and I opened doing things right, so I didn't have to break any bad habits, that is why I turn a profit. "Mills" operate in a way where they know no better and it is impossible for them to change unless the OIG were to force them to do so. The only way things will really change is if we educate the PT's who work for those mills and those who are planning to open a practice. I feel this is a grass roots effort, because there isn't much help available on the state or national level within the APTA, because there are too many people who just don't want to hear about it. You instead get in these long useless discussions about gray areas that don't exist.
[This message has been edited by T. Baldwin, PT (edited February 14, 2002).]
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Re: PT's against Fraud! - February 14, 2002 11:49:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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Good Lord!
I go away for one day to treat children in an outlying rural county, far away from my computer . . . and return to infighting and personal attacks that are getting no one anywhere.
I never thought I'd end up feeling like the parent on this bulletin board, and G-d knows I'm not the most tactfully fellow in physical therapy when I've got a passionate point to get across --- but PLEASE --- let's return to some level of professionalism here.
Let's debate the issues here, not assume and attack each other personally. I know Mcap, and can say without question that just because he's pointing out some of the realities of what's going on out there DOESN'T mean that HE'S doing it. We're all on the same team here folks --- fraud makes ALL of us sick, despite the related points of unethics that some of us are raising about trying to make ends meet. I don't work in the private sector, so I'll ask the same question as Mcap --- without resorting to fraud, and with so many PT's apparently doing so, how do so many ethical practices manage to stay afloat . . . or do they?
Mcap also has a point that questionable billing practices of some chiropractors have actually HELPED the profession of chiropractic. Personally, I don't want to go down that road --- but it is a point worth discussing.
Drew
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Re: PT's against Fraud! - February 14, 2002 1:36:00 PM
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raleigh
Posts: 14
Joined: February 11, 2002
From: Washington
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Admittedly, I don't have nearly the knowledge about the Chiropractic field as the PT field, but how has questionable billing practices by some chiropractors helped their profession? Do you mean the field in general, reputation, profitability?
I just hope that more the five or six of us are reading this forum and asking themselves about the billing practices of their own clinics. Hopefully this will get the word out, so the obviously fraudulent "mills" will have to clean up their act or risk losing valuable employees, patients, etc..
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Re: PT's against Fraud! - February 14, 2002 9:03:00 PM
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T. Baldwin, PT
Posts: 15
Joined: February 10, 2002
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Bird,
I appreciate your comments. The only part that I question is that you stated that you do not feel it is fair that we can be told how much revenue we can generate in a day. Please do not feel like I am picking on you because I am not trying to start a yelling match like what happened before with mcap. Just so you know, I am typing in a calm and interested manner. The amount of billing we are able to generate as PT's should have a limit as there should be a finite number of patients that we can safely treat at one time. Currently this has apparently been defined for us by the AMA, and I do not necessarily agree with it, but I do not wish to break the law intentionally in order to make my rent. I think that there is a way to change the way that things are, but most of the people who should be working for change are just billing how they want anyway.
Forum,
Right now I make a very nice living billing correctly, and to be honest it is much easier blowing the whistle on my competitors rather than fighting for high quantity/low quality care. In my state Medicare pays me approximately $21.00 per 15 minutes for 97110, which comes out to $84.00 per hour assuming that exercise is all that we did. I am not sure what some of you think that your time is worth, but honestly, I do not think that we should be billing out three times this amount for one therapist's time (ie. treating multiple patients at a time). So, if you don't own a clinic, maybe you now have an understanding of how much your boss is making off of you. If you work or own in a region of total HMO, capitated hell, then move. And if you do think that you are worth $300 per hour, then don't give your work to a tech. Even when I call my accountant I pay a lower price for her assistant. Another thought- if you think what you are doing can be given to a tech or assistant, is it really medically necessary or skilled treatment? Don't sell our profession short, by over delegating what we do best- patient care.
[This message has been edited by T. Baldwin, PT (edited February 15, 2002).]
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Re: PT's against Fraud! - February 15, 2002 2:20:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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Good points Baldwin. $21 per unit, working out to about 3 billable units per hour ($84) is a nice living ($168, 000) per year assuming 100% billable time. Even if you're only 80% efficient, someone is making 134,000 off of your time annually. That's all legal . . . and I find it hard to justify many of my physical therapy colleagues (myself included with a clinical fellowship, MBA, and near completion of a PhD) are worth anywhere near that amount. I can, however, bill at a much higher rate for gait training (PWBTT), and given the improved outcomes over traditional therapy alone with that, I fell VERY comfortable billing at the higher rate. Let's see --- better patient outcomes AND more money???? It's unfathomable to me as to why PWBTT isn't being used with greater frequency!
Going back to traditional therapy for a minute, in my previous example, I showed how 6 units per hour could be billed --- and how a PT could burn out quickly --- working out to roughly $252,000 per year at 100% efficiency, and 201,600 at 80% efficiency. HOW IS THIS LEGAllY BILLABLE AMOUNT NOT ENOUGH TO MAKE ENDS MEET????
Does anyone TRULY BELIEVE that his or her billable time is worth THREE TO FOUR TIMES this amount????
Drew
P.S. My girlfriend and I (she's in a doctoral level administration class as we speak) got into a heated discussion a few nights ago about a 23 minute rule. As I understand it, the 23 minute rule applies (billing 30 minutes, or 2 units for 23 minutes of time) ONLY if 2 different codes are used, and would not apply to 23 minutes of 97110 alone. Can someone please clarify . . . and if I'm wrong, bring some hot sauce for the Crow I'm going to have to eat for her at CSM????
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Re: PT's against Fraud! - February 15, 2002 9:28:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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Per the clarification I just got today from the North Carolina Department of Public Health regarding this issue . . . I'm apparently going to be eating some Crow at CSM ... pass the hot sauce. Erin was right, I was wrong.
Calculation of Units Based on Time
For CPT codes that require the reporting of time, the following conventions are used for determining the number of units for which to bill:
Time Reported Per 15 Minutes
0-7 minutes – Do not bill, 8-22 minutes – 1 unit, 23-37 minutes – 2 units, 38-52 minutes – 3 units, 53-76 minutes – 4 units
Important Rules for Reporting Time
Always count total time spent in the CPT activity to determine number of units. We’ll use a psych example so as to not offend anyone specifically. Suppose you are using the CPT code 96100 Psychological evaluation per hour with analysis of data and report. On the Evaluation Encounter form, you must record the total minutes spent in face-to-face contact with the child, the total minutes spent in data analysis and the total minutes spent in generating a report. Suppose the actual time came out like this: 60 minutes of face-to-face, 35 minutes of data analysis, and 35 minutes to write a report. Total time is 130 minutes or 2 units. If you had converted the time for each component to units first, you would have billed for 3 units of time instead of 2. This is referred to as “double dipping” – billing for more time than was actually spent. (If the child had Medicaid or Medicaid and Insurance: this example would not apply as only face-to-face time is counted and billed.) This example transencds psych though, and applies, for example, and barring conflicting codes (which is another issue entirely) to PT’s doing 8 minutes of 97110, 8 minutes of 97112, and 8 minutes of 97116. In this case, ONLY 2 UNITS OF SERVICE MAY BE BILLED BECAUSE THE TOTAL TREATMENT TIME WAS 24 MINUTES!
In other words, if more than one CPT code is applicable and time must be recorded for all codes, always add the total time for all applicable CPT codes before determining the number of units for which to bill. Total units billed cannot exceed the total time spent for all applicable CPT codes.
Example : Suppose you used 3 different CPT codes that were billable in 15 minute units and each activity took 8 minutes. If you round time for each code up, you would bill for 3 units of service. However, total time spent was 24 minutes, so you can bill for only 2 units total. Pick the two CPT codes that best describe the encounter and bill for 1 unit for each of them.
Finally, always document all services provided in the clinical record, regardless of whether a CPT code was billed for or not. If more than one clinician was involved in the delivery of the service be sure all individuals sign the report.
Dovetailing, therefore, it a little bit more reasonable than I'd orignally viewed, but 4 patients and 4 units within 6 minutes??? I still can't get that to work out mathematically.
Drew
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Re: PT's against Fraud! - February 15, 2002 2:31:00 PM
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T. Baldwin, PT
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Joined: February 10, 2002
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Drew- Well worded!!! I will have to print what you typed and use it for future discussions as I seem to have difficulty explaining this issue to others. I am especially appreciative of you also quoting the source of your information. Thanks.
Bird- Interesting concept with 4-6 patients per hour. Wow, I need to take some lessons from you in multi-tasking. I am curious to know what types of patients you are seeing- maybe if they all had the same diagnosis I could safely and effectively see all of them at once. Does your superman cape get in the way of treatment? I am not trying to spark a heated discussion of your abilities- Ihope you have a sense of humor.
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Re: PT's against Fraud! - February 16, 2002 1:50:00 AM
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henryryry
Posts: 100
Joined: September 6, 2000
From: Brisbane, Australia.
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To all:
Just interesting to listen to your discussions regarding some of the problems in the US for Physio's. I think everyone has made some valid points, but I am concerned that many people are jumping to conclusions. Furthermore, we must appreciate and respect the different opinions we all have based on our individual experiences. PLEASE~ no more personal attacks and bald assumptions and keep the discussions professional and productive!
Henry***
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Re: PT's against Fraud! - February 16, 2002 6:21:00 AM
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mcap
Posts: 652
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Drew:
In light of your kind defense of me, I hate to do this....but looking at the numbers, I just had to.........
I don't know anyone that treats with 100% efficiency and no cancelations/open spaces. So let's assume 80.
134,000 dollars at 21 dollars per unit equals
6381 units/year.
6381 units/3 units hour equals
2127 hours
Conservatively assume that you work 49 weeks (that leaves only three weeks for national holidays, vacation, sick, etc). Thats 245 days. Assume 8 hours of work each day (lunch is not included).........that's 1960 hours. Not quite adding up.
To acheive 2127 you would have to work 266 days. Or....you could work 236 nine hour days.
How much work are you expecting?
Here's another factor.........Average price of office space in NYC......40/month/sq. foot.
Take a very, very small office (about 600 square feet). Rent over one year is $288,00O/yr. This leaves us in a little bit of a hole.
Now if there were multiple therapists and the cxl rate was reasonable enough.....yes it could work but the margins would be tenuous. I also know that NYC is an extreme example and not representative of the rest of the country. And I also know that this is no excuse for some of the 4-5 patient/hour (don't know how you do it SJ - my top was 3/hr a few years ago) mills that are out there.
But.....I will say it again, the issue is more complex than that which is being presented. As SJ alluded to........if you audit the books of most clinics, you could probably find some violations.
I like Bobcat, are concerned that most therapists already have a lot on their plate. They work very hard for not so much money. The average new grad PT here earns 20,000 less/yr than a first year nurse at a local hospital. Many new grads are coming out with six figure debt.
So I would hesitate before telling them that they are commiting fraud and should have no other recourse than to take actions that will probably cost them their jobs. Should they be aware of these issues....yes. In that way...we can all work towards a solution.
Respectfully,
Mcap
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Re: PT's against Fraud! - February 16, 2002 5:01:00 PM
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T. Baldwin, PT
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For any of you who would like to see the articles that I have received my information from, you can email me at stopptfraud@lycos.com and I would be happy to fax it to you.
In my experience the tax laws are pretty complicated, but I can't cheat on my taxes in order to pay my rent. I also can't claim that I just didn't know the law because it was too confusing.
Also, as far as numbers go : $40/sq foot per month- I think you may have your numbers wrong. I believe that you told me that you didn't own a clinic so you may be confused on how this works. Usually sq foot is quoted annually- ie. I pay $15 per square foot, per year, which is around $30,000 a year for 2,300 square feet. Somehow, I doubt think NY is that much higher than where I live. I find it hard to believe that you would pay $24,000 a month for 600 square feet (even in NY), but I could be wrong.
As far as not knowing about any clinics that have been closed down by the OIG due to not appropriately using group codes- just wait a few months and I will keep you updated. Don't think they don't send people into your clinic to check you out, because they do. Starting in 2002 it is the first time ever that the OIG is required to report to congress on a regular basis as far as what they are doing to enforce the Stark laws. So they are paying a lot more attention to our field.
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Re: PT's against Fraud! - February 17, 2002 7:11:00 AM
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chipomalley
Posts: 156
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From: Baltimore, MD
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I feel that the administrator's responses in this post and in the "Reimbursement" forum under the topic "Direct one on one" were well written. My belief is that the proper forum for the endeavor should be our local, state and national organizations and I hope that all those posting do maintain membership and support in APTA. If you feel that they are not doing the right job, get involved more with their effort.
Personally, I believe the internet can provide an exciting forum to discuss our treatment related concerns, clearly it will be monumemental in moving us to evidence based practice. I am saddened though by the posts that in my view, lower our professional standards through personal criticism, attacks and counterattacks.
My own professional standards and personal values would preclude discussion of my business affairs on the internet. Discussions held in the approriate forums of district, chapter or section meetings may be more acceptable in my mind.
In summary, I think the billing questions posed here and the quest for the "right" interpretation of regulations can't be solved by any one person's contributions.
The process does place us as a group in the fray along with other providers. We do have a responsibility to police our own ranks for the benefit of our patients and the public that looks to us for care.
Chip O'Malley
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Re: PT's against Fraud! - February 18, 2002 7:18:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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Mcap,
If you're honestly paying $24,000 a month in rent, that works out to $40 a square foot. Contrary to what others on the board have suggested, $40 per square foot is about average in NYC. I understand the going rate in lower Manhattan to be around $30 per square foot, and around $55 per square foot in midtown. Like T. Baldwin, however, I understand these numbers to typically be per year, not per month.
Rent for 500 sq/ft office space Midtown = $330,000 per year if Mcap's right (and 27,500 per year if Baldwin and I are right).
Rent for 500 sq/ft office space Lower M =
$ 180,000 per year if Mcap is right (and 15,000 per year if Baldwin and I are right).
So, your point is well taken, either way . . . rent has a HUGE impact upon bottom line. So if a practice can't hack being located in Midtown AND billing legally, its got a few choices ---
1. Figure out how to sell incidentals and conveniences to patients (like pharmacists) that may have nothing to do with the services you provide. For example, the Yuppie "Weekend Warrior" that many of ya'll treat in outpatient ortho clinics may enjoy the added convenience of being able to buy not only heating pads and ice packs from your office, but also tickets to local sporting events --- your entertainment operations will, of course, charge a fee for that added convenience --- not unlike TicketMaster.
2. A VERY common complaint of PT patients is that therapy takes time out of the day that they could be doing other things, like grocery shopping, picking up clothes from the cleaners, etc. An opportunity exists to stock a convenience store with eggs, milk, etc. so that the patient can "pick-up" a few things on the way out of the clinic. Many cleaners send clothes out to a central location for dry-cleaning, the added convenience of having a physical therapy practice take care of this kind of thing (while the patient is in therapy), may be something to consider . . . The profit margins are certainly higher . . .
3. Work more hours. A 60 hour a week work week never killed anyone.
4. Hire more therapists to work early morning, evening, and weekend hours --- this reduces per capita overhead.
5. MOVE.
That's 5 suggestions that someone can legally use before resorting to fraudulent billing practices.
Again, I calculate that a solo practitioner can bill out roughly 250,000 plus unsupervised codes and incidentals (e.g. pillows, lumbar supports, etc) per year, so we'll say 260,000 as a conservative estimate.
Under your numbers, that leaves the therapist with 79,000 per year minus additional expenses (like US gel, paper, pens, etc.) Even if we assume that to be 30K --- given the numerous discussions we've had lamenting the paucity of true clinical scientists in the profession (as opposed to "expert clinical artists") are you honestly telling me that the services of the average physical therapist are truly worth more than 49,000 a year plus tax incentives for owning a small business?
If the $40 per year, per sq foot is the accurate number, that's 24K per year, not per month. $260,000 minus 24K in rent, and roughly $7500 in utilities, minues US gel, paper, pencils, computers, and hot-packs . . . is STILL a nice chunk of change.
Drew
[This message has been edited by Andrew M. Ball MS MBA PT (edited February 18, 2002).]
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Re: PT's against Fraud! - February 18, 2002 7:29:00 AM
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bendnflex
Posts: 21
Joined: February 12, 2002
From: Long Island
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Chip!
This is an open area! OPEN,,all things are W I D E open to discuss. We all know that Physical Therapy is health care and we all know, like it or not, health care is a business. My goal here is let others know what is correct as a business. Those P.T.'s who care can take it to their state Pt
assoc. in hopes it will get to the A.P.T.A. not as one person, in one area having questions but, P.T.(s) in a few states questioning the billing laws. That my friend is called a grass root effort. I can not think of a better way to do it. No one likes to hear the word fraud but, there is fraud out there. Tell your friends, spread the word. The O.I.G. is coming to a town near you. T.Baldwin is correct! I refuse to compete with clinics who up-charge, stating there is alot of gray area. When in fact that gray area is making them alot of "green" via fraud. If you do it in my town and I find out. I will be the first to turn you in. STOP the fraud, know the law! If you can't figure it out, hire someone who can. The tax laws are complicated that is why I have an accountant. Wow! I am always amazed about the P.T. attitude of I just want to talk about therapy not numbers. Those days are over numbers are not just how many patients your clinic manager made you see. They are about making your clinic manager bill correctly and not putting your hard work and your degree on
the line. Knowledege is power!
[This message has been edited by bendnflex (edited February 18, 2002).]
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Re: PT's against Fraud! - February 18, 2002 8:11:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
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Drew and Baldwin:
I stand corrected. It is good to know that the rents are per year!!! I did seem a bit high. As for 40, that, to me was a conservative estimate. I have seen higher figures and some that were a little lower, so I am guessing that 40 is a relatively conservative number.
I honestly don't know what it is going to take to change things. A grass routes effort would not hurt. And, I agree that the average therapist should be more knowledgable and should be aware of what's going on around them - the bills go out in their name and with their numbers. I just had a friend tell me that he found out that his clinic was billing for the same three codes for every patient whether appropriate or not.
It is just difficult to see what is going to happen to the average PT who (wrongly or not) isn't is much of a position to do much about it. Yes.....they could make the case for change, or start their own place or move on. But most PTs I know are struggling to simply pay rent and their student loans. Add this to it and they will just leave the field.
This is not an excuse. And I agree that the billing mills reduce quality of care, ruin our public image and pay PTs very little while they get rich!! I am on your side as far as that one goes. But new students are coming out with DPTs having financed 3 years of graduate school. I just don't see them going to the barricades on this one even if it would be better for them in the long run. Some movement and clarification from our professional association would be better.
I have written three APTA presidents on various issues in P.T. All three of them wrote me back personally and promptly. Why don't you see what he has to say????
mcap
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Re: PT's against Fraud! - February 18, 2002 11:35:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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What's our problem? Other clinical doctorates such as Dentists and Optomotrists certainly don't marry themselves to insurance, and they do just fine.
Why?
Because the public sees thier services as both unique, and valued. Such is not the case with physical therapy . . . yet.
I suggest that the REAL reason that so many slimeballs double-dip and bill fradulently is an issue of self-lothing, recognizing that in a free-market, much of physical therapy wouldn't survive. If that's the case, then physical therapy isn't the profession I thought it was . . . if that's the case, then technically, it's not a profession.
The DPT's tend to have a different approach. Most of them don't give a **** one way or the other what insurance will or will not pay. Like other clinical doctors, they are thinking outside the box and expect (like DDSs, DCs and ODs) to be paid out of pocket and help the patient file their insurance for reimbursement.
Why are the "experienced" artists so afraid of such a model? I have my ideas, but I'll keep them to myself . . .
Drew
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