As an entrepreneur, I’m prone to breaking rules and taking risks. But as a PT—and an ethical businessperson—I tend to adhere to regulations, because in those roles, risky moves often come with hefty consequences. So, what happens when the lines between growing a business and providing quality patient care blur—as they so often do in private practice? You want to do right by your patients, but you also have to keep the lights on. And that’s exactly how billing bad behaviors rear their ugly heads. In an effort to maintain—and possibly even grow—their businesses, PT owners and their staffs exhaust every possible option to save, until finally, they decide to cheat the system—just a little. They think, “No one will find out, and even if they do, I’ll just feign ignorance. How can they punish us when everyone has to be doing these things?”
And in some cases, it actually is ignorance that leads to bad billing behavior; some clinics unintentionally cheat the system, either because:
- they learned incorrect practices from the get-go, or
- they made a mistake once and still received payment, so they decided it must be acceptable.
If you’re one of those who aren’t in the know, these bad behaviors can actually result in you making less. And what payer is going to clue you into that?
Listen, I know it’s hard out there for small private practice owners. Reimbursements are dwindling; regulations are intensifying. Payers hold way too many of the cards, and our current fee-for-service payment model encourages us to treat longer and bill more. The system ain’t fair, but neither is cheatin’. And the consequences for breaking the rules are real and severe. Furthermore, if you’re cheating yourself out of hard-earned dollars, simply because you and your staff are unknowingly billing incorrectly, then that ain’t fair, either.
So, let’s swiftly put the kibosh on billing bad behaviors—and bill accurately and by the rules. Here are several common examples of PT billing blunders that’ve got to stop:
Are You Over?
Overbilling most commonly occurs in PT in the following ways:
- Upcoding: This happens when clinics “charge for more extensive and costly services than they’ve delivered, entering incorrect billing codes that lead to overcharges,” according to LifeHealthPro. Sometimes upcoding occurs accidentally in the process of determining the most applicable code; other times, though, it’s a tactic for wrongfully obtaining higher payments.
- Utilization abuse: Clinics should not schedule extra visits or provide unnecessary services simply to generate additional revenue—a practice known as utilization abuse. The treatment plan must fit the diagnosis, and the therapist must determine patient-specific needs—including frequency and duration of visits—during the initial evaluation.
- Overcharging: Similar to upcoding, this billing bad behavior entails charging additional units of the services the therapist performed or tacking on codes for services the therapist didn’t perform at all.
Are You Under?
On the other side of the billing coin is underbilling. This typically occurs when clinics:
- incorrectly follow the 8-minute rule for Medicare beneficiaries,
- document and bill using the 8-minute rule with payers to which that rule doesn’t apply,
- attempt to cancel out Medicare overpayments,
- fail to identify all billable codes,
- undercode due to CCI edit/bundled code confusion (this issue is especially common; many PTs don’t understand modifier 59), or
- do patients “favors” by either providing more units or services than they actually bill for—or worse, waiving fees or copays altogether.
- Pardon the steam shooting from my ears, but this particular bullet really grinds my gears. I appreciate your empathy, but you’re running a business! Whether you’re the owner or the therapist, stop devaluing your services, practice, and profession like this. You’re worth too much to give handouts, and your patients need to understand this. (If this seems like a tough habit to break, allot a pro bono amount in your budget, monitor your clinic’s generosity, and really calculate whether this behavior is sustainable or smart.) Furthermore, depending on the recipients, conditions, and frequency of your payment breaks, you could leave your practice vulnerable to discrimination accusations or lawsuits. If you want to offer discounts to people, offer them across the board.
These billing bad behaviors are just the tip of the iceberg. That’s why we’re devoting this entire month to billing best practices. In addition to sharing a wealth of how-tos for proper PT billing on our blog, we’ll delve into all kinds of billing no-nos (including the ones I’ve highlighted here)—as well as explain how to correct those mistakes—in our April webinar. Register for it here.
In the movies, risky business often pays off (especially when Tom Cruise dances in his skivvies), but as a businessperson, I can tell you that I would never bet on a cheater. That’s not a risk worth taking. Do your clinic, the PT profession, and your patients a monumental favor and save the risks for the Shark Tankers of the world. Know the rules, and follow them. Your livelihood—and freedom—matter too much to take that kind of gamble.