I'm licensed in both Illinois and WI as I live in IL close to the WI state line. Does it matter where I put my practice in terms of direct access? Wisconsin has direct access but Illinois doesn't. Is one more beneficial than the other? I'm still debating if I should put up a clinic in Wisconsin due to direct access. Any experienced practice owner?
I understand that. However, in terms of patient population coming to the clinic with MD RX vs without MD RX, is it a significant difference? I'd like to put my practice in IL, but if patient population without RX will be the issue, I'd rather practice in Wisconsin. In IL we can evaluate but can't tx without MD rx. I'd like to focus on pain management and I'd like people to come to me whenever they have pain. Would it actually matter in terms of number? I always get people in IL with referrals already on hand. So, not having direct access is not much of a problem. But I'd like to know if I'm missing patients without MD rx because they don't want to go to their MD just to get a script for PT.
Joined: May 11, 2004
You can target your marketing directly to the consumers. You don't have a gatekeeper. You can do various types of other programming that might not be within insurance plans but consumers might pay - preventative kinds of things. You would not need a referral for those activities. From a business perspective, when limitations are in place in generating business (i.e. needing a referral to treat), your target population is reduced. With true direct access, you have the full population available as a potential consumer. With co-pays and deductibles as high as they are, you better bet some people are doing the wait and see philosophy... and then at the end of the year, wham, after their financial responsibilities are used, they go to their physicians for the issues that they figured they'd wait on. What you really need to know... even though Wisconsin is direct access, that doesn't mean you would actually practice "direct access." IF the majority of the population you would treat had health insurance coverage and physical therapy benefits were only covered IF the patient was referred for services by a physician, then technically, for those subscribers it really isn't direct access for physical therapy services. That doesn't mean they couldn't pay out of pocket though...
So, if the patient is paying out of pocket, we don't need any rx from MD? I wonder if it's also applicable in states without direct access. I thought I could go cash based in Illinois but state practice act might disagree. I'll look it up, thanks!
Direct Access depends on the state's laws. Some most states allow you to see a pt without a MD referal for 30 days, some are less... some might be more. There is also a condition as to whether or not what they are seeing you for has already been seen by an MD. So, you'll have to check with the WI state practice act to know for sure. Under certain conditions you might be able to see them as long as medically necessary. Best to look it up.
To practice PT in a state without direct access, I believe is illegal. You must have that referral. (AKA: its NOT direct access). That's losing license type of stuff if something "bad" happens and you get caught. The only powers to treat with physical therapy are those that are granted by that state's practice act. You're out of your scope of practice if you do anything not on there. (Sorta like the PT's who gamble with their careers by even suggesting a pt take a NSAID to reduce swelling. We aren't MD's and technically can't even suggest it. If there was a problem and the pt says to someone "my PT told me to take this medication"... you're F'd to put it bluntly.
DA is a good step forward for PT. Unfortunately, if insurances don't pay without a referral then most pt's won't do PT without it. Why pay out of pocket when they can pay a little to see their MD, then go to you, and have insurance cover most of it?
< Message edited by Tom Peterson -- September 24, 2009 7:42:30 PM >
?Direct Access? is defined as: The right of the public to directly access physical therapists for evaluation, examination, and intervention. In other words, a member of the public does not need to secure a referral from a physician or other health care practitioner in order to receive physical therapy services. The public is best served when access is unrestricted. In Wisconsin, the law allows the public to access physical therapy directly in most instances. An individual who has been diagnosed by a physician with a neurological or medical condition who seeks physical therapy services to treat the condition, by law may directly access a physical therapist. Additionally, an individual who has experienced a musculoskeletal injury (with or without a diagnosis by a physician) may access a physical therapist directly for care of the injury or condition. In the event that the physical therapist suspects that an acute bone fracture or tendon rupture has occurred, the physical therapist must refer the patient to another appropriate health care provider (such as an orthopedic physician) before initiating physical therapy treatment. Finally, the public may consult a physical therapist directly to receive guidance in physical conditioning, injury prevention techniques, and a variety of other services.
I guess Wisconsin really has direct access to some extent. Only problems that need referral are fracture and tendon rupture! I'm so glad I have a Wisconsin license. Sitting for an oral exam in front of the board 4 years ago is worth it! Feel sad for Illinois, though.
Joined: May 11, 2004
Direct access is what WI legally allows. Direct access does not mean payers recognize that physical therapists have direct access. You first have to meet state practice requirements... you then also have to meet third party payer requirements IF you participate with the third party payers. If you don't participate with third party payers, then you just have to worry about the state practice act.
Thanks, SJ. I heard from a PT who runs a private practice in WI that insurance does not bother him most of the times treating without MD rx. The problem with the city of WI I'm close to is that they have major hospitals and clinics operating like mushrooms, they're everywhere given the small population! I know my services will be new but unique as I know the area pretty well. Also, I've made contacts thru the years I worked home health. My medicare provider number is good in IL, not sure about WI. With all the issues raised, it appears that it doesn't really matter if I'm in IL or WI. How's the cash based in your area? Do you still have alot of people doing this? In my area, I have a lot of uninsured people, IL and WI. So, I'm pretty sure I'll have to price my services low for cash based just to get them in.
< Message edited by cowboybuboy -- September 25, 2009 8:07:45 AM >
Joined: August 20, 2005
I believe it is illegal to have a dual fee schedule. You can't charge a BC/BS patient $100 for 15 min. of ther. ex, then charge a medicare patient $25 for 15 min. of ther.ex, and then a cash patient $10 for ther.ex.
I'm not sure if its illegal, but I know its unethical to charge one person one fee, and another a different fee. But reading what you said... you might have implied you will just have a low fee schedule for everyone.
If you tell an out-of-pocket person that your manual therapy skills are worth $20 per unit, how is it ethical to tell someone with insurance that your manual skills are worth $60 per unit?
This was always a big discussion in my ethics class. Basically, how would you feel that if you went to Best Buy and everyone else was buying a TV for $600... but something about "you" made you have to pay $1,300 for that same TV?
Your treatments and skills are worth the lowest amount you charge for them. You can't raise it on someone just because they are richer or because a 3rd party will foot the bill for them.... you could justify charging Bill Gates $10,000 per unit with that mentality
< Message edited by Tom Peterson -- September 25, 2009 6:43:26 PM >
Actually, what I meant was, I'll have my standard price for all insurance patients. Cash based will have a set price also. I don't think I can compare Best buy shopping with patient care. In fact, if one buys at Best buy and opt for financing, denial is also possible due to credit issues. I can't deny service due to credit but - can offer a lower price for cash based as I'm not bound by any contract. Same with giving pro bono service. If I give it for free, it's entirely up to me. I just don't see why it becomes unethical to do so.
Joined: May 11, 2004
I don't think you can do that, cowboy.... what you can do... charge everyone the same. When the person without insurance cannot pay your fees, then you "negotiate" a fee schedule that would need to be slightly above Medicare's fee schedule IF you participate with Medicare. In my opinion, we have a contract with third party payers because they are saying, "I'll only pay $xxx" and we sign the contract agreeing to the $xxx. In the case of someone without insurance, they get billed the same, but say, "I can't pay $xxx" and you create a contract where the $xxx is lower than the billed but reasonable for the uninsured. There are many specialists and family docs that do this for their uninsured patients. The patient has to contact the office though to negotiate different terms. In other words, your billed amount is always the same... the "allowed" amount or "expected" amount is what is always different.
You explained it better than I did. I know there's more to be done like making them sign a hardship contract so we can negotiate amount for the service. All in all, that's what I was trying to explain.
Joined: March 15, 2006
How is it then, that insurance companies can negotiate their own prices? We have one set fee and Medicare pays one percentage of it, BC/BS pays a different percentage, work comp pays a different percentage, Medica pays a different percentage and the poor dude with no insurance pays a different percentage (100%).
I get it. But one way to lower health care costs is to eliminate negotiations with insurors. We bill $50 we get $50. instead of billing 120 and getting 50 from one, 60 from another, 30 from another, and putting the self employed plumber in the poor house because he has to pay $120.
Joined: May 11, 2004
"Negotiate" probably isn't the right term. Third party payers are generally a take it or leave it kind of thing. I have only had luck negotiating with auto insurance payers.
The problem, Tom, is what fee schedule is "reasonable." I wouldn't trust Ingenix data. The provider will of course try to obtain as much money as possible and the third party payer will always try to pay as little as possible. It is a ridiculous game... I agree.
Joined: March 15, 2006
As I have ranted in other posts on other topics, the best way to lower costs is for me to set my price and advertise my outcomes. Let my competitors do the same. If my product/service is better at that price point I will be busy and make a good living. If I am too high, I will either go hungry or lower my price. My competitor will either have to get better or lower their price.
Insurance as a concept has gone from catastrophic coverage to "cradle to grave- i don't want to pay anything for any service" coverage. That in my opinion is one of the pillars of the destruction of American heallthcare.
You're right about setting the price and outcomes, Tom. I believe I have something excellent to offer. Most of the skills I've learned throughout the years are worth paying for. That's why I have develop a "unique" fee schedule that might work in my area. I will have the same fee schedule for all insurance contracts and I'll use that "unique" fee schedule for cash based patients without lowering my price. I believe some PTs in private practice are doing this already. It's just a matter of going around the cost to add more value to the service.
Just signed my lease today in Illinois. Any recommendations for credit card processing? I just got the lease for $350/month including utilities. Also, it includes my own billboard! I'm so excited to get this whole practice moving.
< Message edited by cowboybuboy -- September 29, 2009 2:53:43 AM >