Tag Archives: pt

Value of Onsite Physical Therapy

Physical therapy can be one of the biggest cost drivers of a workers’ comp claim. In addition to the treatment itself are the expenses for travel and the employee’s time away from work. Onsite clinics can reduce the expenditures. They are cost-prohibitive for all but the largest companies, but many organizations are starting to turn to an alternative that combines the need for easily accessible PT at a cost comparable to or lower than clinic-based therapy.

Called therapy on demand, onsite PT involves a physical therapist going to the injured worker’s worksite — or home, in some cases — setting up equipment he brings and spending an hour focused solely on a single injured employee. Contrary to what some industry practitioners fear, the logistics are fairly simple.

“All we really needed to provide was a room that looks like a big closet; a room big enough to fit a massage table,” said Sandra Palacio, a claims adjuster at Royal Caribbean International. “We had several meetings before we put this in place. We tested it out for the first week or two, got great feedback and have continued to use it. It’s been a great experience.”

See also: Therapy Charges Are Being Inflated  

Royal Caribbean teamed up with OnSite Physio, a mobile physical medicine company, to treat injuries sustained by the cruise line’s newly hired dancers and actors who train at a Miami-based facility. With the need to keep the entertainers away from work as little as possible, onsite PT has been a natural fit.

“The dance studio is a unique system where they are only here for four to six weeks, so we need to have medical appointments on a fast basis,” Palacio said. “OSP has been great in that they come to us, get the person treated with PT, and injured workers are back doing their normal daily activities within an hour.”

The fact that the workers can stay at their workplace for treatment eliminates the costs for travel and lost work time. Some companies have reported savings of as much as 30% by using onsite PT services. One, Marriott International, will discuss the results it has seen during a session at the National Workers’ Compensation and Disability Conference & Expo, Dec. 2, in New Orleans. (For a reduced registration rate, visit www.onsite-physio.com.)

Focused PT

Among the cost savings reported are fewer PT appointments needed. The one-on-one attention given to each injured worker — often by the same therapist for the duration of the treatment — and being at his workplace allows the therapist to target each patient’s unique problems and job tasks, which can result in quicker recoveries.

“In a clinic, I might work with Mrs. Smith for 10 minutes, then Mr. so-and-so, then Mr. Brown. It’s this constant juggling act while you are in the clinic because, unfortunately, that’s just the model of outpatient PT,” said Daniel Sanchez, a physical medicine expert and a founder and VP of operations for OSP. Working onsite, “there is an ‘aha’ moment, when you realize you can do so much more with this injured worker than you ever could in a clinic. You have that one-on- one time with the patient so we get to really see and put into practice our treatment alongside what it is they do. We can perform therapy that is more meaningful, treatment that is work-related and more transferable to the real world. In a clinic, you have to simulate those things.”

RTW

A key difference between clinic-based PT and onsite is the focus on returning the employee to work. Sanchez makes the analogy of treating an athlete. “If the quarterback for the Jets gets a sprained ankle…what do they have onsite for the injured worker?” he asked. “They have people who specialize and treat them to get them back to their job. They are worried about whether the quarterback can get onto the field and do specific things. All of his treatment is around that.”

That same type of thinking is at play with onsite PT companies such as OSP. One of its clients, for example, is a solid waste disposal company. While the workers in that industry no longer do as much manual labor as they did years ago, workers nevertheless sustain injuries. Repetitive motion injuries to the hand or elbow are typical, as are twisted knees and sprained ankles from getting off a truck improperly.

See also: Employers Solving Healthcare Crisis One Onsite Clinic at a Time  

“If I say, ‘this is a garbage worker,’ and I am in a clinic, I used to think I knew what that meant. Not until I did a ride along and looked at how they are pushing, pulling, spending time sitting in the heat, did I understand what the job entails,” Sanchez said. “In a clinic, I might have that worker going up and down steps. Onsite, I can train him right on that step. It’s the actual piece of equipment he uses, so his treatment is 100% functional. We’re taking the time to really understand what they do and tailor the therapy to it.”

While onsite PT is not necessarily the best option for every injured worker, advocates say it offers many advantages over clinic-based therapy. “I definitely see this as a great benefit to companies that have a lot of workers’ comp claims because they can have the worker at the office, have OSP come and within an hour that worker can be back to work instead of the worker having to leave the job early just because he has to travel early and probably is not able to return that day,” Palacio said.

End the Dysfunction in Functional Exams

Functional capacity exams (FCEs) are in dire need of quality standards. Employers who want better workers’ compensation claim results must take the lead.

The FCE is intended to objectively test a patient’s thresholds of pain, strength and movement. An FCE should play a major role in things like qualifying a claimant to return to work, ascribing reasonable permanency awards, calculating objective settlement valuations, indicating malingerers, providing defense evidence and essentially helping you close cases.

As I see it, the FCE has been under a quality assault because of fee-squeezing managed care schemes. Managed care means only steering work to those “in-network,” which emphasizes use of the lowest-fee providers. The overriding value premise of “managed care” is fee reduction, not quality assurance.

As such, the peripheral specialty of functional exams has gone unchecked. They have become a perfunctory step in a chain of litigation activities, conveniently extending an adjuster’s diary with the appearance of action. When was the last time your WC case turned on FCE results? When was the last time your defense counsel’s essential witness or deposition list included the FCE provider? The answer may escape you, just as has the missed opportunity to leverage and move churning cases.

Quick Tip: Demand Quality FCE Standards and Expect Actionable FCE Results

Institute FCE standards in your claim account service instructions. Craft them from the checklist to follow. Require that you or your WC coordinator pre-approve FCE referrals to ensure quality in the application and outcome expectations. Along with selecting a quality provider, you need to provide adequate medical history and other background while asking specific questions.

When it comes to provider selection, apply this quality-question checklist:

Who is performing the test and what is her certification? Demand licensed physical therapists, optimally with enhanced related certifications. Do not accept PT assistants, sports trainers, vocational counselors or others who are less qualified.

Is modern computerized instrumentation used for validity? Do not accept manual systems, which involve subjectivity and simple gauge reading. For example: A manual hand-squeeze test shows pounds of squeeze strength, while modern testing measures isometric contraction and provides an actual “force curve” indicating effort, true point of muscle fatigue and pain. Simply stated, modern computerized systems can indicate real physical capacity while pointing out faking subjects.

Will raw data be fed into appropriate computer applications for reliable objective results? Functional exams need to process individual body-part tests and things like coefficient of variance formulas to ascertain whole-body determinations such as “lifting capacity” or other job-specific activities. Calculating these aspects by hand, based on assumptions, is not reliable, and the results may crumble under legal cross-examination.

Will heart rate and blood pressure be monitored during testing? This is essential to establishing consistency and overall patient effort.

Will the process measure distracted testing? This is a specific technique whereby one test is cross-checked by the appearance of a separate test. For example, back-bending angles are first tested; later, a “straight leg raise” test is performed, which actually re-creates the back bending angles and can be compared with the thresholds of prior back-angle results. This is a critical part of establishing patient credibility.

Will the results be admissible as strong evidence? Adherence to aforementioned aspects combined with early communication and input from defense counsel will strengthen evidence.

In conclusion, employers must confront a status-quo claims service process to demand FCE standards. Agree to pay for higher-priced FCE providers if you can establish the appropriate quality level. Pick your cases wisely and use detailed oversight. The power of a good FCE will help you move cases.

Therapy Charges Are Being Inflated

Your physical therapy (PT) costs may be $15 to $19 per visit higher than they should be. Here’s what’s going on:

It’s common for therapists to perform multiple procedures at the same time on a single body part. Under nationally accepted standards (under the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative), the therapist is to be reimbursed for only one of these procedures. Sometimes, it is appropriate for the PT to bill for multiple procedures — for example, if two procedures commonly done simultaneously are performed at separate times. But, unless the therapist adds a special modifier to the procedure code, only one will be reimbursed.

If multiple procedures are to be reimbursed, the “59 modifier” is added to the end of the CPT code, and the treating provider documents the reason for the variance in coding in the medical notes. The 59 modifier should be on about 11% to 15% of lines on PT bills.

But some payers are seeing 59 modifiers on almost ALL BILLS. It appears the 59 modifiers were not added by the therapist; they were added by a PT network company.

There’s no explanation in the treatment notes for this billing practice; no evidence the affected procedures were actually performed at separate times; no indication the PT network company reviewed the treating provider’s notes prior to upcoding. No documentation, no record, no history.

It appears that the intermediary was adding the 59 modifier as an automated system edit without reviewing the treatment notes. The systemic upcoding has resulted in higher costs for payers.

You should look at bills processed between 2009 and 2014:

  • If more than 20% of lines on your PT bills have the 59 modifier, you MAY have a problem.
  • If more than 40% of the lines on your PT bills have this modifier, you DO have a problem.

For the full blog from which this is excerpted, click here.

Is Controlling Workers' Comp Costs Really the Answer?

The agendas of all the big workers' compensation seminars agree. Controlling costs is the biggest and most pressing issue. Some might say it's the only issue. But I wonder if this emphasis isn't counterproductive….

The regulatory side

From a regulator's point of view, cost control is accomplished by imposing restrictions, by establishing fee and treatment schedules and, occasionally, by providing incentives that encourage the desired behavior. At bottom, the basis of regulation is distrust.

Controls are generally set to make everyone play by a single set of rules that allow the illusion of predictability and fairness.

I say “the illusion” because a clear understanding of the most common style of regulation shows a dysfunctional relationship. The regulator issues a regulation controlling, say, billing by physical therapists. The physical therapists will always collectively understand their business better than the regulator and will soon find a way to “work around” any portion of the regulations that they find objectionable. The regulator will eventually become aware of the “hole” in the regulations. The regulator will then move to reassert control by tightening the regulations, only to start the cycle all over again. 

In the meantime, the regulator comes to believe that the stakeholders (physical therapists in this example) cannot be trusted. The stakeholders have to be ever more closely controlled. When that fails, it “must be” because those pesky PTs are trying to make excess profits; the belief that they are self-serving becomes entrenched. Multiply this phenomenon by all of the various groups of stakeholders and service providers, and you see the atmosphere of “us against them” that is all too common in regulatory circles.

The trouble with this pattern for controlling costs is that it really is a cost driver. Every time the regulations change, two things happen. 

First, the change itself is costly. Computer programs have to be changed. People have to be retrained. Time that used to be spent doing the work of the industry is spent doing the work of the regulator. At the end of the day, the passive-aggressive resistance of the industry will win, and the cost of cost controls will outweigh the savings.

Second, the services to the injured get constrained by the cost controls, and the ability to provide individualized services suffers. One size does not fit all in injury management, and attempts to make it so usually end up fitting virtually no one.

The claims side

When the claims payer tries to impose control costs, the result is a different kind of cost driver. Once again, the whole system is based upon distrust. The claim must be investigated before it is accepted –even though only about one in 20 of the claims reported for suspected worker fraud justifies a finding of illegal behavior.[i1] Rehabilitative services that the research clearly shows are most effective if provided within the first days of the claim are delayed because this claim just might be the one in 20 (or worse, in a cynical attempt to save money by getting the injured worker with a legitimate claim to “just go away.”) Unfortunately, the delay of necessary services makes the claim more likely to become complex, more likely to attract the ungentle ministrations of the lawyers[ii], and less likely to resolve uneventfully.

Not only does the delay hurt, but the process of investigating the claim creates its own opportunities for adverse outcomes. Investigation is a statement of distrust. Tell the worker that you question whether she is really as hurt as she claims, and the natural reaction is to push back and try to prove that the injury really is severe. Sometimes, in that process, workers become attached to the belief in the seriousness of their injury, with unfortunate results.

Medicalization of the claim often occurs in the process of seeking a diagnosis. The diagnosis is not necessary for treatment of the injury in many cases – conservative care for, say, lower back pain is the same for the first few weeks whether it has a diagnosis or is just unspecified pain. Yet, because of the payer's distrust of the claim, we routinely get a diagnosis even though that risks losing control of the claim. 

Once the claim has been accepted, the scrutiny and distrust continue, again in the name of cost control. Adjusters and third-party payers have to justify their work, so claims are scrutinized. Frustration, delay and anger may be created in another self-perpetuating cycle of distrust.  

The outcomes of this dysfunction are often visited on the injured worker, in the form of reduced or curtailed injury management and lack of time for patient education that has proven value in durable recovery. 

We fail to realize that many cases of failure to recover as anticipated are caused by distrust, expressed in the system as cost-control measures. Moreover, the evidence is overwhelming that claims with unexplained failure to recover make up a large percentage of the 20% of claims that result in 80% of our loss costs. We might save a few dollars on some claims with our cost-control scrutiny, but at the risk of creating unnecessary complex, long-tail claims. We also risk pushing some of the cases into becoming one of those relatively rare cases of genuine misconduct, as people try to make the system work for them, in any way they can.

So, where are the savings?

A way forward

There are many other ways that cost controls actually become inadvertent cost drivers in the system. I'm not going to belabor the point further, because the important take-away is that an alternative exists. If 20% of claims create 80% of costs, then any efforts to prevent claims from falling into that 20% are heavily leveraged in their cost-savings impact.

If we want durable and sustainable cost control, the first step is to understand the dynamics that allow some people to recover and thrive while others with similar injuries spiral down to despair and dependency. While there isn't the space to discuss that topic here[iii], a better understanding about what helps injured people to avoid becoming “disabled” almost certainly leads to real and sustainable cost savings. And the distrust that currently permeates our systems isn't any part of it.

We created our situation, so we ought to be able to control it. Einstein said: “Any intelligent fool can make things bigger, more complex and more violent. It takes a touch of genius – and a lot of courage – to move in the opposite direction.” Our current fixation on cost controls certainly makes the system more complex and full of new players eagerly selling us the latest magic bullet. The understanding to move us in the opposite direction also exists, if we can find the internal fortitude to use it.


[i1] The 5% average comes from presentations at the National Workers' Compensation College, International Association of Industrial Accident Boards and Commissions, 2004-2006, and from the author's own personal observation while supervising the New Mexico Workers' Compensation Administration fraud investigation unit over the course of five years.

[ii] See Aurbach, R.  “Suppose Hippocrates had been a Lawyer,” Psychological Injury and Law, Volume 6, pages 215-237, 2013.

[iii] See Aurbach, R. “Breaking the Web of Needless Disability” Work: A Journal of Prevention, Assessment and Rehabilitation, http://iospress.metapress.com/content/y50n1479vj054364/?p=7d6ab3539cd840bea6e14dbe8f2874dd&pi=0