of a physical therapy clinical reviewer
Part 1 Sing-A-Long
To the tune of “A Day In The Life” by John Lennon/Paul McCartney. Lyrics by me 🙂
I was in the news today, oh boy
Just a lucky man who made the grade
And though the news was rather glad
Well, I just had to laugh
I saw the photograph
I blew my soul out in a clinic
I had noticed clinic life had changed
The crowd of patients stood or stared
They’d become numbers filed in a drawer
Not really knowing what career was being worked towards
I worked from home today, oh boy
Took my kids to school in the car
While a crowd of people drove away
But I just had to look
At all that time it took
I’d love to tell you more:
Woke up, fell out of bed
Dragged a comb across my head
Found my way downstairs and drank a cup
And looking up I noticed I was (not) late
Didn’t need my coat or my hat
Donned slippers in seconds flat
Made my way upstairs to start at work
Logged on and checked the emails from my team
I read the PT notes today, oh boy
Four thousand visits all from my peers
And though they said they were to prevent a fall
I then had to count them all
Now they know how many visits they get to prevent that fall
I’d love to show you.
Part 2 The Narrative
When I was first converted to a new life as a clinical reviewer I tried to hide it from all of my professional friends and colleagues. When asked at conferences or meetings what I was up to I came up with sly, vague updates like, “Oh I am just doing some therapy work from home”, “I found some consulting in authorizations” or “LOOK! A squirrel!! (followed by a quick exit)”. Over time though, I have come to realize there is good reason for clinical review and utilization management. More so, I have found there are MANY with desires to be in the same type of work. Many that have discovered, for them, that clinic business is not what they had pictured and there must be something different. I will likely share much about my experiences and work through out other posts. To share what I have learned about our profession and what we can each do to uplift physical therapy. First though. I want to give some perspective on what I do as a clinical reviewer each day.
Please understand that there are many companies that offer rehab clinical review positions. Not all of them will have the same work standards and policies. This is just a look into my day. There will certainly be similarities, but I am just one individual. With that said . . .
Yes, I have worked in my pajamas before. It was cool the first 30-40 times. It can start to be a bit depressing though. I have since upgraded to sweatpants. That happened after the one day I went to pick up my kids from school and realized I was at their school in my pajamas. Yeah, that was rock bottom!
Currently, I am scheduled to start work in the late morning every day. The company I work for has to cover being “open for business” from 8-6 PM for EST, CST, MST, PST time zones within my division. So I am one of later workers. My commute consists of 12 stairs and about 5 ft of hallway. I do have a set schedule and I do clock in. I don’t get to just work whenever. I have a company computer that logs me into their site. I check messages and updates and then pretty much get working. There are about 30 remote reviewers on the team I work on. All are rehab professionals of one sort or another, PT, OT, Chiro, Speech. For each of us, our primary work is to review requests for additional skilled care services sent in by providers. It sounds basic, but there is so much more to it.
Once I am logged in and ready the cases start coming! I work one case at a time (as does everyone else). Request cases are defined by a few different identifiers: diagnosis, age, and provider type are the primary ones. Based on my clinical experience I review primarily orthopedic physical therapy and occupational therapy cases. I do have the ability to help with some neurological cases as well. I do not review pediatric cases. Those are done by pediatric specialists. (I am currently doing some puppy clinical review cases though as everyone knows those are the first step before taking on children).
Reviewing a case can vary based on the case. I am required to look at all the clinical information provided by the physical therapist, etc. First steps are to make sure the information matches with the patient in the system and type of care requested. I have to check the state and health plan company as each has different requirements we must follow. From there I review the current information provided. Then I review past information provided as far as needed to see patterns, progress, lack of progress and just get an understanding of what is going on. Once I can determine if significant progress has been made or not over an appropriate time frame then I have to look at when care started and what the current plan of care is assessing of the situation. This gets compared with clinical practice guidelines.
With all of that data in front of me, a decision does have to be made. For those with appropriate information (look for more on this in future posts) and plan of care, additional visits are generally allowed. Unfortunately, the rehab world is not all rainbows and leprechauns. Not every request is going to be appropriate. You will see this as I share more experiences in future blogs. I thought I knew what a “numbers mill” was before I started this non-clinical physical therapy career. Wow, have my eyes been opened. Suffice it to say, there are cases that are not appropriate and they don’t support additional visits. Those are decisions I do not take lightly.
For the most of the day that is how it goes, complete . . . repeat. As soon as one case is completed and notes are entered I move on to the next. One might be for a 65 year old female who is 12 weeks out from her hip replacement. Then the next could be for a 16 year old male with anterior hip avulsion who just can’t seem to stay away from football two-a-days. One case might take 15 minutes, when another might take 45 minutes.
Part of my typical day I also work on more complex cases such as those that a reconsideration or appeal has been requested. The process is similar, but again, all the information has to be taken into account and any decision has to be supported in my notes on the case. These notes include significant information from the provider, what may be lacking, what is recommended by current evidence and what is supported under the definition of medical need that the health plan has adopted.
Throughout the day I can also be asked to respond to a provider’s request for a peer to peer discussion. A chance for the provider to give additional information and perspective or to ask questions about a previous case. I won’t say any more as I have plans for a whole post on peer to peer conversations.
Some days we have team meetings or training that are done via web portals. We discuss current best evidence and difficult cases. I have also been able to work on updating and creating clinical practice guidelines that are used to guide our decisions. Generally in the first of every year some of us in the team work together to go over the best evidence that can be found to support and update the CPGs. Any evidence we use to support the CPG has to be of high standard (you heard of PEDro? No, not the “vote for Pedro” Pedro. Physiotherapy Evidence Database. So, we are talking 6 or higher on their scale). So some days have been spent deep in published practice guidelines, systematic reviews and randomized trials; only to find little to no support for much of what is called “physical therapy”.
For the most part, that is my day. Looking at your paperwork! (some of you should be extremely proud . . . and to honest, some of you are flirting with an audit; not just flirting, like dirty-dancing flirting! So watch out). There are other side projects and complex cases. As a team we constantly are consulting each other based on each others skills. I DO NOT have a specific daily quota. I AM NOT required to complete a certain amount of cases as denials. I AM a licensed DPT. I AM NOT scared of being in the clinic and I (and most of the team I work with) keep some part time clinical hours each week as well. I currently work with adults with disabilities and fall prevention.
Working from home is both a blessing and a curse. I do not miss a commute. I do miss social interaction. I very much enjoy being able to take a short break when needed. My break sometimes means unloading the dishwasher, taking out the trash, or in the winter shoveling show. I have learned my pajama lesson. I love only getting gas like twice a month!(for my car you sicko) I love being more at home with my family, but it can be very hard to be at home but “working” with family. I love seeing how providers are caring for patients on a national scale; but I also dread seeing how some are not caring for their patients and giving cause for people like me to have a job.
I log off for the day. Trudge down my 5 feet of hallway and 12 stairs. Then give my attention to my wife, kids and chickens. No really, we have backyard chickens.
Would love to hear your questions. Thanks for reading, and singing, along.