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REP 2 - Fraud, abuse and waste

Melissa Anderson, PT

When thinking about protecting the reputation of the physiotherapy profession, we need to understand three terms and how they relate to our practice.  These terms are fraud, abuse and waste.

 

Fraud

Fraud is “the crime of using dishonest methods to take something valuable from another person.” (Merriam Webster)  Fraud is part of the Criminal Code of Canada.  Our provincial regulatory bodies do not define fraud, as the investigation and any subsequent charges are not in the jurisdiction of the registrar, but are the responsibility of the police and justice systems.

When considering how fraud relates to health care benefits, it is, in simplest terms, a crime. It is “the intent to obtain reimbursement for goods or services that were neither received nor provided.” (Manitoba Blue Cross, n.d.)  

Fraud related to health benefits can be a single person acting alone, or an entire ring of people working together in an elaborate scheme to profit from the fraudulent reimbursement of health care benefits. 

While fraud in physiotherapy in Canada is relatively rare, there are several well-publicized examples that are cause for concern in both the physiotherapy and insurance communities.

There is intent to get money illegally from a payer when insurance fraud is committed. Insurance investigators and auditors are looking for intent, along with prior knowledge and available evidence, when evaluating a tip or complaint. (Humana Inc., 2016)

It seems that health care fraud schemes are limited only by the imagination of the perpetrators.  Health insurance fraud can be as simple as providing false information on a receipt, or as complex as a staged car accident resulting in false health benefit claims being made.  Unfortunately, Canadian physiotherapists and physiotherapy clinic owners have been involved in several of these examples.

 

Some examples of health care insurance fraud can be:

  • Misrepresenting services supplied or the provider of services on receipts

  • Returning items after reimbursement and not refunding the insurer

  • Submitting claims for services not rendered

  • Forging or altering receipts - including patient name, billed amount, service date, etc.

  • Using another providers’ billing credentials or license

  • Knowingly providing care to a patient who is using someone else’s insurance card or coverage

  • Waiving patient co-pays or deductibles and over-billing the insurance carrier

  • Practicing without a license (Manitoba Blue Cross, n.d.) (Manulife Financial, n.d.) (Cigna, 2016)

 

Abuse

Abuse is “a corrupt practice, or improper or excessive use.” (Merriam Webster) We all know of people who may abuse alcohol or drugs (excessive use), or who may abuse their authority (improper behaviour).  But how exactly does ‘abuse’ fit with physiotherapists and extended health benefits?

In health care, abuse counts as “practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.” (John Hopkins Medicine, n.d.)  

Specifically, insurance abuse is “any action that utilizes the plan in a way that is contrary to the intended purpose of the benefit, which results in unnecessary cost to the plan.” (Manitoba Blue Cross, n.d.)  

In physiotherapy, this is most often seen when a patient’s insurance, rather than the patient are treated.  This means that if a person has $500 of physiotherapy insurance in their benefits plan, then quite often they require $500 worth of physiotherapy treatment before they are discharged, when in fact they may have improved after only one or two treatments.  Abuse is closely related to fraud, but may not include criminal intent. Another difference is that the treatment in abuse cases has often been actually provided to the client, it is simply not necessary.

 

In addition to the example above, some common sources of health care abuse are:

  • Misusing codes on a claim

  • Providing exercises classes, but billing for physiotherapy

  • Charging excessively for services or supplies

  • Billing for services that were not medically necessary

  • Payment for services that fail to meet professionally recognized standards of care (John Hopkins Medicine, n.d.)

 

Waste

Waste is “a situation in which something valuable is not being used or is being used in a way that is not appropriate or effective.” (Merriam Webster, )  Waste is often difficult to ignore in our everyday lives, but may be harder to spot in relation to health care and insurance.

In health care, waste is an “overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system… It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.” (Humana Inc., 2016)

 

Some examples of waste in physiotherapy include:

  • Providing treatment that has been proven to be ineffective

  • Prescribing sub-optimal exercise programs- therefore not achieving desired results

  • Physiotherapists doing tasks that could be performed by Physiotherapist Assistants (e.g. in public practice settings)

  • Treating patients for inappropriate reasons

 

Not all of the behaviours described here will lead to stories of criminal charges or in the media. However, if combined, then they could all lead to the deterioration of the physiotherapy professional reputation in Canada. 

As social media and word of mouth now eclipse traditional advertising and promotion, it is necessary that we physiotherapists, physiotherapy assistants, physical rehabilitation therapists (in Quebec) and clinic owners work together to protect the good reputation of this profession. 

We need to be a truly self-regulating profession, where we hold ourselves and our peers not to a basic standard, but to the high standard that Canadians have come to expect. 

We need and want to retain our places as respected members of Canada’s health care system.

 

What do you think?

1. After reading this, what is your biggest concern about fraud, abuse and waste?

2. What examples of health care insurance fraud worry you the most? 

3. How do you mitigate insurance fraud in your practice? Waste? 

 

Written by: Melissa Anderson, PT
 

Works Cited

Abuse. (n.d.). Retrieved 02 05, 2016, from Merriam-Webster.com: http://www.merriam-webster.com/dictionary/abuse

Cigna. (2016). Report Fraud. Retrieved 02 04, 2016, from Cigna.com: http://www.cigna.com/reportfraud/

Fraud. (n.d.). Retrieved 02 08, 2016, from Merriam-Webster.com: http://www.merriam-webster.com/dictionary/fraud

Humana Inc. (2016). Adressing Fraud, Waste and Abuse. Retrieved 02 08, 2016, from Humana.com: https://www.humana.com/about/legal/disclaimer-and-licensure/fraud-waste-...

John Hopkins Medicine. (n.d.). Health care fraud and abuse. Retrieved 02 04, 2016, from hopkinsmedicine.org: http://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physic...

Manitoba Blue Cross. (n.d.). Insurance Fraud and Abuse. Retrieved 02 08, 2016, from mb.bluecross.ca: https://www.mb.bluecross.ca/fraud

Manulife Financial. (n.d.). Fraud and Abuse Prevention. Retrieved 02 08, 2016, from Manulife.ca: https://www.manulife.ca/wps/wcm/connect/76dc2e3b-749f-464f-ac81-e1de86f9...

Waste. (n.d.). Retrieved 02 08, 2016, from Merriam-Webster.com: http://www.merriam-webster.com/dictionary/waste

 

 

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Comments

melissa: thank you for a succinct "cautionary tale". i have practised physiotherapy, reputably i believe, for 35 years. it is a constant frustration to me that "because of a few bad apples" all physiotherapists "get tarred with the same brush" in the eyesof the insurance industry. it is my opinion that (pardon my naivete) much of the paper work we all dislike so much is the consequence of the insurance industry (and them prevailing upon provincial physiotherapy regulators) creating hoops through which we must jump in our practices, in order to demonstrate to the industry that we, the honest practitioners, are, in fact "good boys and girls".

Thank you for your comments.  We agree that the majority of physiotherapists follow the rules, and share your frustration that the "few bad apples" cause risk to the reputation of the profession. 

@CPA_Melissa

Melissa: thank you for this article. I have practiced for the past 25 years and get frustrated when private practices try to manipulate the extended health care benefits of certain employers to their benefit. We have a prime example here in Nova Scotia of one clinic provider offering discounts to the union based employees who a  Blue Cross plan covering 80% of all physiotherapy services, thus creating a 20% co-pay. This clinic provider offers to all unionized members a 20% discount (thus not charging the 20% co-pay) in direct violation of the Blue Cross policy. I am glad to hear that this is an actual act of fraud and the provider should be taken to task on this practice.

Thanks for joining the conversation.  In most jurisdictions, clinics can offer discounts on their services. The problem arises when a clinic provides a receipt for more than was actually charged, thus reducing the co-pay fee.  This could constitute insurance fraud, and should be reported.

@CPA_Melissa

 

A very good review of what constitutes fraud, abuse and waste. As an assessor for the Insurance industry regarding the MVA's, I can attest to the fact that there are a lot of abuse taking place in our profession. How can one justify treating a simple WAD 1 or 2 with physiotherapy, chiropractic, massage therapy and acupuncture? Duplication of services is also waste.

Thank you for your perspective.  It is important for us to discuss this issue as a profession.  Especially when cross referral patterns, like you mentioned, have been explored in the media. https://www.thestar.com/business/personal_finance/2015/04/13/the-rise-of...

@CPA_Melissa

I found it interesting that as an example of waste you wrote: that physiotherapists doing tasks that a physiotherapist assistant could do is considered waste (this is a dangerous situation of opinion; whose by the way?). This kind of thought will open the arena for insurance companies to refuse payment or provide only partial payments if they believe this is so because in some clinics there are assistants who are used for certain services, in others assistants are used for very different services and yet in my clinic, I have no assistants and perform all of these "same" tasks . So everything I do that in other clinics they use assistant is actually "wasting" someones money? Assistant's are not mandatory to our roles as physiotherapist's (or not yet anyway but the cautionary tale here is that it may no longer be a choice?) and even in clinics where assistants do exist, it currently is a physiotherapist's judgement to decide whether it is appropriate to even offer some services to a patient to be done by an assistant (that they, the patient, has the right to refuse anyway; so is the patient wasteful too? Will insurance companies then take away the patients' right of consent to decline services by an assistant?) That here is definitely some dangerous waters we are opening up by that statement. By this particular example of waste are you then saying small town/rural/small business anywhere for that matter, physiotherapy clinics have to have assistants and all that that then entails and if they don't they are judged as being "wasteful"? 

Other than that point of example, I thought the piece was very thorough (obviously thought provoking) and relevant Melissa; thank you. Also, I agree with the first physiotherapist's of 35 yrs practice ( I myself am at 31 yrs) comments that the "few bad apples" have created so much more paper work (and cost to us) from the third party knee jerk responses of the insurance world.

 

Thank you for your thought provoking comments. My previous 25 years of experience was in public practice, so my experience may influence my thoughts on this subject.  In the public setting where I worked, physiotherapist assistants were readily available.  When there is work waiting that only a physiotherapist can do, and that physiotherapist is doing a task that could easily be assigned to a physiotherapist assistant, in my opinion, that is wasteful.

However, your points regarding private practice are all very valid.  What we need to have insurers recognize is that there are many different models of care, all of which can be effective and efficient, and all will need to be considered from a reimbursement perspective.

The model you describe, where you do not utilize a physiotherapist assistant, is a valid and effective model.  I do not want insurers to change the way they reimburse for your services.

In other models, physiotherapist assistants and other workers are utilized.  Currently, many insurers will not reimburse work done by these therapy extenders.  In markets where there are limited physiotherapy resources, the use of therapy extenders needs to be considered.

CPA is engaging in advocacy work on behalf of the profession.  We believe that all models of care that provide quality service should be supported.  We do not want to allow insurance companies to direct how physiotherapists practice.  We do, however, want to be proactive and advocate for those who do use extenders as a valid model of care, so they can be paid for the work done by their assistants.

 

I appreciate you taking the time to raise your concerns, and am happy to discuss further if you wish to contact me (manderson@physiotherapy.ca)

@CPA_Melissa

 

Hi, I think that in many of the publically funded systems (provinical hospitals/facilities), physiotherapist assistants who are hired to work with and help the physiotherapists.  They can allow the physiotherapist to spend more time on assessments, re-assessments and discharge planning while ensuring that patients have the appropriate supervised activities/exercises treatement times that will allow them to safely and effectively transition to a more independent status.  

When a physiotherapist does not effectively assign treatment tasks to the PTA, the whole systems may be affected.  The patient may need to stay in hospital longer as they haven't reached the milestone necessary for discharge.  Or the facility may then be paying a PTA to count crutches and clean mats instead of treating a patients.  Or the physiotherapist is getting stressed because they may feel inadequate as they are unable to give the patients what they need.  All 3 of these situations cost the system, in some cases money that could have been used to support patient-centered care or the physiotherapist being unsatisfied with thier employement/job or perhaps suffering some burn-out which then affects the rehabilitation department, the facility, and all the patients. . 

When I have worked in private practice, a number of situations/patient caseloads do not lend themselves to using PTAs.  When you are in an acute setting and patients are changing quickly, it is not always time effective to have another doing what you can do as easily or quickly.  But in population who have more chronic conditions or conditions which change more slowly, would lend themselves to having some of thier treatment/exercise interventions assigned to a PTA. .  

Hi Melissa,

As a relatively new grad (4 years out now) I am glad you have brought this issue to light. Before getting into physiotherapy, I worked as a physiotherapist assistant in a private outpatient clinic that was commiting outright fraud -- ex misrepresenting physiotherapy services as chiropractic, mandating that all patients get assessed by everyone who worked at the clinic, and supplying all patients with "free shoes (ie custom orthopedic shoes).  The difficult part is that it was owned by an individual who did not have a college licencing body, and the law seems to be very lax with regards to these people. It was upsetting to me to see this type of blatant fraud occuring.

I believe that physiotherapy clinics should be owned by physiotherapists (in whole or at least in majority), which will at least allow for legal action to be taken should there be suspicion of fraud. 

Its nice to hear from the more experienced PTs here who clearly have kept strong to their values, and remained honest and ethical practitioners. 

Nadir

Hi Nadir, thank you for sharing your experience. I am saddened to hear about what you witnessed. We are hoping that the #30reps series and the toolkit that will be launched at the end of the month will give practitioners the knowledge, tools and more importantly, the courage to speak up. 

Fraud is a judicial matter, not a regulatory one. So it should be reported to the payor and the police to be investigated. 

@CPA_Chantal

I found the last discussion point and your reply Melissa, to be most interesting to me as well.  And actually the comment about " physiotherapists doing a task that a physiotherapist assistant could do being wasteful" raised quite a visceral response for me as well.  

I think as you have detailed, we need to look at models of care and funding. As a physiotherapist practicing for 25 plus years in many different payment models and models of care, I have worked with assistants in public practice, I have worked in public practice where there is not funding for secretarial support thus physios are left to complete many aspects of support work such as faxing that are a complete waste of dollars but that current ministry funding does not address.  This is a problem but one we need to address through appropriate models of care in various situations.

As well physiotherapist need to be aware of avoiding waste within our practices but can also assist with reducing waste in our system. Various roles can help to ensure that the right care is given by the right person at the right time. Making use of our full set of skills and expanded scope practice in a multitude of settings.

Thank you for sharing your thoughts.  I agree that there is more than one 'best' model of care, and it depends on the situation.  

@CPA_Melissa

Melissa, thank you for this succinct and informative piece. I am impressed that CPA has chosen this difficult and controversial topic as the focus of this year's 30 Reps. I imagine that the upcoming blog posts this month will invite some controversy, but I think that is exactly what this profession needs. We need to bring awareness to these issues so that we can identify the problems and find solutions to avoid them in the future. I look forward to following along in the comments section and on Twitter this month. 

@dkjacks

Unfortunately, there may be some controversy over some of the #30Reps, but we feel that it was important to get the conversation started. You are right, we need to raise awareness, so that as a profession we can be proactive.. In my heart, I know that the vast majority of physiotherapists, PRTs and PTAs continuously demonstrate the highest level of professionalism.  I also know that the actions of a few could harm the good reputation of this profession.  In terms of reputation- one bad apple can spoil the whole basket!

@CPA_Melissa

 

I can completely understand how not using a physiotherapist assistant can be seen as a waste of money

if the facility has PTAs on staff and the PT is not assigning appropriate tasks to the PTA and they are not being used to their full potential then the facility is paying for skills that they are not using

PTs have a responsibility to understand or learn how to effectively assign tasks to PTAs as well as know the range of tasks that can be assigned. 

Thanks for your cautionary words Melissa. I do have a question about your second statement on abuse - providing exercise classes and billing for physiotherapy. Exercise is an essential component of physiotherapy treatment and many individuals benefit from doing exercise with others. Many sites provide hip and knee exercise classes and the GLA:D program is currently being rolled out across the country which is an evidence based exercise program for individuals with hip and knee OA that is done in a group setting.  

 

Exercise Classes

We are so pleased with the engagement with #30Reps, and are enjoying the comments, both on line and on the phone.  We have had some interesting conversations regarding the example about exercise classes- which made us realize that we should clarify that point further.

When we wrote “Providing exercise classes, but billing for physiotherapy” as a form of insurance abuse, we were not thinking about evidence-based, physiotherapy treatment programs, delivered in a class setting- but rather a group exercise class that you would expect to find in a public gym or community centre, or as part of a recreation program in a long-term care facility.

As physiotherapists, we have a multitude of tools in our tool box.  Exercise is, no doubt, the biggest among them. When used as part of the therapeutic process, including assessment, goal setting, reassessment and collection of outcomes, then exercise classes can certainly be considered ‘physiotherapy’ without the use of other modalities or manual therapy techniques.  In some cases, physiotherapy including exercise in group settings, has proven to be more effective than one-on-one treatment.

When exercise classes are used, and there is no evidence of assessment, goal setting, reassessment, and the collection of outcomes- then we would argue that this is an exercise class, and should not be billed as ‘physiotherapy.’

As always, know your regulations and standards of care for the jurisdiction in which you practice, and ensure that you are transparent in your billing practices.

@CPA_Melissa

@CPA_Chantal

 

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