Healthcare professionals confront a range of ethical and regulatory issues in today’s ever-changing practice environments. Doing what’s best for the patient is often influenced and, at times, compromised by external factors, including rules and regulations associated with third-party payment systems.1,2 Medicare, Medicaid and commercial insurance carriers have established conditions of participation and fiscally driven regulations, such as payment caps that often direct practice parameters and may affect patient care and outcomes. Ethical issues that create dilemmas between what is and what should be may confront practitioners. Optimal care for a given patient may be compromised by limited benefits and changing regulations.
To confront these dilemmas, physical therapists need to know their available options and develop strategies that consider best practices within the confines of contemporary payment systems.
Patient Scenario
A 56-year-old man is referred to physical therapy (PT) for sciatica, degenerative disc disease and degenerative joint disease. He is the sole caretaker for his disabled wife. Over the past month, he has lost his capacity to bend, lift and carry during activities of daily living and work. While registering at the Outpatient Rehabilitation Center, he learns that his Medicaid benefits provide for a PT evaluation only, without any follow-up services.
Upon completion of the initial examination, the physical therapist considers treatment options given the identified impairments and loss of function, including manual therapy for the lower lumbar spine, stabilization and strengthening exercises for the low back and trunk, and instruction in a home exercise program and proper body mechanics. The physical therapist recommends follow-up twice a week for four weeks. However, given the limitations of the patient’s insurance benefits, these additional treatments will not be covered.
How would you proceed? Ask the patient to pay out of pocket for optimal care, or proceed with only the evaluation that is covered? Should the patient be offered free or discounted services because it seems like the right thing to do?
The Environment
Physical therapists practice in a wide range of delivery system models, including academic, hospital-based, home health and private office practices. Physical therapists are also members of a wider healthcare team for patients with rheumatic diseases and musculoskeletal conditions. Other team members may include rheumatologists, orthopedic surgeons, nurses, occupational therapists, social workers, pharmacists and psychologists, to name a few. Rules and expected behaviors and priorities vary across these systems and cultures and are subject to change.
Major changes in healthcare delivery systems in physical therapy followed the creation of Medicare and Medicaid in 1965 and the introduction of Diagnosis Related Group (DRG) Codes in 1982. Physical therapists must also be aware of the Physician Quality Reporting System (PQRS).3 Fiscal intermediaries, such as commercial insurance companies and the Centers for Medicare and Medicaid Services, publish rules and regulations, with associated payment criteria, that can affect patient care and need to be a component of the therapist’s playbook.
All of these stakeholders in physical therapy have different and sometimes conflicting values and priorities. Physical therapists often identify high-quality patient care, professional values and self-fulfillment as motivators in professional growth and satisfaction. Conversely, an organization managing or paying for healthcare services may prioritize fiscal viability, institutional efficiency and competitive positioning in the marketplace. These differences and potential loyalties may cause dilemmas in arriving at acceptable patient care outcomes based on evidence-based practice standards.
Physical therapists can also face Medicare audits and are accountable for compliance issues associated with documentation, coding and billing procedures. Changes in regulations without ethical content complicate the way healthcare is now being organized and financed. This changing environment places the patient and healthcare provider in a difficult position, as illustrated by the above scenario.
Understanding the rules and regulations so you can avoid mistakes that might be considered fraud is paramount.
The Objective
What are the driving forces, principles and guidelines that shape professional behaviors and ethical standards?
The short answer comes from the Code of Ethics adopted by the American Physical Therapy Association (APTA). It states, in part, “Physical therapists shall … act in the best interests of patients/clients over the interests of the physical therapist.”4
In physical therapy, the literature is rich with texts and publications that address ethical issues.5-8 And physical therapists can rely on The Guide to Physical Therapist Practice and state-directed practice laws in their quest to act ethically and provide the best care for their patients.4,9
However, not knowing the applicable laws, rules, ethical codes and practice guidelines is not an excuse for a lapse in judgment.
Back to Our Scenario
The opening scenario poses both an ethical dilemma (i.e., Do you provide the optimal care even if the insurance won’t cover it?) and a regulatory dilemma (i.e., Medicare regulations require that all patients be billed in accordance to the CMS fee schedule without consideration to patients’ ability to pay).2 If you offer the service for free or at a discounted rate, you could be in violation of Medicare regulations and face fines or be dropped from the program.
The dilemma facing the physical therapist is to choose between suboptimal care or risk a breach of regulations—and possibly incur a fine—to accommodate the patient’s needs. None of these options is ideal. Regardless of the choice made, documentation must be defensible and proper billing procedures must be in place.
The therapist might consider the following course of action:
- Start by explaining the insurance limitations and promote the importance of a self-managed, home-treatment plan;
- During the initial examination, offer instructions for a home program, stressing continued compliance, back safety and regular exercise;
- Provide written instructions that guide progression of the individualized home program; and
- Suggest available websites and other educational resources related to the identified impairments and offer follow-up phone consultation, as needed.
These actions are time consuming, but may prove helpful with regard to patient satisfaction and treatment outcomes.
Alternatives
In the future, physical therapists will need to use alternatives to traditional education methods, frequency and duration of care plans, and gaining compliance with home exercises to address the changing ethical, regulatory and financial environment.
Physical therapists are already looking to untraditional initiatives, such as telehealth, and promoting the use of technology, including smartphones and electronic communications, to assist in education and compliance efforts. However, payment for such services varies widely and usage is limited. Going forward, practitioners will need to provide Web-based links to quality educational resources and develop user-friendly educational tools to serve disadvantaged patients without adequate rehabilitation benefits.
When it comes to providing rehab services (and many other healthcare services) this version of the Golden Rule often applies: Those with the gold make the rules. Although this may be the unfortunate reality, exploring practical alternatives while balancing priorities and the needs of various stakeholders is essential to ensure the ethical delivery of patient care.
Robert W. Richardson, PT MEd, FAPTA, is a past president of the American Physical Therapy Association and a past president of the ARHP.
Additional Resources
APTA.org and CMS.gov are valuable resources for physical therapists. The following documents and publications can help you avoid fraud, waste and abuse, and gain an understanding of changing regulations.1-4,9
- APTA Core Documents: www.apta.org/Policies/CoreDocuments features links to the Code of Ethics, Guide to Physical Therapist Practice and Guide for Conduct and Professionalism.
- APTA Coding and Billing: www.apta.org/Payment/CodingBilling includes links to courses (also see http://learningcenter.apta.org and http://www.apta.org/Courses/Online/NavigatingCompliance).
- Compliance: http://www.apta.org/Compliance offers information on fraud and abuse, and Medicare audits.
- The federal government’s websites and the Federal Registry publish changes in rules and regulations that affect physical therapy. For example, the U.S. Department of Health and Human Services Centers for Medicare and Medicaid publishes documents that provide an overview of facts and laws regarding Medicare fraud and abuse. Changes are also published in other forms in the public record. Government websites can be useful, but be forewarned that most will induce sleep with a full dose.
References & Recommended Reading
- Centers for Medicare and Medicaid Services. http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html.
- Medicare Claims Processing Manual. Chapter 5—Part B Outpatient Rehabilitation and CORF /OPT Services. http:www.cms.gov/Medicare/Billing/TherapyServices/downloads/clm104c05.pdf.
- Final 2015 Physician Fee Schedule and Physician Quality Reporting System (PQRS) Measures. APTA Information Bulletin. October 2014.
- Code of ethics for the physical therapist. American Physical Therapy Association. http://www.apta.org.
- Purtillo RB, Doherty RF. Ethical Dimensions in the Health Professions, fifth ed. Saunders, an imprint of Elsevier: 2010.
- Scott R. Professional Ethics: A Guide for Rehabilitation Professionals. Mosby: 1998.
- Richardson JK. The challenging roles facing physical therapists. Healthc Trends Transit. 1993;5(1):34.
- Gabard DL, Martin ML. Physical Therapy Ethics. FA Davis, Philadelphia: 2003.
- Guide to Physical Therapist Practice 3.0. American Physical Therapy Association. http://www.apta.org.
