Posted and filed under Fraud, FWA, Healthcare.

This week’s Fraud Spotlight features guest contributor Mark R. Brengelman, JD, MA. Be sure to tune into the column for more expert insights from our network of providers, investigators, and fraud experts.

This article begins a multi-part series covering the top ten violations of law against physical therapists that are enforced by state licensure boards against these health care practitioners. 

We will cover three violations at a time in three subsequent articles leaving a final article for a bonus violation making ten in total to review. Here is our introduction to the issues.

In most states, physical therapists have independent practice rights and scope of practice to diagnose, treat, and bill for their professional services in their realm of physical medicine.

Making things more complicated, it is not that easy to leave it at one kind of practitioner.

Like so many health care professions that proclaim they have unique education, training, and experience and deserve to be recognized in the law as such, physical therapists then create health care workers who perform procedures and modalities under their supervision and who have less education, training, and experience. Those are often certified physical therapist assistants who also bill for their professional services performed under supervision and who also hold a credential from the state to practice physical therapy.  

Finally, physical therapists often use helpers called physical therapist technicians – anyone can be a technician as no education, training, and experience are required. The technician’s job is to assist the patient’s treatment by the physical therapist, who is billing for their own professional services. Think of it in a way as another set of hands to hold an ice pack or to assist the patient in a walking exercise directed by the physical therapist.

Perhaps you can see where this is headed – a situation ripe for possible fraud. How does the patient keep straight who’s who, let alone how insurance companies can police the level of services billed? Unscrupulous physical therapy offices may bill the unbillable technician as a certified physical therapist assistant, or the lower billed assistant as the higher billed licensed physical therapist. Or a physical therapist may pad the bill a bit by inflating the time spent with the patient in order to cover their own employee expenses to hire the technician because the physical therapist cannot do it all, but needs to make enough money to pay themselves and a technician who is helping them?

If the assistant and the physical therapist both work on the patient at the same time, is that double-billing? If the assistant is doing (at least some) of the work and procedure, why isn’t the assistant doing all of the work and procedure at that lower rate instead of the licensed physical therapist’s higher billable rate?

Our review of the top ten violations expands on possible fraud to show various licensure violations which first affect the safety of care to the public and which can then constitute fraud when services are wrongfully billed to the patient, an insurance company, or other third-party payors. Violations can affect the patient, the employer, third-party payors, and others.

Physical therapists and insurance companies need to know how fraud can come from any of the top ten violations of law against physical therapists. These are topics for future articles, so stay tuned to this column.

About the Author

Mark R. Brengelman, JD, MA, practices health care law in Frankfort, Kentucky, where he is the immediate past Chair of the Health Law Section of the Kentucky Bar Association. For fifteen years, he was the Assistant Attorney General assigned as General Counsel and Prosecuting Attorney to the Kentucky Board of Physical Therapy. His e-mail is Mark@MarkRBrengelmanPLLC.attorney.