A Big Problem in Physical and Occupational Therapy
This new year 2020 has every physical therapist, occupational therapist and speech therapist on pins and needles as to how clinics and rehab centers are going to stay open. Opinions, rumors and even conspiracy theories abound in regards to the major payment changes Medicare introduced late 2019 and just recently January 1st 2020 (Currently referred to as PDGM and PDPM ).
These changes frightened many rehab companies to mass layoffs and salary reductions for PT, PTA, OT, COTA and other rehab staff. These layoffs came with little to no warning nor any waiting period to see how all this would play out. The ethics of these companies have certainly been in question due to their shotgun reactions.
The purpose of this article is not to delve deep into the history and workings of CMS nor is it to fan the fires of rumors and theory as to what is going to happen. This article is about solutions and how you can be a part of them. Before we get to those solutions I do want to give just a touch of perspective for better understanding as to the solution presented shortly.
Really, I could sum it up with “Well, Medicare did warn us!”.
I graduated with my doctor of physical therapy degree in 2006, prior to this I was working as a PT Aide for a large hospital based PT clinic. This was back as early as 2001. Back then managed care was just making an entrance into physical therapy. As an aide, one of my tasks was to track the various forms health plans were now wanting, including Medicare 700 and 701 forms, for the PT team I was part of. Each year at this clinic we would get additional training on small changes to these forms and other requirements. In these trainings, there was always some education about fraud in healthcare and physical therapy . Each year that training became more involved and more specific.
Once in PT school and even in the first few years out of school I recall starting to hear how Medicare was going to ramp up audits (here is an article from 2006 talking exactly about this) and investigations. Payments started being capped. They started requesting functional reporting. We fought about the CAP. They mandated functional reporting. Back and forth with each new policy. Each time more training, more warnings about fraud, waste and abuse!
All this while Medicare increased the use of these audits and investigations. They find more and more evidence of fraud in rehab care. Why? Could it be because so many clinics and facilities would find anyway they could to maximize billable units despite proof of needed care? Could it be that Medicare started to see that there is no way every patient in one facility needed the maximum allowable care?
Medicare started to realize their warnings were not heeded and the leaking money had to be stopped. They dropped the hammer! Major reform in how care is paid for has now begun. We forced their hand. These recent changes may only currently affect parts of long term and home health care; but could this just be the beginning?
If you read between the lines of my quick and basic synopsis you will see that what really led to the current situation was wasteful and fraudulent healthcare practices by unethical providers and companies. These may have been a minority, but their acts have affected us all. The interesting thing is that, just like for me, many of these companies and their employees are required to go through fraud, waste and abuse training on an annual basis. I am sure most reading this will be familiar with this training. So I will assume anyone reading this has at least basic knowledge of fraud, waste and abuse.
So let’s talk about what we can do to help stop this unethical and unlawful behavior. What we can do to prevent further sweeping reforms. What we can do to help lift the reputation of rehabilitation care nationwide. We need to apply the current saying being used for when we see other crimes being committed. We need to “SEE SOMETHING, SAY SOMETHING”.
Whistleblowing = Saying Something
We need to face it, we are no longer on the school playground where we could get beat up for tattling on Jimmy for kissing Jenny at the flagpole. Health care waste, abuse and fraud in physical, occupational and speech therapy needs to stop; and it won’t without our help. There is just too much of it for the investigative agencies to find it. If we want to preserve our careers and the ability to give much needed care to those that really need it we need to be willing to speak up.
Try this right now – Open a new tab and follow this link to search the US Deptartment of Justice website for “physical therapy”. At the time I searched the DOJ website it brought up about 3700 responses!
Take a quick second and just add up the amounts of money highlighted in the above snapshot when I searched the website …$2.05 BILLION in fraud related to physical therapy, and that is just the first 7 responses of 3700. What is the total for your search?
Yes, I agree with you. Reporting fraud in healthcare is a scary proposition. Fear of getting found out. Fear of getting fired. Fear of retaliation. Fear that maybe even you would get named as part of it. But who better to do it than those of us that see it happening everyday. We need to take a dose of our own medicine here. How many patients do we help face their fear of pain, falling, injury, weakness, returning to work, playing a sport? We must face this fear.
How This Can Help
We need to look at our profession as a whole and not just as an individual; and see that every occurrence of fraud or waste hurts our reputation and has many other associated costs. At a time when many of us are worried about job security, declining reimbursement and time consuming reforms we cannot afford to miss the impact of this on each of us.
We have a duty to our patients and our profession to work together in stopping those that commit these fraudulent acts. We need to show society, governments and payers that the majority of us are honest, hard-working therapists. We also need to show that we recognize fraud, waste and abuse as a problem within our profession; one we want to bring to a stop.
In a 2016 PTNews article, by the American Physical Therapy Association, Roshunda Drummond-Dye, JD, APTA’s director of regulatory affairs said, “Over the past few years, we’ve witnessed stepped-up efforts by the federal government to root out waste, abuse, and fraud, an effort very much supported by APTA.”
This article continued in pointing out that whistleblowers were responsible for initiating investigations for two very large cases. Some of those were specifically physical therapists that had worked for the company. Some of you may recall a $7.1 million settlement against Drayer Physical Therapy a few years back? That investigation was started by reports from physical therapists that decided to say something.
$2.05 billion and much more! Remember that amount from our little math exercise at the beginning of this article. How many more patients could have been helped with that money if it was used honestly? What kind of impact do you think all that wasted money and care had on health insurance companies and Medicare? How much of that money could (or should) have been in your pocket?
I would like to share just one more statistic to help show that this is a much larger problem than it may seem. In the annual DOJ Criminal Report for 2018 , go to Table 3B Criminal Cases and Defendants in the US District Court – All occurrences 2018 fiscal report (pictured below). Highlighted in green you can see 613 cases were filed for health care fraud with 927 defendants named. Now compare that to the other white collar crimes such as tax fraud, computer fraud, and even identity theft! Health care fraud is one of the largest white collar crimes on the list. Also remember, this is just a snapshot of 2018 US District court cases only.
One Last Appeal for Action
Now if trying to reduce your fear, and appealing to your sense of duty and honesty as a provider hasn’t quite convinced you to say something I have one more thing to point out. Whistleblowers generally have claim to a percentage of any settlement money. Simply put, you can get paid to be a whistleblower!
It depends on several factors, but it could be between 15-25% of the amount paid to the government after settlement. Remember the Drayer PT case mentioned above. $7 Million settlement x 15-25% = $1,050,000 to $1,750,000! I would say that is a lot of potential reasons to speak up and help fight against health care fraud in physical therapy.
The health care system is massive. It is extremely complex. It has many moving parts. It also has many problems. It is not a secret that things need to change. Change this big needs as much help as it can get from all parties involved. Reducing fraud, waste and abuse is a very important step to this change. It will save money. It will reduce unethical care. As the providers get more involved it will also show the rehab clinics and companies that we no longer are willing to put up with their bad practices. It will show the government and health insurance companies we are not just a bunch of overusing, maximum billing technicians.
I hope you found this information helpful. This article was written for general information on fraud, waste and abuse in skilled care. There is certainly a process to how this is done, and one you should not go alone.
So let’s keep going to Part 2! Getting Help!
Whistle blowing is something that I certainly would not want to guide you through on my own. You will be dealing with some big laws and will want someone in your corner. So that is what Part 2 is all about. Questions and answers all about reporting fraud, waste and abuse directly from a licensed attorney. One who deals in medical fraud cases. It should not replace obtaining proper legal counsel, but will certainly give you a much better idea of what you will need to start the process.
I hope that this information has shed some light on the gravity of this problem in physical, occupational and other therapies. As we work together, we can make a change and put a stop to those hurting our profession. Thanks everyone!