Guest guest Posted October 6, 2010 Report Share Posted October 6, 2010 Hi everyone, I would like to play devil's advocate here. Would this patient decline without periodic and continuous therapy? Can you justify in any way that this is the case. Forget about goals and progress and look at the human condition of this. Take the insurance out of the picture for a second - what does your experience say about this? BUT, if there is a way to justify it under insurance, then why not continue to get paid for the service? I have worked with dementia patients and truthfully, standard goals and progress do not work for this population. Time frames for goals are much longer and progress, as determined by experience and not by insurance, is usually seen in inches not miles. Are you keeping the patient from physical decline that would lead to falls? (this may take months). Can you provide a better quality of life for the client? For the family? It is up to you to justify it based on accepted knowledge and experience about this patient population. And think about the service you are doing to the family which is apparently struggling with care. Also realize that change can affect these clients in very negative ways. Changing the therapy environment might not be the best idea. Certainly, your job is to provide all options but please take another look at what you can do for this client at your clinic first. If you really cannot justify continuing to bill insurance then don't. Your options at that point remain private pay, referral to daycare or pro bono service. If you are concerned with family backlash, get a letter from the insurance company stating that they will not continue to pay. I would not worry about the Code of Ethics especially if you can justify continued treatment (whether it falls under the definitions of " skilled care " or " maintenance therapy " or not). We continue to get hung up on goals and rules set by insurance. Progress and skilled services are defined by insurances not by us. " Maintenance therapy " is defined by insurance, not us. As professionals, we have the knowledge and experience to know what is best for our clients, not insurance. Families will never understand insurance rules either, especially maintenance therapy. They will understand, and spread the word, if you handle this situation poorly and cut this client off from therapy with no options. And , of course, in my opinion, we should get paid for that knowledge and experience even in difficult cases such as this that do not " fit " the rules that insurances have set but do fit what is the right thing to do. If this were at my clinic, I would keep treating and keep billing and find a way to justify and document based on all available evidence about this. If I reached a point where I was truly sure that insurance should not be billed, then I would continue to see this patient pro bono and give the family time to come to terms with options. I would have regular meetings with family as a condition of continued care and set a contract with them asking them to meet certain obligations at home and to explore options (while I continued pro bono care). If the family is not meeting their obligations, they would know the consequences (discharge). I would be sure to document family meetings to have a record of everything discussed in case they do not meet their obligations and caused a fuss. This would allow a process where everything has been tried and the family is completely aware and involved. I know this has been a passionate reply and I hope that it has made everyone think. Remember: we are the professionals, we determine what is best for this client first, then we try to fit it within the system and with the family dynamics. Patients/clients and families should come first. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of Kathleen e Sent: Wednesday, October 06, 2010 9:03 AM To: PTManager Subject: Re:maintenance PT I need to clarify that our 92 y/o with dementia has a private insurance,NOT Medicare, that continues to pay for maintenance therapy in our outpatient clinic. Our concern is the Code of Ethics referencing excessive service. We are not even trying to document this as skilled service and the insurance has been paying for months of this. Kathleen e,PT HSA of Stanislaus County Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2010 Report Share Posted October 7, 2010 I agree. Our Code of Ethics states that is it wrong to perform services that are of no benefit to the patient. Maintenance programs benefit the patient (why else would we refer to restorative or HEP?), and non-payment is strictly an insurance issue. Wendland PT Ohio _____ From: M. Howell, PT, MPT To: PTManager Sent: Wed, 06 Oct 2010 18:27:25 -0400 Subject: RE: Re:maintenance PT Hi everyone, I would like to play devil's advocate here. Would this patient decline without periodic and continuous therapy? Can you justify in any way that this is the case. Forget about goals and progress and look at the human condition of this. Take the insurance out of the picture for a second - what does your experience say about this? BUT, if there is a way to justify it under insurance, then why not continue to get paid for the service? I have worked with dementia patients and truthfully, standard goals and progress do not work for this population. Time frames for goals are much longer and progress, as determined by experience and not by insurance, is usually seen in inches not miles. Are you keeping the patient from physical decline that would lead to falls? (this may take months). Can you provide a better quality of life for the client? For the family? It is up to you to justify it based on accepted knowledge and experience about this patient population. And think about the service you are doing to the family which is apparently struggling with care. Also realize that change can affect these clients in very negative ways. Changing the therapy environment might not be the best idea. Certainly, your job is to provide all options but please take another look at what you can do for this client at your clinic first. If you really cannot justify continuing to bill insurance then don't. Your options at that point remain private pay, referral to daycare or pro bono service. If you are concerned with family backlash, get a letter from the insurance company stating that they will not continue to pay. I would not worry about the Code of Ethics especially if you can justify continued treatment (whether it falls under the definitions of " skilled care " or " maintenance therapy " or not). We continue to get hung up on goals and rules set by insurance. Progress and skilled services are defined by insurances not by us. " Maintenance therapy " is defined by insurance, not us. As professionals, we have the knowledge and experience to know what is best for our clients, not insurance. Families will never understand insurance rules either, especially maintenance therapy. They will understand, and spread the word, if you handle this situation poorly and cut this client off from therapy with no options. And , of course, in my opinion, we should get paid for that knowledge and experience even in difficult cases such as this that do not " fit " the rules that insurances have set but do fit what is the right thing to do. If this were at my clinic, I would keep treating and keep billing and find a way to justify and document based on all available evidence about this. If I reached a point where I was truly sure that insurance should not be billed, then I would continue to see this patient pro bono and give the family time to come to terms with options. I would have regular meetings with family as a condition of continued care and set a contract with them asking them to meet certain obligations at home and to explore options (while I continued pro bono care). If the family is not meeting their obligations, they would know the consequences (discharge). I would be sure to document family meetings to have a record of everything discussed in case they do not meet their obligations and caused a fuss. This would allow a process where everything has been tried and the family is completely aware and involved. I know this has been a passionate reply and I hope that it has made everyone think. Remember: we are the professionals, we determine what is best for this client first, then we try to fit it within the system and with the family dynamics. Patients/clients and families should come first. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of Kathleen e Sent: Wednesday, October 06, 2010 9:03 AM To: PTManager Subject: Re:maintenance PT I need to clarify that our 92 y/o with dementia has a private insurance,NOT Medicare, that continues to pay for maintenance therapy in our outpatient clinic. Our concern is the Code of Ethics referencing excessive service. We are not even trying to document this as skilled service and the insurance has been paying for months of this. Kathleen e,PT HSA of Stanislaus County Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2010 Report Share Posted October 7, 2010 I will reiterate-this is the only insurance plan that I have ever worked with in my long career that pays for maintenence therapy. This son does not feel that he or his paid caretaker should do stretching,etc as someone else will pay for it. I am trained and fully understand goal setting for people with dementia versus an althelete with ACL repair. This lady is 1.5 or 2 at best-dependent in ADLS, transfers, and non-ambulatory. Maintenance,in my professional opinion, should be done by non-skilled caretakers after being trained by a therapist. We all have seen that people on a maintenance will decline over a period of time, as we can do those simple interventions so much better than anyone else. Periodic re-assessment is appropriate to redesign the maintenance program or restart a course of therapy if there is potential to restore function. Thanks for your input and opinion on this very unique situation! ________________________________ To: PTManager Sent: Thu, October 7, 2010 8:03:00 AM Subject: RE: Re:maintenance PT  I agree. Our Code of Ethics states that is it wrong to perform services that are of no benefit to the patient. Maintenance programs benefit the patient (why else would we refer to restorative or HEP?), and non-payment is strictly an insurance issue. Wendland PT Ohio _____ From: M. Howell, PT, MPT To: PTManager Sent: Wed, 06 Oct 2010 18:27:25 -0400 Subject: RE: Re:maintenance PT Hi everyone, I would like to play devil's advocate here. Would this patient decline without periodic and continuous therapy? Can you justify in any way that this is the case. Forget about goals and progress and look at the human condition of this. Take the insurance out of the picture for a second - what does your experience say about this? BUT, if there is a way to justify it under insurance, then why not continue to get paid for the service? I have worked with dementia patients and truthfully, standard goals and progress do not work for this population. Time frames for goals are much longer and progress, as determined by experience and not by insurance, is usually seen in inches not miles. Are you keeping the patient from physical decline that would lead to falls? (this may take months). Can you provide a better quality of life for the client? For the family? It is up to you to justify it based on accepted knowledge and experience about this patient population. And think about the service you are doing to the family which is apparently struggling with care. Also realize that change can affect these clients in very negative ways. Changing the therapy environment might not be the best idea. Certainly, your job is to provide all options but please take another look at what you can do for this client at your clinic first. If you really cannot justify continuing to bill insurance then don't. Your options at that point remain private pay, referral to daycare or pro bono service. If you are concerned with family backlash, get a letter from the insurance company stating that they will not continue to pay. I would not worry about the Code of Ethics especially if you can justify continued treatment (whether it falls under the definitions of " skilled care " or " maintenance therapy " or not). We continue to get hung up on goals and rules set by insurance. Progress and skilled services are defined by insurances not by us. " Maintenance therapy " is defined by insurance, not us. As professionals, we have the knowledge and experience to know what is best for our clients, not insurance. Families will never understand insurance rules either, especially maintenance therapy. They will understand, and spread the word, if you handle this situation poorly and cut this client off from therapy with no options. And , of course, in my opinion, we should get paid for that knowledge and experience even in difficult cases such as this that do not " fit " the rules that insurances have set but do fit what is the right thing to do. If this were at my clinic, I would keep treating and keep billing and find a way to justify and document based on all available evidence about this. If I reached a point where I was truly sure that insurance should not be billed, then I would continue to see this patient pro bono and give the family time to come to terms with options. I would have regular meetings with family as a condition of continued care and set a contract with them asking them to meet certain obligations at home and to explore options (while I continued pro bono care). If the family is not meeting their obligations, they would know the consequences (discharge). I would be sure to document family meetings to have a record of everything discussed in case they do not meet their obligations and caused a fuss. This would allow a process where everything has been tried and the family is completely aware and involved. I know this has been a passionate reply and I hope that it has made everyone think. Remember: we are the professionals, we determine what is best for this client first, then we try to fit it within the system and with the family dynamics. Patients/clients and families should come first. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of Kathleen e Sent: Wednesday, October 06, 2010 9:03 AM To: PTManager Subject: Re:maintenance PT I need to clarify that our 92 y/o with dementia has a private insurance,NOT Medicare, that continues to pay for maintenance therapy in our outpatient clinic. Our concern is the Code of Ethics referencing excessive service. We are not even trying to document this as skilled service and the insurance has been paying for months of this. Kathleen e,PT HSA of Stanislaus County Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2010 Report Share Posted October 7, 2010 Hi Kathleen, I will respectfully disagree that maintenance " should be done by non-skilled caretakers after being trained by therapists " . In my opinion, this is a pervasive attitude of our profession that has contributed to us losing clients to other professions such as massage therapists and personal trainers. We should not narrow our perspective that we are only skilled at treatments that provide what insurances have defined as " progress " " function " and " maintenance " . We should be more focused on what is healthy, what is in the best interest of our clients and why we, not anyone else has the skill and knowledge to treat and to provide services to help our clients attain health and wellness. We keep giving away parts of our skill to others until there will be nothing else left to justify us as a profession. Plus if we keep narrowing our service to only what insurances dictate, they too will, narrow reimbursement (as we have painfully seen in the last 20 years) so drastically that it too will put us out of a profession. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of Kathleen e Sent: Thursday, October 07, 2010 12:02 PM To: PTManager Subject: Re: Re:maintenance PT I will reiterate-this is the only insurance plan that I have ever worked with in my long career that pays for maintenence therapy. This son does not feel that he or his paid caretaker should do stretching,etc as someone else will pay for it. I am trained and fully understand goal setting for people with dementia versus an althelete with ACL repair. This lady is 1.5 or 2 at best-dependent in ADLS, transfers, and non-ambulatory. Maintenance,in my professional opinion, should be done by non-skilled caretakers after being trained by a therapist. We all have seen that people on a maintenance will decline over a period of time, as we can do those simple interventions so much better than anyone else. Periodic re-assessment is appropriate to redesign the maintenance program or restart a course of therapy if there is potential to restore function. Thanks for your input and opinion on this very unique situation! ________________________________ From: Wendland <jlwendland@... <mailto:jlwendland%40abstherapy.com> > To: PTManager <mailto:PTManager%40yahoogroups.com> Sent: Thu, October 7, 2010 8:03:00 AM Subject: RE: Re:maintenance PT I agree. Our Code of Ethics states that is it wrong to perform services that are of no benefit to the patient. Maintenance programs benefit the patient (why else would we refer to restorative or HEP?), and non-payment is strictly an insurance issue. Wendland PT Ohio _____ From: M. Howell, PT, MPT [mailto:thowell@... <mailto:thowell%40fiberpipe.net> ] To: PTManager <mailto:PTManager%40yahoogroups.com> Sent: Wed, 06 Oct 2010 18:27:25 -0400 Subject: RE: Re:maintenance PT Hi everyone, I would like to play devil's advocate here. Would this patient decline without periodic and continuous therapy? Can you justify in any way that this is the case. Forget about goals and progress and look at the human condition of this. Take the insurance out of the picture for a second - what does your experience say about this? BUT, if there is a way to justify it under insurance, then why not continue to get paid for the service? I have worked with dementia patients and truthfully, standard goals and progress do not work for this population. Time frames for goals are much longer and progress, as determined by experience and not by insurance, is usually seen in inches not miles. Are you keeping the patient from physical decline that would lead to falls? (this may take months). Can you provide a better quality of life for the client? For the family? It is up to you to justify it based on accepted knowledge and experience about this patient population. And think about the service you are doing to the family which is apparently struggling with care. Also realize that change can affect these clients in very negative ways. Changing the therapy environment might not be the best idea. Certainly, your job is to provide all options but please take another look at what you can do for this client at your clinic first. If you really cannot justify continuing to bill insurance then don't. Your options at that point remain private pay, referral to daycare or pro bono service. If you are concerned with family backlash, get a letter from the insurance company stating that they will not continue to pay. I would not worry about the Code of Ethics especially if you can justify continued treatment (whether it falls under the definitions of " skilled care " or " maintenance therapy " or not). We continue to get hung up on goals and rules set by insurance. Progress and skilled services are defined by insurances not by us. " Maintenance therapy " is defined by insurance, not us. As professionals, we have the knowledge and experience to know what is best for our clients, not insurance. Families will never understand insurance rules either, especially maintenance therapy. They will understand, and spread the word, if you handle this situation poorly and cut this client off from therapy with no options. And , of course, in my opinion, we should get paid for that knowledge and experience even in difficult cases such as this that do not " fit " the rules that insurances have set but do fit what is the right thing to do. If this were at my clinic, I would keep treating and keep billing and find a way to justify and document based on all available evidence about this. If I reached a point where I was truly sure that insurance should not be billed, then I would continue to see this patient pro bono and give the family time to come to terms with options. I would have regular meetings with family as a condition of continued care and set a contract with them asking them to meet certain obligations at home and to explore options (while I continued pro bono care). If the family is not meeting their obligations, they would know the consequences (discharge). I would be sure to document family meetings to have a record of everything discussed in case they do not meet their obligations and caused a fuss. This would allow a process where everything has been tried and the family is completely aware and involved. I know this has been a passionate reply and I hope that it has made everyone think. Remember: we are the professionals, we determine what is best for this client first, then we try to fit it within the system and with the family dynamics. Patients/clients and families should come first. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... <mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com> ] On Behalf Of Kathleen e Sent: Wednesday, October 06, 2010 9:03 AM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: Re:maintenance PT I need to clarify that our 92 y/o with dementia has a private insurance,NOT Medicare, that continues to pay for maintenance therapy in our outpatient clinic. Our concern is the Code of Ethics referencing excessive service. We are not even trying to document this as skilled service and the insurance has been paying for months of this. Kathleen e,PT HSA of Stanislaus County Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 7, 2010 Report Share Posted October 7, 2010 I would like to submit that the skilled monitoring, reassessment and prevention of further decline is a quality of life issue first and a potential risk management from the insurance perspective. Are you maintaining mobility and positioning options that would otherwise degrade rapidly thus reducing her to bed only and painful contractures, ulcers and dysphagia issues? Medical treatment for this and pneumonia among other things are being avoided. Is the service you provide allowing family to keep her in the home environment and out of institutionalized care? If the family/ POA is uncomfortable with providing medical service then is the patient at risk by going without? Clearly, we each care for the patient and want to do our best professionally. Other questions might be reduced frequency with family providing a supportive role overseen by PT, possible splinting if the patient can tolerate and family willing. Keep the family informed and discuss options for their desire when the insurance does cut services. It is an interesting situation, hopefully something I have said in this late night message will help.. From: jonmarkpleasant To: PTManager Sent: Wednesday, October 06, 2010 6:54 PM Subject: Re:maintenance PT Kathleen, Is it right to bill a third party payor for services when it has been determined that there will be no return on their investment? The fact that insurance continues to pay for your services shouldn't even factor into the equation. Jon Mark Pleasant, PT Methodist Medical Center > > I need to clarify that our 92 y/o with dementia has a private insurance,NOT > Medicare, that continues to pay for maintenance therapy in our outpatient > clinic. Our concern is the Code of Ethics referencing excessive service. We are > not even trying to document this as skilled service and the insurance has been > paying for months of this. Kathleen e,PT > HSA of Stanislaus County > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 8, 2010 Report Share Posted October 8, 2010 Funny how we, as a class, allow outsiders to define us, in spite of us. Armin Loges, PT Tampa, FL From: M. Howell, PT, MPT Sent: Thursday, October 07, 2010 6:24 PM To: PTManager Subject: RE: Re:maintenance PT Hi Kathleen, I will respectfully disagree that maintenance " should be done by non-skilled caretakers after being trained by therapists " . In my opinion, this is a pervasive attitude of our profession that has contributed to us losing clients to other professions such as massage therapists and personal trainers. We should not narrow our perspective that we are only skilled at treatments that provide what insurances have defined as " progress " " function " and " maintenance " . We should be more focused on what is healthy, what is in the best interest of our clients and why we, not anyone else has the skill and knowledge to treat and to provide services to help our clients attain health and wellness. We keep giving away parts of our skill to others until there will be nothing else left to justify us as a profession. Plus if we keep narrowing our service to only what insurances dictate, they too will, narrow reimbursement (as we have painfully seen in the last 20 years) so drastically that it too will put us out of a profession. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of Kathleen e Sent: Thursday, October 07, 2010 12:02 PM To: PTManager Subject: Re: Re:maintenance PT I will reiterate-this is the only insurance plan that I have ever worked with in my long career that pays for maintenence therapy. This son does not feel that he or his paid caretaker should do stretching,etc as someone else will pay for it. I am trained and fully understand goal setting for people with dementia versus an althelete with ACL repair. This lady is 1.5 or 2 at best-dependent in ADLS, transfers, and non-ambulatory. Maintenance,in my professional opinion, should be done by non-skilled caretakers after being trained by a therapist. We all have seen that people on a maintenance will decline over a period of time, as we can do those simple interventions so much better than anyone else. Periodic re-assessment is appropriate to redesign the maintenance program or restart a course of therapy if there is potential to restore function. Thanks for your input and opinion on this very unique situation! ________________________________ From: Wendland <jlwendland@... <mailto:jlwendland%40abstherapy.com> > To: PTManager <mailto:PTManager%40yahoogroups.com> Sent: Thu, October 7, 2010 8:03:00 AM Subject: RE: Re:maintenance PT I agree. Our Code of Ethics states that is it wrong to perform services that are of no benefit to the patient. Maintenance programs benefit the patient (why else would we refer to restorative or HEP?), and non-payment is strictly an insurance issue. Wendland PT Ohio _____ From: M. Howell, PT, MPT [mailto:thowell@... <mailto:thowell%40fiberpipe.net> ] To: PTManager <mailto:PTManager%40yahoogroups.com> Sent: Wed, 06 Oct 2010 18:27:25 -0400 Subject: RE: Re:maintenance PT Hi everyone, I would like to play devil's advocate here. Would this patient decline without periodic and continuous therapy? Can you justify in any way that this is the case. Forget about goals and progress and look at the human condition of this. Take the insurance out of the picture for a second - what does your experience say about this? BUT, if there is a way to justify it under insurance, then why not continue to get paid for the service? I have worked with dementia patients and truthfully, standard goals and progress do not work for this population. Time frames for goals are much longer and progress, as determined by experience and not by insurance, is usually seen in inches not miles. Are you keeping the patient from physical decline that would lead to falls? (this may take months). Can you provide a better quality of life for the client? For the family? It is up to you to justify it based on accepted knowledge and experience about this patient population. And think about the service you are doing to the family which is apparently struggling with care. Also realize that change can affect these clients in very negative ways. Changing the therapy environment might not be the best idea. Certainly, your job is to provide all options but please take another look at what you can do for this client at your clinic first. If you really cannot justify continuing to bill insurance then don't. Your options at that point remain private pay, referral to daycare or pro bono service. If you are concerned with family backlash, get a letter from the insurance company stating that they will not continue to pay. I would not worry about the Code of Ethics especially if you can justify continued treatment (whether it falls under the definitions of " skilled care " or " maintenance therapy " or not). We continue to get hung up on goals and rules set by insurance. Progress and skilled services are defined by insurances not by us. " Maintenance therapy " is defined by insurance, not us. As professionals, we have the knowledge and experience to know what is best for our clients, not insurance. Families will never understand insurance rules either, especially maintenance therapy. They will understand, and spread the word, if you handle this situation poorly and cut this client off from therapy with no options. And , of course, in my opinion, we should get paid for that knowledge and experience even in difficult cases such as this that do not " fit " the rules that insurances have set but do fit what is the right thing to do. If this were at my clinic, I would keep treating and keep billing and find a way to justify and document based on all available evidence about this. If I reached a point where I was truly sure that insurance should not be billed, then I would continue to see this patient pro bono and give the family time to come to terms with options. I would have regular meetings with family as a condition of continued care and set a contract with them asking them to meet certain obligations at home and to explore options (while I continued pro bono care). If the family is not meeting their obligations, they would know the consequences (discharge). I would be sure to document family meetings to have a record of everything discussed in case they do not meet their obligations and caused a fuss. This would allow a process where everything has been tried and the family is completely aware and involved. I know this has been a passionate reply and I hope that it has made everyone think. Remember: we are the professionals, we determine what is best for this client first, then we try to fit it within the system and with the family dynamics. Patients/clients and families should come first. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... <mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com> ] On Behalf Of Kathleen e Sent: Wednesday, October 06, 2010 9:03 AM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: Re:maintenance PT I need to clarify that our 92 y/o with dementia has a private insurance,NOT Medicare, that continues to pay for maintenance therapy in our outpatient clinic. Our concern is the Code of Ethics referencing excessive service. We are not even trying to document this as skilled service and the insurance has been paying for months of this. Kathleen e,PT HSA of Stanislaus County Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 8, 2010 Report Share Posted October 8, 2010 Re this: " Funny how we, as a class, allow outsiders to define us, in spite of us. " I think, if we can look just a little bit deeper at this, we will see that we are as guilty as anyone of attempting to impose " outsider " views. Remember that the question of maintenance therapy " value " exists only because, in this unnatural, crazy, outsider-controlled world, the patient is not the customer. Third-party payers and other controllers have divided the undividable (or attempted to---there is always resistance when going against nature) by separating the personal interest one has in the care of one's own body from decisions about care delivery. Controllers of all types---payers, regulators, and providers---seem very comfortable these days defining what is " right " for everybody, including the defining of service values. Think again if you feel righteous in this regard. This very thread suggests that we therapists are more than comfortable debating how this or that person ought to spend their money. Is it any surprise that at the end of the debate we discover, apparently without irony, that WE are the ones who should be making the decisions? The right to self-determination is very, very basic to humanity. Outside controllers by definition interfere with that right. We ought to, personally and professionally, stand in opposition to them. Educate patients, yes! Promote evidence-based practice, yes! Honestly measure outcomes, yes! But do not become dictators, benevolent or otherwise. Instead allow decisions of value and correctness to come from the patient. Unambiguously support the devolving of control back to individuals. (Healthcare savings accounts (the unadulterated variety), by the way, help do just that.) Dave Milano, PT, Rehabilitation Director Laurel Health System " The whole modern world has divided itself into Conservatives and Progressives. The business of Progressives is to go on making mistakes. The business of the Conservatives is to prevent the mistakes from being corrected. " Gordon Chesterton ________________________________ From: PTManager [mailto:PTManager ] On Behalf Of Armin Loges Sent: Friday, October 08, 2010 9:50 AM To: PTManager Subject: Re: Re:maintenance PT Funny how we, as a class, allow outsiders to define us, in spite of us. Armin Loges, PT Tampa, FL From: M. Howell, PT, MPT Sent: Thursday, October 07, 2010 6:24 PM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: RE: Re:maintenance PT Hi Kathleen, I will respectfully disagree that maintenance " should be done by non-skilled caretakers after being trained by therapists " . In my opinion, this is a pervasive attitude of our profession that has contributed to us losing clients to other professions such as massage therapists and personal trainers. We should not narrow our perspective that we are only skilled at treatments that provide what insurances have defined as " progress " " function " and " maintenance " . We should be more focused on what is healthy, what is in the best interest of our clients and why we, not anyone else has the skill and knowledge to treat and to provide services to help our clients attain health and wellness. We keep giving away parts of our skill to others until there will be nothing else left to justify us as a profession. Plus if we keep narrowing our service to only what insurances dictate, they too will, narrow reimbursement (as we have painfully seen in the last 20 years) so drastically that it too will put us out of a profession. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@...<mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf Of Kathleen e Sent: Thursday, October 07, 2010 12:02 PM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: Re: Re:maintenance PT I will reiterate-this is the only insurance plan that I have ever worked with in my long career that pays for maintenence therapy. This son does not feel that he or his paid caretaker should do stretching,etc as someone else will pay for it. I am trained and fully understand goal setting for people with dementia versus an althelete with ACL repair. This lady is 1.5 or 2 at best-dependent in ADLS, transfers, and non-ambulatory. Maintenance,in my professional opinion, should be done by non-skilled caretakers after being trained by a therapist. We all have seen that people on a maintenance will decline over a period of time, as we can do those simple interventions so much better than anyone else. Periodic re-assessment is appropriate to redesign the maintenance program or restart a course of therapy if there is potential to restore function. Thanks for your input and opinion on this very unique situation! ________________________________ From: Wendland <jlwendland@...<mailto:jlwendland%40abstherapy.com> <mailto:jlwendland%40abstherapy.com> > To: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> Sent: Thu, October 7, 2010 8:03:00 AM Subject: RE: Re:maintenance PT I agree. Our Code of Ethics states that is it wrong to perform services that are of no benefit to the patient. Maintenance programs benefit the patient (why else would we refer to restorative or HEP?), and non-payment is strictly an insurance issue. Wendland PT Ohio _____ From: M. Howell, PT, MPT [mailto:thowell@...<mailto:thowell%40fiberpipe.net> <mailto:thowell%40fiberpipe.net> ] To: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> Sent: Wed, 06 Oct 2010 18:27:25 -0400 Subject: RE: Re:maintenance PT Hi everyone, I would like to play devil's advocate here. Would this patient decline without periodic and continuous therapy? Can you justify in any way that this is the case. Forget about goals and progress and look at the human condition of this. Take the insurance out of the picture for a second - what does your experience say about this? BUT, if there is a way to justify it under insurance, then why not continue to get paid for the service? I have worked with dementia patients and truthfully, standard goals and progress do not work for this population. Time frames for goals are much longer and progress, as determined by experience and not by insurance, is usually seen in inches not miles. Are you keeping the patient from physical decline that would lead to falls? (this may take months). Can you provide a better quality of life for the client? For the family? It is up to you to justify it based on accepted knowledge and experience about this patient population. And think about the service you are doing to the family which is apparently struggling with care. Also realize that change can affect these clients in very negative ways. Changing the therapy environment might not be the best idea. Certainly, your job is to provide all options but please take another look at what you can do for this client at your clinic first. If you really cannot justify continuing to bill insurance then don't. Your options at that point remain private pay, referral to daycare or pro bono service. If you are concerned with family backlash, get a letter from the insurance company stating that they will not continue to pay. I would not worry about the Code of Ethics especially if you can justify continued treatment (whether it falls under the definitions of " skilled care " or " maintenance therapy " or not). We continue to get hung up on goals and rules set by insurance. Progress and skilled services are defined by insurances not by us. " Maintenance therapy " is defined by insurance, not us. As professionals, we have the knowledge and experience to know what is best for our clients, not insurance. Families will never understand insurance rules either, especially maintenance therapy. They will understand, and spread the word, if you handle this situation poorly and cut this client off from therapy with no options. And , of course, in my opinion, we should get paid for that knowledge and experience even in difficult cases such as this that do not " fit " the rules that insurances have set but do fit what is the right thing to do. If this were at my clinic, I would keep treating and keep billing and find a way to justify and document based on all available evidence about this. If I reached a point where I was truly sure that insurance should not be billed, then I would continue to see this patient pro bono and give the family time to come to terms with options. I would have regular meetings with family as a condition of continued care and set a contract with them asking them to meet certain obligations at home and to explore options (while I continued pro bono care). If the family is not meeting their obligations, they would know the consequences (discharge). I would be sure to document family meetings to have a record of everything discussed in case they do not meet their obligations and caused a fuss. This would allow a process where everything has been tried and the family is completely aware and involved. I know this has been a passionate reply and I hope that it has made everyone think. Remember: we are the professionals, we determine what is best for this client first, then we try to fit it within the system and with the family dynamics. Patients/clients and families should come first. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@...<mailto:thowell%40fiberpipe.net> <mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> ] On Behalf Of Kathleen e Sent: Wednesday, October 06, 2010 9:03 AM To: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> Subject: Re:maintenance PT I need to clarify that our 92 y/o with dementia has a private insurance,NOT Medicare, that continues to pay for maintenance therapy in our outpatient clinic. Our concern is the Code of Ethics referencing excessive service. We are not even trying to document this as skilled service and the insurance has been paying for months of this. Kathleen e,PT HSA of Stanislaus County Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 8, 2010 Report Share Posted October 8, 2010 After a year of this, I am the insider making <I hope, a good ethical decision. From: PTManager [mailto:PTManager ] On Behalf Of Armin Loges Sent: Friday, October 08, 2010 6:50 AM To: PTManager Subject: Re: Re:maintenance PT Funny how we, as a class, allow outsiders to define us, in spite of us. Armin Loges, PT Tampa, FL From: M. Howell, PT, MPT Sent: Thursday, October 07, 2010 6:24 PM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: RE: Re:maintenance PT Hi Kathleen, I will respectfully disagree that maintenance " should be done by non-skilled caretakers after being trained by therapists " . In my opinion, this is a pervasive attitude of our profession that has contributed to us losing clients to other professions such as massage therapists and personal trainers. We should not narrow our perspective that we are only skilled at treatments that provide what insurances have defined as " progress " " function " and " maintenance " . We should be more focused on what is healthy, what is in the best interest of our clients and why we, not anyone else has the skill and knowledge to treat and to provide services to help our clients attain health and wellness. We keep giving away parts of our skill to others until there will be nothing else left to justify us as a profession. Plus if we keep narrowing our service to only what insurances dictate, they too will, narrow reimbursement (as we have painfully seen in the last 20 years) so drastically that it too will put us out of a profession. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... <mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com> ] On Behalf Of Kathleen e Sent: Thursday, October 07, 2010 12:02 PM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: Re: Re:maintenance PT I will reiterate-this is the only insurance plan that I have ever worked with in my long career that pays for maintenence therapy. This son does not feel that he or his paid caretaker should do stretching,etc as someone else will pay for it. I am trained and fully understand goal setting for people with dementia versus an althelete with ACL repair. This lady is 1.5 or 2 at best-dependent in ADLS, transfers, and non-ambulatory. Maintenance,in my professional opinion, should be done by non-skilled caretakers after being trained by a therapist. We all have seen that people on a maintenance will decline over a period of time, as we can do those simple interventions so much better than anyone else. Periodic re-assessment is appropriate to redesign the maintenance program or restart a course of therapy if there is potential to restore function. Thanks for your input and opinion on this very unique situation! ________________________________ From: Wendland <jlwendland@... <mailto:jlwendland%40abstherapy.com> <mailto:jlwendland%40abstherapy.com> > To: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> Sent: Thu, October 7, 2010 8:03:00 AM Subject: RE: Re:maintenance PT I agree. Our Code of Ethics states that is it wrong to perform services that are of no benefit to the patient. Maintenance programs benefit the patient (why else would we refer to restorative or HEP?), and non-payment is strictly an insurance issue. Wendland PT Ohio _____ From: M. Howell, PT, MPT [mailto:thowell@... <mailto:thowell%40fiberpipe.net> <mailto:thowell%40fiberpipe.net> ] To: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> Sent: Wed, 06 Oct 2010 18:27:25 -0400 Subject: RE: Re:maintenance PT Hi everyone, I would like to play devil's advocate here. Would this patient decline without periodic and continuous therapy? Can you justify in any way that this is the case. Forget about goals and progress and look at the human condition of this. Take the insurance out of the picture for a second - what does your experience say about this? BUT, if there is a way to justify it under insurance, then why not continue to get paid for the service? I have worked with dementia patients and truthfully, standard goals and progress do not work for this population. Time frames for goals are much longer and progress, as determined by experience and not by insurance, is usually seen in inches not miles. Are you keeping the patient from physical decline that would lead to falls? (this may take months). Can you provide a better quality of life for the client? For the family? It is up to you to justify it based on accepted knowledge and experience about this patient population. And think about the service you are doing to the family which is apparently struggling with care. Also realize that change can affect these clients in very negative ways. Changing the therapy environment might not be the best idea. Certainly, your job is to provide all options but please take another look at what you can do for this client at your clinic first. If you really cannot justify continuing to bill insurance then don't. Your options at that point remain private pay, referral to daycare or pro bono service. If you are concerned with family backlash, get a letter from the insurance company stating that they will not continue to pay. I would not worry about the Code of Ethics especially if you can justify continued treatment (whether it falls under the definitions of " skilled care " or " maintenance therapy " or not). We continue to get hung up on goals and rules set by insurance. Progress and skilled services are defined by insurances not by us. " Maintenance therapy " is defined by insurance, not us. As professionals, we have the knowledge and experience to know what is best for our clients, not insurance. Families will never understand insurance rules either, especially maintenance therapy. They will understand, and spread the word, if you handle this situation poorly and cut this client off from therapy with no options. And , of course, in my opinion, we should get paid for that knowledge and experience even in difficult cases such as this that do not " fit " the rules that insurances have set but do fit what is the right thing to do. If this were at my clinic, I would keep treating and keep billing and find a way to justify and document based on all available evidence about this. If I reached a point where I was truly sure that insurance should not be billed, then I would continue to see this patient pro bono and give the family time to come to terms with options. I would have regular meetings with family as a condition of continued care and set a contract with them asking them to meet certain obligations at home and to explore options (while I continued pro bono care). If the family is not meeting their obligations, they would know the consequences (discharge). I would be sure to document family meetings to have a record of everything discussed in case they do not meet their obligations and caused a fuss. This would allow a process where everything has been tried and the family is completely aware and involved. I know this has been a passionate reply and I hope that it has made everyone think. Remember: we are the professionals, we determine what is best for this client first, then we try to fit it within the system and with the family dynamics. Patients/clients and families should come first. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... <mailto:thowell%40fiberpipe.net> <mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> ] On Behalf Of Kathleen e Sent: Wednesday, October 06, 2010 9:03 AM To: PTManager <mailto:PTManager%40yahoogroups.com> <mailto:PTManager%40yahoogroups.com> Subject: Re:maintenance PT I need to clarify that our 92 y/o with dementia has a private insurance,NOT Medicare, that continues to pay for maintenance therapy in our outpatient clinic. Our concern is the Code of Ethics referencing excessive service. We are not even trying to document this as skilled service and the insurance has been paying for months of this. Kathleen e,PT HSA of Stanislaus County Quote Link to comment Share on other sites More sharing options...
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