PT Compliance Violations & Insurance Coverage Gaps Zoomcast Recap

Do you know exactly what is needed to keep your physical therapy practice safeguarded against Compliance violations?

If you don’t have a solid answer to this question, we can help.

There are 3 phases in the life of a physical therapy practice: 1) the Startup phase 2) the Growth phase and 3) the Mature phase (or veteran practice).

Believe it or not, mistakes can be (and ARE) made in each of these phases.

Yes, this probably should worry you. But we’re not ones to give a problem without an actionable solution! As we always like to say with Compliance, “An ounce of prevention is worth a pound of cure.”

The following information is from our most recent Zoomcast which was conducted on the 19th of November. If you missed it and would like to explore our other great Zoomcasts like this one, check out our Zoomcast vault

Let’s start with some introductions of our guest panelists.

Who is Daniel Hirsch, DPT?:

Certified Healthcare Auditor and Officer of Healthcare Compliance

A licensed physical therapist, Daniel worked in the Insurance world and enjoys helping owners protect what they proudly built. Combining his skills as a therapist, auditor and Compliance Officer, Daniel has now audited over 850 clinics. He loves teaching owners how to maintain ethics & compliance and helps identify gaps in a physical therapy practice’s Compliance program. 

He reminds his clients to be offensive and defensive when dealing with Compliance. After all, just because you have the Policies & Procedures binder on your bookshelf, does not automatically guarantee that your practice is compliant. 

Who is William Sullivan?

Executive VP of CM&F Group

CM&F group is a family owned and operated insurance company which has been around for over 100 years. They cover 100,000 clients nationally, in 200 different healthcare specialties. They’re well-versed and familiar with the physical therapy world, having worked with thousands of therapists nationwide. William’s background includes a strong focus in healthcare law. 

First question asked to the panelists: “What code am I allowed to bill for certain procedures in the clinic and how can I stay compliant while working through a full caseload?”

Daniel’s answer (paraphrased): Your resource cannot simply be Google. EMRs are helpful, but you need a resource. Templates are very helpful to record patient information. Some references give you a competitive advantage and fill in the gaps, but you need to know what the rules are, and how to apply them. 

A lot of (especially new) physical therapists get nervous about over coding. Check out Daniel’s app, PT Pocket Coder.

Daniel continues: Those with “more experience” make errors, but they’re different than the mistakes of the new grad. You don’t know what you don’t know. Unless they have a resource, people don’t really know what they’re missing. 

Compliance is a constantly moving target. Compliance today does not look like it did 10 years ago. You MUST keep a close eye on the ever-changing rules & regulations and establish a malleable Compliance Program for your practice. 

Will’s answer: physical therapists who just come out of school are thought to have the most up-to-date knowledge. So you start to see ethics and compliance issues hitting after 5+ years. You have to keep an eye on things the longer you’re in practice and the bigger your practice is. 

The bottom line is, if you’re seeing 80 visits a week versus 800, your risk exposure is different. But it still exists across the board and at every level. You still need to be protected, as anyone can try to sue you for anything. 

Next question: Why do I need to formally complete an internal audit if I have a small private practice? 

Daniel: You’re only as strong as that weakest employee. Volume may impact that, but it’s really about how you’re training your employees. The internal audit is when you review the current controls that are in place to make sure it’s all compliant and your operational procedures are working properly. For this, you want a fresh, objective pair of eyes.

There are also different types of audits, so we asked: What does a clinic facility audit look like? 

Daniel: The facility audit is assessing and inspecting all parts of the physical environment of the clinic. This impacts the rate and eventual cost of the premium. Your staff needs to know the industry standards of risk mitigation and best practices. The whole point is that this has to be checked on a routine basis. 

Daniel: A front desk audit is completely different – it assesses the workflow of that specific position. The majority of breaches we see are actually from emails. Accidentally sending to the wrong recipient, etc. 

How can I assess what items are likely to cause potential claims? 

Daniel: An avoidable cause of negligence is burning the patients. This happens commonly when the office gets busy, etc. Staff must be trained to prevent this. There are many ways to mitigate that risk, and that claim should always be zero. 

What are your most common claims that you see with the physical therapy private practices, Will?

Will: We’re seeing a lot of care that’s pushing down too hard on rotator cuffs, for instance, and the patients not having a good enough relationship with the therapist to go to the clinic with the concern, so they go the lawsuit route. Also with the burns that Daniel talked about, and cosmetic. Another simple one is just moving from point A to B! Therapists can get overambitious and negligent with how they’re managing their time and exercises with certain patients. 

Will: You also need to keep an eye on the nuances that could be happening with sexual misconduct, especially in these hands-on kinds of professions. 

Will: Our focal point is malpractice and cyber-liability, but we do recommend additional coverages. Home health can also be a hotbed for fraud. 

What about Mobile PT? 

Daniel: You are exposed when you’re doing Mobile PT, not just insurance-wise but with Compliance. You need to understand what your vulnerabilities are. Typically this is Med-B, which is regulated, and the same rules apply to you. The place of service is code 15. Home health is code 12. 

Q&A: Currently I have my own professional insurance as an independent contractor. When my business is up and running, it will just be me and I plan to pay myself a salary. Therefore, is it necessary to insure the business as well through the professional insurance? 

Will: There are multiple ways to do this. You start with coverage of yourself personally and then you have an additional insured, which is your entity. When you expand, you then make the primary insured name the LLC. You want to transition to have the entity covered. If you’re your own provider, it’s smart to have your own coverage too. However, you will be covered under the umbrella of the entity (business, hospital, etc). 

Last question: What is an example of an insurance policy a physical therapy practice should have, but typically does not? 

Will: Right now, cyber is definitely a major one. Ransomware, phishing issues, email issues. You shouldn’t just have general liability in case there is an incident. You need to make sure you’re fully covered before you even start with professional liability. 

Daniel: You need to know who’s drafting the contract, what the terms are, and you need to read it. Having your own policy is also incredibly affordable. We’re always therapists, we can’t just turn it off. 

Conclusion: being covered personally is beyond worth it! 

Final thoughts…

Daniel: You can’t anticipate everything. But you can try to mitigate everyday risks. You have to have a formal Compliance program in your physical therapy clinic. 

Will: This is the time to know what you’re doing, and make sure you’re covered before you start. 

Many owners don’t understand the risk that they take when they put off Compliance for later. 

With the guidance of a Compliance Officer like Daniel or the coverage from William Sullivan at CM&F Group, you will never have to lie awake at night wondering if there’s a gaping hole in your Compliance that could cost you everything.

Don’t take that chance, put on your entrepreneur hat and get the training you need to keep your business protected. 


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