Four Considerations for Hiring a Medicare Compliance ConsultantLast week I discussed the risks associated with Medicare non-compliance and shared some tips for protecting your practice. While drafting a compliance plan and conducting self-audits are definite must-dos, you may eventually find your clinic in a situation that requires absolute expertise. Yes, an in-house compliance officer is ideal, but many small to mid-size clinics simply cannot afford to staff someone full-time. Thus, you may want to consider a consultant. Of course, it’s crucial you’re selective. Here are four things to consider before hiring a Medicare compliance consultant.


As is the case with hiring for any position, experience is key. When shopping around for a Medicare compliance consultant, make sure they have the necessary credentials to ensure trustworthiness and peace of mind.

One must-have credential? Compliance certification! The Certified in Healthcare Compliance (CHC) website breaks down their certification process and details the following benefits of certification:

  • Enhances the credibility of the compliance practitioner as well as the credibility of the compliance programs staffed by these certified professionals.
  • Assures that each certified compliance practitioner has the broad knowledge base necessary to perform the compliance function.
  • Establishes professional standards and status for compliance professionals.
  • Facilitates compliance work for compliance practitioners in dealing with other professionals in the industry, such as physicians and attorneys.
  • Demonstrates the hard work and dedication necessary to perform the compliance task.

The Health Care Compliance Association also promotes CHC and encourages certification. In fact, the HCCA CEO wrote quite a passionate letter regarding the topic entitled “Compliance certification by the profession, for the profession, and of the profession.” The AAPC also issues certification (Certified Professional Compliance Officer), which one can attain through an AAPC membership and rigorous examination.

Besides certification, you should also consider background. WebPT Billing Operations and Onboarding Manager Stacey Abelman offers some advice: “Make sure the consultant is highly experienced (or exclusive) in rehab therapy. PT compliance is very different from that of hospitals, labs, or family practices.” seconds Stacey’s advice, encouraging therapists to find someone who is a therapist, too, and has certifications in compliance and insurance. Two resources you can turn to for therapy-specific compliance are Gawenda Seminars and the PT Compliance Group.

Last but not least: referrals! Ask fellow therapists you trust for names of compliance consultants they have used and find out specifically what results they experienced. Here’s a tip from Summit Consulting Group: “Don't ask the consultant for references, because they will be hand-selected, wonderful, and meaningless.”

According to PT Compliance Group, while compliance is an expense, non-compliance (think audits, penalties, and loss of business) is far more costly. And compliance creates sustainability: “You become known for your business integrity, and you gain a high level of respect from community members, patients, and referral sources. Your employees give you their complete loyalty because they trust that you have their long-term best interest in mind. You build a culture within your practice that is confidently compliant, billing for everything you do with confidence knowing that your systems are in place to ensure that your level of billing is justified. And you receive the priceless benefit of great sleep knowing your conscience is clear.”

As I stated in my introduction, hiring a consultant can be more cost-effective than employing a dedicated, in-house compliance officer. For consultants, fees typically depend on clinic size, and once they help you achieve your compliance goals, the contracted work is complete. So how does your clinic handle that fee (whatever it may be)? PT Compliance Group says to not think of compliance as a cost: “In your gut right now, if you don’t feel that your culture is confidently compliant, then you are experiencing lost [opportunities]. Compliance should be your number one investment in taking your practice from good to great. Think of compliance as an investment in your business, not a cost.”


If your prospective consultant has the credentials, background, referrals, and price point to satisfy your clinic’s needs, then your next item to consider is strategy. Does your potential consultant have a plan? Here are the Federal Register’s seven elements of an effective compliance program:

  1. Implement written policies and procedures
  2. Designate an internal point person for the compliance officer
  3. Conduct comprehensive training and education
  4. Develop accessible lines of communication
  5. Conduct internal monitoring and auditing
  6. Enforce standards through well publicized disciplinary guidelines
  7. Respond promptly to detected offenses and undertake corrective actions

In addition to these seven elements, consider asking your potential compliance consultant such questions as:

  1. What should my clinic staff and I expect?
  2. What will your first day, week, and month look like here at my clinic?
  3. How many records will you review? What else will you analyze?
  4. How will you conduct training?
  5. What does your follow-up process look like?

Summit Consulting Group recommends you request a proposal: “The consultant should provide you with a proposal that is based on achieving clear business outcomes, and not on merely delivering technology or methodology. In other words, running focus groups or delivering training programs is simply a task; improving sales results or enhancing customer satisfaction is a business outcome. Achieving the former and not the latter is worthless.”

Compliance is a tough nut to crack; might as well crack it with someone you like. Meet with your prospective consultant several times before signing the contract. Does the candidate seem like a solid peer, even a potential partner? Respect and trust are key. “If you don't respect them, or [if you] see them as merely a vendor or subordinate, don't hire them. You don't need another employee; you need a business partner for a particular issue,” says Summit Consulting Group.

As you get to know your prospective consultant, consider these questions:

  • Does he or she look and act professional?
  • Is he or she organized?
  • Does he or she return your calls and emails promptly?
  • Is his or her language clear and articulate?

It’s important to trust your gut. The entire process should feel solid.

Nowadays, it’s tough to provide exceptional patient care, while staying aligned with your business principles and keeping up with all of Medicare’s laws, rules, and regulations. If you’re unable to appoint an in-house, full-time certified compliance officer, then consider hiring a consultant. Doing so is not only cost-effective and essential to your clinic’s sustainability, but it also takes a heaping, anxiety-laden load of your shoulders. In contracting a consultant, you’re enlisting a specialist that knows the ins and outs of compliance. They’ll not only assist you in correcting existing errors and developing a plan to avoid future errors, but they’ll also help you ensure your practice remains organized, professional, and profitable.

What experiences have you had with compliance consultants? What tips or considerations do you have for fellow therapists on hiring them?

The State of Rehab Therapy in 2019 - Regular BannerThe State of Rehab Therapy in 2019 - Small Banner
  • Wave Goodbye to Waivers: The Case for Consistent Copay Collection in PT Image

    articleApr 14, 2015 | 9 min. read

    Wave Goodbye to Waivers: The Case for Consistent Copay Collection in PT

    If you’re a private practice physical therapist or clinic owner, I’m willing to bet you—and your staff—have had more than one uncomfortable copay conversation at your front desk. After all, copays for physical therapy are often astronomical compared to those for other healthcare services—especially considering that many PT patients require multiple treatment sessions per week. Still, no matter how tough—or awkward—it is to collect those payments upfront, it’s imperative that you take a page from Nike and …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • The Legality of Performance-Based Employee Incentive Programs in Rehab Therapy Practices Image

    articleJan 14, 2016 | 3 min. read

    The Legality of Performance-Based Employee Incentive Programs in Rehab Therapy Practices

    The concept of pay-for-performance (PFP)—that is, the idea that an individual receives payment based on what he or she produces—seems very American to me and is certainly part of our capitalistic society. To use a sports analogy, a professional athlete who is one of the top performers in his or her sport commands higher compensation than an average or poor performer. So, why would therapy practice owners, directors, and executives not consider offering salary/compensation rates based on …

  • Gifts, Donations, and Discounts: What Medicare Needs You to Know Image

    articleJul 24, 2014 | 7 min. read

    Gifts, Donations, and Discounts: What Medicare Needs You to Know

    The world of private practice physical therapy is certainly competitive, so it makes sense that owners and directors consider every angle when it comes to promoting their businesses. (On that note, be sure to check out our free modern PT marketing guide to learn fresh—and legally compliant—promotional strategies.) Unfortunately, some of those angles can get you and your practice in hot water with Medicare. Today, I’ll discuss handling gifts, donations, and discounts in a way that doesn’t …

  • Preparing for ICD-10 Image

    webinarApr 29, 2014

    Preparing for ICD-10

    At the end of March, Congress passed legislation that delays the mandatory transition to ICD-10 until October 1, 2015. With all that extra time, some of you might be eager to push the new code set to the back of your mind. Au contraire! Even though we now have a year and six months until the US goes live with ICD-10, there’s still a lot to be done—and we’re here to help. In this month’s webinar, we’ll …

  • The How and Why of an Effective Rehab Therapy Compliance Program Image

    articleAug 9, 2018 | 7 min. read

    The How and Why of an Effective Rehab Therapy Compliance Program

    It’s no secret that the US healthcare industry is heavily regulated—and those regulations are strictly enforced. Take this recent press release from the Department of Justice (DOJ), for example. It explains how the DOJ charged 601 individuals with fraud—the largest healthcare fraud takedown in history. Among them: 71 physicians charged with falsely billing Medicare, Medicaid, and TRICARE in cases involving the prescription and distribution of narcotics. And in New York, 13 individuals were charged with conspiracy for …

  • Should Physical Therapists Enroll as Medicare Providers? Image

    articleJul 8, 2014 | 9 min. read

    Should Physical Therapists Enroll as Medicare Providers?

    If you’re starting—or have ever started—a private physical therapy practice, then you’ve almost certainly grappled with the decision of whether to accept Medicare patients. And unless your patient demographic absolutely demands that you do, I’m guessing it is—or was—a pretty tough call to make. I’ll be upfront: the title of this post is perhaps a bit misleading, because honestly, there is no one-size-fits-all answer to this question. As such, I can’t, in good conscience, definitively tell you …

  • The PT’s Guide to Surviving a Medicare Audit Image

    articleMay 30, 2016 | 5 min. read

    The PT’s Guide to Surviving a Medicare Audit

    “How can I avoid being audited by Medicare?” This is one of the compliance questions I hear most frequently, and the honest answer is, quite simply, that you can’t. Just because CMS or one of its auditing entities hasn’t come knocking on your door doesn’t mean you’re not being audited. In fact, every claim you submit undergoes statistical analysis, and Medicare compares your claims data to the data for all other claims submitted. Furthermore, Medicare now analyzes …

  • The Importance of Collections / Avoid Writing Off Copays Image

    articleMar 25, 2013 | 7 min. read

    The Importance of Collections / Avoid Writing Off Copays

    Today's blog post comes from WebPT Co-Founder Heidi Jannenga, PT, MPT, ATC/L. Today, copays are the norm, and they’re only becoming more costly. To top it off, many insurance plans—especially those that individuals and small businesses purchase (including HSAs)—have very large deductibles that patients must meet before insurance will pay for anything. While it’s obvious that these increased copays and deductibles put a burden on patients, they also burden physical therapy practices. How? Many practices don’t have …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.