There is really only one definitive way of identifying when PT reimbursement for treatment falls short. That measurement is when you don’t get paid. Whether we like it or not, filing claims for reimbursement for physical therapy treatment with Medicare or with the patient’s insurance company represents a huge percentage of how any PT practice will generate revenue.

At times it seems that insurance companies make the process of submitting a claim for reimbursement difficult and complicated on purpose. This may not be true, but it does not change the fact that if you make mistakes in how you go about submitting your claim to an insurance company, you may see that claim denied. That leads to having to correct and resubmit the claim, which takes time and delays when you get that revenue. Insurance companies have identified a number of typical reasons why claims do not get paid. To streamline your own PT reimbursement procedures, it pays to take note of the seven top reasons why most claims for physical therapy treatment fall short:

• The treatment must have a recognizable goal.

Any physical therapy treatment must have a purpose to be approved for treatment. That goal must be achievable and measurable so that progress toward that goal can be tracked. It cannot be a vaguely stated goal of better health or for the affected area to be better. The goal must be stated in such a way that the insurance company knows that when that goal is reached, coverage can stop. If that statement of goal falls short, the claim could be denied.

• Failure to prove authorization for treatment.

Securing proper authorization from the patient’s referring physician is usually a habit that is deeply ingrained in the procedures of a physical therapy practice. In most cases where authorization is not correctly submitted with the claim, it is an oversight during the preparation of the claim. This is a discipline that must be carried through from getting authorization before you approve your clinic to give treatment to recording that authorization correctly and passing it along during the reimbursement process. If proof of authorization causes reimbursement to fall short, it is time to tighten up the discipline of your reimbursement process.

• Failure to show that the therapy is making progress.

This is a similar problem to failure to state a recognizable goal mentioned earlier. Starting with the initial measurable objective of the therapy, each claim must report in a measurable fashion the progress the patient is making toward the realization of that goal. The purpose of these requirements is clear. The insurance companies support physical therapy to return a patient to full health but they wish to avoid what is called “maintenance” therapy that has no concrete end to coverage. Not only should you make sure that the verbiage of your claim includes concrete progress documentation, you should review that text to make sure how you state that progress is not vague or ambiguous.

• Mistakes in completion of the form and coding errors.

Completion of claims for physical therapy reimbursement can become a tricky task at best. This is especially true in worker’s compensation or Medicare cases. It is essential the staff member who completes these applications for payment understands what is required, including the fee schedules and other coding details. It pays to review each form before it is submitted to assure that all fields on the form that are required are filled out correctly. Even a relatively minor error in a critical field can result in denial of the claim.

• Claim form is too wordy.

The agency you are sending the request for payment to gets hundreds of these applications for payment as part of their line of work and they are looking for very specific information to process the claim. Because physical therapists are often very empathetic people, it is easy to get carried away with comments that are not essential to this particular payment instance. Keep a single focus when sending in forms for reimbursement and it will get processed more quickly and successfully.

• Billing a number of the times for the same treatment.

Treatment for a specific kind of injury often calls for various PT forms of treatment for related areas of the body. For treatment of a leg injury, there may be treatment for the knees and hips. All of these forms of treatment should be reported for reimbursement on the same form. It is common for insurance companies to see multiple applications for reimbursement come in for the same injury but with each kind of treatment billed separately for payment. This is a mistake that can result in the reimbursement being denied.

• The claim is never successfully filed.

Sometimes there is a procrastination factor that can hold up claims processing. Other times an application for reimbursement does not get to the payer for one reason or another simply because of flaws in delivery or mistakes made at the office level of your practice. It is even possible for an application for reimbursement to get lost once it reaches the insurance company and never get processed.

Many of these problems can be resolved with an automated PT practice reimbursement management system. This software solution will make the filings for reimbursement electronically, thus reducing the chances of a claim never being filed. The coding and completion of the form from patient records is automated so mistakes are reduced. The tedium and difficulty of preparing forms for reimbursement is reduced as is the time and expertise in staff talent to keep up with this important part of your practice. The outcome is applications for reimbursement that are denied fewer times and that are prepared with less overhead to the practice. That is a win-win solution.

"Going to WebPT has been one of the best decisions I have made as a clinic owner. Between the time saved organizing, faxing & managing records - as well as the less paper, toner and charts I no longer have to purchase - WebPT saves me money." Michael F, PT, Clinic Owner, Vermont