Any rehab therapist that has dealt with insurance companies understands the particular frustration in dealing with an organization that may not be aligned with patients’ best interests. In a Stanford Medicine Magazine article annotating the rise of insurance companies in America, Elisabeth Rosenthal writes: “The very idea of health insurance is in some ways the original sin that catalyzed the evolution of today’s medical-industrial complex.” I know that sounds a bit harsh, but it’s ultimately true.

Here’s the painful reality: commercial enterprises are not incentivized to actually make patients better, faster or even prevent injuries before they happen. Rather, public companies are pushed by shareholders to grow revenue and expand profit margins; this paradigm seems to have shifted many insurance companies away from protecting patients and towards protecting the bottom line. And as PT owners have experienced in their own practices, health care can be an expensive business that is frequently at odds with financial returns.

In case we needed any proof of where these payers’ priorities lie, there’s this story from the New York Times exposing how nearly all of the top Medicare Advantage providers have allegedly:

• over billed
• added fictitious or falsified diagnoses to boost claim values with higher-dollar codes, and
• otherwise engaged in fraudulent practices that have extracted billions from the program and brought the ire of a number of regulatory and law enforcement agencies

Unsurprisingly, those same payers have done quite well for themselves with the returns on Medicare Advantage patients relative to the individual and group markets… for what I’m sure are completely unrelated reasons.

Commercial insurance hasn’t always been like this.

Health insurance has existed for nearly a century, beginning with what would become Blue Cross in 1929. And like many goods and services of the time, premiums in those early days were a downright steal by today’s standards: the precursor to Blue Cross charged members $0.50 a month—about $8 in 2022, adjusted for inflation. Things began to change in the 1970s and 1980s, as the industry saw drastic health spending increases driven by new medical technology and cost-based reimbursement systems. Nonprofit and individual providers were also replaced by new managed care models and for-profit health service providers. Suddenly, health care was a big business, and private insurers and others began acting accordingly (which is to say greedily).

The irony of this is that, according to Louis S. Reed’s Private Health Insurance in the United States: An Overview, insurance executives during the industry’s infancy in the 1930s “did not show much interest in hospital or surgical-medical expense insurance” with many believing that “the field should be left to the nonprofit plans.”

How PTs can work within the system.

Unfortunately, the system as it exists today is the system rehab therapists have to work within. Where we are fortunate is that physical therapy is well-positioned to survive—and even thrive—in this profit-driven environment. If commercial payers are looking to lower costs to maximize profits, then they should be looking at physical therapy as a proven method of reducing healthcare costs, both in the short and long term. But it’s on us to demonstrate that effectiveness and efficiency to payers. How? There are a few concrete steps therapists can take to help make their case.

Keep your claims as clean as possible.

As my colleague John Walllace pointed out in this blog post, many major commercial payers are using outside companies to do third-party reviews of patient claims—and those reviewers are looking for any reason to deny a claim and save a few bucks. That’s why submitting clean claims is so important for the overall efficiency and profitability of clinics that are already working on tight margins.

Based upon our own work at WebPT, we’ve found that the cost of a denied claim is about $29 and requires at least two additional touches to rework—each of which equates to about 15 minutes spent on reworking the claim (so, 30 minutes in total). Compound that across multiple claims over multiple months, and it’s clear just how much of an impact billing errors can have on your organization’s bottom line and productivity. Thus, scrubbing your claims for errors ahead of submission is essential to avoiding denials and maintaining efficiency—and if you can find a reputable rehab-specific billing solution that can do it for you, even better.

Fix scheduling errors to reduce no-shows and minimize cancellations.

You can’t afford not to make full use of both your time and space during your working hours—which is why no-shows and cancellations are particularly painful to deal with. Having a waitlist in place to offset cancellations can help you keep a full schedule, and sending appointment reminders via text, phone, or email can help cut down on no-shows. However, these are merely table stakes to preventing gaps in your schedule. I would also recommend:

• implementing a penalty for patients who don’t show;
• incentivizing front office staff to reschedule patients within the same week of their original appointment if possible); and
• encouraging patients to arrive early to help avoid delays.

These simple, yet effective strategies can seriously help maximize your clinic schedule capacity and grow your clinic revenue.

Organize your billing practices to reduce denials.

Adapting to our new reality was something that John Wallace and I discussed during our most recent billing webinar. One point John really drove home was that the best way to remain compliant and maximize reimbursements is by getting organized around your billing practices. This starts by defining roles and responsibilities for each member of your billing team to ensure every task is covered, including:

• dividing the handling of appealable and non-appealable denials (and determining whether they are due to technical or medical policy);
• responding to all payer requests in a timely manner; and
• staying up to date on any important regulatory updates.

These are but the starting points for any high-performing billing team. John provides an even deeper plan of action in this aforementioned blog post.

Introduce hybridized care plans.

One simple efficiency therapists can take advantage of is incorporating a hybrid model of care with their patients. Rather than limiting treatment to office visits, you can leverage telehealth and remote therapeutic monitoring in addition to home exercise plans to offer patients a mix of in-person visits and at-home care. Not only does this model help reduce your own costs and cut down on the clinical space needed, but it can also make it more convenient for time-constrained patients to keep up with their treatment plans (in turn helping to cut down on your cancellations, no-shows, and dropouts).

Create operational benchmarks within your practice.

If you don’t have your own internal benchmarks, then you better get going! With clinic margins continuing to shrink, it’s imperative that you have data, metrics, and an understanding of benchmarks in your area (or region) to determine where you should be improving and where you should be piling on. Knowing your all-in cost per visit, revenue per visit and payer contracted amounts are basic starters for any business—but that’s only the beginning. Aggregating and managing all clinic and billing metrics in a dashboard can help you know which areas of the business must be prioritized. This can also identify areas where you can solicit (and even incentivize) your staff’s assistance to help improve. What’s most important is that you clearly establish these benchmarks, communicate them to your team, and review them often with your PTs so they’re fully on board with the goals of your business (and invested in helping achieve them).

Collect and share better outcomes data.

I’ve been beating the drum for better outcomes tracking for a long time—and it’s a drum I will persistently beat until we as an industry stop dragging our feet in this area. Despite payers having both claims and cost evidence to show the value of physical therapy, our community has fallen short of showcasing our greater outcomes measure results—unless there is a penalty or incentive associated with capturing and sharing this data. However, the value of outcomes completion doesn’t just pertain to payer relationships and clout— it has a great impact on our internal staff and patients. Outcomes measurement solutions are essentially engagement tools that can:

• help unveil educational and professional development opportunities for your clinicians;
• drive your bonus programs; and
• help improve the overall patient experience in your practice (when used along with patient satisfaction surveys).

Lobby for the PT cause.

I know it often feels like PTs are powerless over what happens to us, but if this midterm election has shown us anything, it’s that there is power in advocacy and in our vote. To this end, clinician engagement with legislation that affects the rehab therapy profession is imperative to its future. Furthermore, learning to advocate for positive change is a powerful way to establish a deeper connection with your industry.

There’s currently a number of bills working their way through Congress that, if passed, would help PTs provide quality treatment, reach more patients, and at least maintain current reimbursement levels.

• The Stabilizing Medicare Access to Rehabilitation and Therapy (SMART) Act would eliminate the 15% Medicare payment cuts for services provided by OTAs or PTAs and would reduce the supervision requirements from “direct” to “general.”
• The Supporting Medicare Providers Act of 2022 would negate the proposed 4.4% cut in the 2023 proposed fee schedule.
• The Expanded Telehealth Access Act of 2021 would make Medicare telehealth privileges permanent for PTs and OTs
• The Physical Therapist Workforce and Patient Access Act would allow PTs to take part in the National Health Service Corps student loan repayment program, which offers up to $50,000 in student loan repayment in exchange for two years of service in an underserved area.
• The Improving Seniors’ Access to Timely Care Act would create an electronic prior authorization system for Medicare Advantage that would improve processing times and expedite access to care for seniors.

While these are obviously bills that relate specifically to Medicare, they’re examples of the importance of paying attention to healthcare legislation and getting involved. If we band together and exert our influence by pushing our elected leaders to pass meaningful legislation that will benefit Medicare providers and patients, we know it will trickle down to also have an effect on commercial payers as well—especially in light of the NYT report. (Not that I’m holding my breath on that one.)

(Note: If you’re looking to stay up-to-date on what PT-related legislation is in the works, check out this APTQI resource.)

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Griping about private payers can be cathartic, especially when you’re dealing with another headache they’ve created for you, but it’s ultimately not going to help in the fight for better pay and better treatment. Instead, rehab therapy business owners and clinicians are going to need to get scrappy (and creative) to improve practice efficiency, employee engagement, and staff and patient retention—all the while continuing to advocate for positive change. The future of PT is bright, but it will take some adjustment—and perhaps some discomfort in the short term—to continue delivering the best non-invasive care in the MSK arena. But we are resilient. We are intelligent. And we’ve got this!