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REP 21 - Undercover investigation: healthcare edition

The phrase “I am an undercover investigator” is a fantastic opening line at cocktail parties and networking events. 

You will always be met with an “Oh my goodness! Really?” followed by, “You have to share your craziest undercover sting ever!” to which I politely decline and quickly change the subject. 

Why? Well, mainly it’s because when most people hear the words undercover investigator, it conjures up images of hiding behind tall bushes, snapping photos of a cheating lover in the arms of his mistress, or of breaking into a building Mission Impossible style, hacking into a computer and hastily downloading hundreds of incriminating files onto a USB. 

The fact is, I work in healthcare, not Hollywood, and so while my experiences may not be sound stage worthy, I am happy to share two of my more memorable encounters with you.

 

Psychic physiotherapist?

I conducted an undercover investigation where the physio performed an extremely short assessment – it was less than five minutes. The assessment consisted of answering a few questions and then setting me up with a 12-week treatment plan. 

During the assessment the physiotherapist did not ask me to move or stand up and did not provide any hands-on assessment either. They simply watched me walk into the treatment room and then provided a diagnosis.

 

Is it personal training or physiotherapy? 

A common issue I’m seeing more of is personal training being billed as physiotherapy. I conducted an undercover investigation where I visited a physiotherapist with no injuries, no weaknesses and no pain - I only indicated that I wanted to lose weight. 

The physiotherapist performed a short assessment and set me up with 13 weeks of personal training.  I received a great workout at my next visit, but the entire encounter was billed as physiotherapy.

 

So what does it all mean?

Disappointed? Not exactly riveting undercover stories, are they? 

I know, but investigations are important. 

They’re used to ensure that the standards of practice of the profession are maintained, which in turn is beneficial to patients and the entire profession. I want to stress that there are only a small percentage of cases at the College that require undercover investigation. Undercover work is only one of many tools an investigator uses to answer the question: What happened in this case?

Furthermore, and this is the big one, when I go out on investigations, I am not trying to trick anyone into making errors. There is no “gotcha” moment. I simply want to experience the average patient experience for that member’s practice. 

Being an investigator might not be as glamorous or action packed as people imagine, but I’m proud of the crucial role I play in keeping patients safe. 

 

Over to you

  1. Were you aware that there are such things as “physiotherapist undercover investigators”? 
  2. What else do you want to know about them or the process?

     

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Comments

This is not the first time in these sessions that the issue of a physiotherapsit supervising and billing something like an exercise program has been presented. Whether it be Pilates, yoga, personal training or the like why would a physiotherapist, who has assessed that person and determined that they require a supervised program, not be able to bill their service as physiotherapy? Is not preventative programs just as valuable as rehabilitative programs? The implication that has been created is that physiotherapy is for injured individuals only. Who is better able to determine a movement program than a qualified physiotherapist?

No one is saying that prevention isn't as valuable as rehabilitation. What we are trying to point out is that each 3rd party payor has guidelines on what they are willing to pay for. In the case of Extended Health Benefits, it is up to the client to know their plan and clarify. 

@CPA_Chantal

So you are saying that the insurer decides what can or cannot be classified as 'treatment'...

Wow, what a slippery slope that is.

Hi thanks for posting - I had no idea such individuals were out there.  Judging from some of the stories shared on 30 reps -- I'm not surprised.  I have learned alot this month even though a seasoned practitioner.

A couple of quick questions for education purposes,

1. Are investigators hired by a insurance companies, or Colleges?  Also is this a jurisdictional practice or nation wide?

2. What I don't know is if there is a continuum of approaches or a system in place to rasie flags when there is concern about a therapist's practice/conduct.  If there is an intial complaint or concern  how are therapists made aware of these concern,  do they have an opportunity to remediate behaviour and where does an investigative role fit in.

My concern is that if our goal is to increase transparency of practices for all involved including modelling good practice.   

Tough issues!

From our understanding, inverstigators could be hired by either an insurance company or a regulator depending on the situation.  This would vary from province to province.

Unfortunately, we don't know the answer to question two, it would depend on the severity of the incident and how the issue was raised and reported.

Thanks for the thought provoking questions!

 

@CPA_Melissa

I've got to say these #30reps examples paint an awful picture of what I feel, by overwhelming majority, is a very respectable and credible profession. I don't know the frequency of these fraudulant behaviors and horror stories, but I suspect (and expect!) that they are minimal. I, and the colleauges close to me have worked hard to provide a quality driven, competitive practice and to represent our profession with integrity. This has been an enlightening campaign and although I am compelled to read each 'rep', I feel awful in anticipation of opening the email, disheartened, let down and not well represented after reading. So, enlightening and good to know? Yes. Postive, motivating, well timed and received? Not at all. 

You know, to put it bluntly, this 30 reps thing is ticking me off.  

There seems to be this idea that we are doing a lot of bad things.

So here we are, in a discussion that I started 30 years ago when I was a kinesiologist.  I kept saying that physiotherapists have very basic training in exercise prescription and that kinesiologists were the exercise experts.  I was set upon by the Physios who screamed bloody murder.  Fast forward 10 years and I decide, "fine, I want to see pathology and other types of patients...I'll become a physio."  In the last 20 years, our profession has claimed to be exercise experts, that we want to focus on preventative medicine...hell, we even see people like Dr. Mike Evans talking about how exercise is medicine, especially preventatively.

Now, here physiotherapists are being investigated for providing the very exercise programs we have been claiming to be the experts of.  Well, guess what?  It IS a physiotherapy service.  I would and will go to court to defend any exercise program I give a person preventatively.  I document the programs, many patients have had prior issues with their lower backs, necks, etc and don't want them again.  Others just simply do not wish to have pain that their parents do. I correct technique, I assess effectiveness, I keep detailed records...what part of it is not a physiotherapy service?  If a patient sees a physiotherapist for an exercise program to maintain their blood sugar levels because they are a diabetic (a role highlighted by the CPA in their previous Expanding Roles of Physiotherapists media blitz a few years ago), then why can the overweight person not get one to prevent the inevitable hip and knee OA, diabetes and heart issues that are coming?  Or do we need to wait for them to have a stroke first?  THEN we can bill for it?  How utterly un-patient focused of you.

So which is it, CPA and CPTO?  Are we exercise experts or not?  You can't have it both ways.  Why can SOME patients receive the benefits of our services reactively while those who wish to be proactive cannot?

The logic of your position is ridiculous, NOT in the patient's and public's best interests (which is the CPTO's entire reason for being) and goes against the evidence in ALL of the current literature.  So please, enlighten us as to how you defend your contention that only some reactive exercise programs are considered "physiotherapy services."

I agree with the previous writer. This 30 REPS 'publicity thing' is also ticking me off and should be stopped immediately. Very unprofessionally written. Stupid arguments. Really unbelievable that CPA is behind this. 

I am totally for promoting and supporting ethical competence but not done in this fashion. 

This REP is in direct contrast to REP 6.

I find the last example very troubling with the respect to exercise prescription. For someone embarking on an exercise program regardless of the goal a physiotherapist should be an ideal health care practioner to see. Proper technique for preventing injuries, working at an appropriate level and factoring in comorbidities are all well within the scope of practice of a physiotherapist. I find it hard to believe that there was also no weakness or faulty movement patterns present that didn't need to be addressed with a modified program and appropriate progressions. How many times have we treated injuries due to innappropriate exercise prescription/training. Just because there are more and more non regulated/ non healthcare avenues for exercise does not mean it is not in our scope of practice.

Confirmation Bias?  Is this an interpretation by the investigator to confirm their belief of what should be included within the scope of practice for physiotherapists?  Isn't exercise prescription and education one of the cornerstones of our profession?  What profession can more fully understand the link between exercise science (aerobic, anaerobic lactic, anaerobic alactic, phases of tissue of healing) and pathology?  Shouldn't proactive exercise program be seen as a benefit to the patient and our society as a whole? 

You called it personal training, not the physiotherapist! It is physiotherapy--- in that scenario you presented, a legitimate problem was presented -- weight loss -- (over weight is a health concern afterall); an appropriate assessment was performed, accordingly a treatment plan was created and supervised, re-assessment and documentation would have been done (I assume) and goals/outcomes would have been monitored and analyzed. So, there is no problem. A physiotherapist is trained in weight management problems; we were educated in dietary management, nutrition, body metabolism considerations, health considerations for attention to any weight management programs we prescribe such as diabetes, C.O.P.D, cardiac conditions, osteoporosis etc., measuring/assessment of body fat content ratios, target heart rates, BMI, etc. Where did it ever say that we as physiotherapists only see people who are in pain? weakness? injury?

That is two reps commentary now that I have read, that has tried to remove/narrow our scope of practice and training. Is it that because other career professions have expanded and encroached into aspects of OUR scope of practice in the private world (while we were working in these very aspects under the hospital systems -- so "joe public" didn't know we did these things and then as our profession was pushed suddenly out into the private sectors in greater numbers from the denial of job prospects in hospitals), that some party's have assumed its the other way around? I suppose the next thing we will read is that physiotherapist shouldn't be treating sport team athletes because along the way, the professions of athletic therapy and Sports Medicine doctors emerged? or that soon in the future we will be criticized for doing the work of a kineisiologist (because now they can "treat" people not just "study and research" human biomechanics -- which is how historically that profession came to be and physiotherapy used what they researched to substantiate what "normal" was to treat the abnormal (which includes body weight management)! 

It is exactly the same issue with the statement that its an abuse of physiotherapy to perform "maintenance" goals with an individual. I wrote about that one as well; to maintain is a legitimate goal because the obverse side of that is that some individuals will decline without our support and then they will weigh down more of the healthcare dollars in doctors, hosiptals, labs, nursing homes, be off work, go on disability etc...

I'm done.

Well said.  Shouldn't the CPA be promoting our profession instead of doing the work of the provincial Colleges. 

I agree with the previous two comments. If someone comes to me for a maintenance or a prevention issue - for example, an active senior who has a family history of osteoarthritis, wanting to work on balance, strength, and ROM - so they can stay active in their chosen hobbies... then why can I not bill that as physiotherapy?  I am assessing, providing goals and a treatment plan based on the findings of that assessment.  I am reassessing and changing the program as needed. I am preventing further health issues and saving healthcare dollars.

Good series of reps, and this has provided lots of areas of discussion in our office.  But also pretty depressing.  I love my job, but maybe it's time to retire.   

I agree. I wish I could give this response a thumbs up.
Prevention is key, especially people at high risk of complex chronic conditions. And with the healthcare system the way it is its important to reduce risk. We have the time and education to support this (see Elizabeth Dean's articles).

And it's very risky to allow insurers to determine what is and isn't physiotherapy. Sometimes they don't even know what PTs do. I've heard of people being denied submissions for vestibular rehab or pelvic floor rehab because the insurer didn't know it was physiotherapy. A bit outrageous.

Hi everyone, as a PT student I am quite perplexed by the personal training vs PT. I was under the impression physiotherapist are able to implement a weight loss program and over see its execution by a physiotherapy assistant, be it a kinesiologist or PTA. While I can understand if the patient was handed off to another professional and never seen again by the PT, this is would be wrong. But if the PT is part of the communication and performing the reassessments, I don't understand why it would be billed as PT. Some clarification on this would be quite helpful. Thank you.

About 50% of my caseload is chronic disease management.  I work in the public system and feel it should be the same in private: where the proper assessment is done with proper treatment plan and proper decisison about how much supervision is needed to apply the treament plan: it is NOT personal training!  Even if the plan is entirely exercises- which is usually not the case as I try to educate my patients about their condition- it would still not be presonal training!  And what about our role in prevention?  Would you call that personnal training?  It is all about judging the amount of supervision required: I have patients I follow 2-3 times per week and others once per month and guess what, it varies in time: this is part of reassessing my patient needs and where they are at in reaching their goals.

I do realize some people abuse the system but please do not restrict our practice and put all of it in the same basket.

I agree. Much of our practice as physios is about education, prevention and empowerment. A good exercise program demonstrating good techniques and tailored to the specific individual and monitored for results is well within our scope and not fraudulent behaviour.

The fustration is palatable. But its not time to retire!  Many of us has lived this dance in different shape and forms over the years. 

Documentation of plans, rationale, reassessment and outcome measurement continue to be key.   Those are the same things I was taught over 25 years ago -- when I was being mentored by POTS with certificates in PT, OT, or combined trained.  Then I was the next generation therapist with my 4 year BSc and now I have mentored the next generation who are MSc.

Please indulge me for a moment.

When I was fustrated with my role in the profession mid-career, I went to grad school and that allowed me to take a slight detour outsie the profession to work on health projects and observe the health system from outside of the PT role.   When I saw how heavy the boulders were  in that world and how hard one has to push over periods of years to make incremental change, I disovered my joy came from being a therapist where I could work 1:1 with indivduals and receive immediate feedback regarding my efforts.  I need that kind of feedback to regenerate and restore me.

So I left the federal/provincial world and came back humbly to our profession -- being grateful for system wide experience I gained -- becuase those project management skills where what I integrate with my skills as a clinician; it was learning about how to manage compexity.   Meaning we are thearpists who  may or may not have to supervise assistants, who may or may not links with other members of multi-disciplinary teams who may work with us on site or be off site, with varying levels of training, regulation themselves, all of us operating in a context where clients are accessing information and we are faced with fostering self-management, health promotion, chronic disease management, managing multiple comorbidities.  

Managing complexity is now becoming core competenices not just the domain for experienced seasoned practitioners.

And we  are living in an age of complexity.  Which can only means we need to be work differently (again...and in a professional which allows that growth). 

Everyone is trying their best in their own corners.   Some may be abusing the system (willingly? out of ignorance? due to info overload? due to lack of coaching/mentoring complexity?).

Having worked for the feds and and provincial bodies for 7 years -- I appreciate the level of complexity that professional and regulatory bodies are faced.  So if I am a team oriented thinking as a clinician I  believe I have to be humble in my role and do best to keep current and remain above board in my practices.  

The best way I've learned from a vareity of roles I've heald -- is to leave a clear paper trail and document my reasoning along the way.   That way if in future I have inadvertantly cross lines (which like most of us am very diligent about preventing, avoiding, not doing) then at least my rationale for my actions are clearly documented reflecting my understanding, challenges or dilemmas along the way.    If I ever get audited, or questioned I feel I have a clear basis to illustrate I have always followed my best instincts, used my experience and made reference to the resources and information I had access to through my college and national body.

If there is lack of clarity I don't want to get stuck in the blame game.  Its something we all have a collective responsibility to discuss, review and contribute to -- knowing system change is incremental and is slow.

So in the same way that I promote self-management with my clients --I must walk this same walk myself in an adminstrative sense.  I have to take that responsibility do my best and try to focus on the parts that I can control.

I am deeply sorry to hear about the difficulties and fustrations other face.  We are all in the same boat.

At the end of the day, I take a moment and ask myself  "why am i doing what I am doing?" meaning I have to remind myself of my true intent as a therapist and own it, not wish I was someting else. 

I dont' know about you but my intention has always been to help, heal and learn-- without damaging myself in the process.

With regards.

 

I greatly appreciate many of the comments I am reading. Personally - and professionally - I have a number of concerns about many issues which have been identified here. I've been thinking about many of these for some time now, and have decided to start a independent and private working group of like minded private practice owners/practitioners who are concerned about the state of physiotherapy (in particular, private practice) with respect to the many managed care dictums and agendas coming from a multi-billion dollar insurance industry which is purely profit-driven and cost containment focussed. The working group will be unpaid and voluntary, and there is no cost to join.  This working group will be for physios only, and independent of the CPA at this time.  The objectives of the group include identifying current risks/threats to, and opportunities for our profession; identifying market conditions and market drivers impacting our profession;  developing strategies for protecting our profession, and private practice professionals and clinics in particular. Please note, the working group will be private, but not anonymous. It will also not be a chat group, but an action group. If interested in being involved with, or contributing to this working group in any way, please email me in confidence at physioconnexion@gmail.com.

If preventative maintainance is not physiotherapy but personal training, what do they have PTs working in nursing homes for?  Most of the clientele there are receiving therapy to maintain or slow the risk of injury, not to get them running down a hallway!

 

I'm really disappointed in the #30 reps content this year. Our profession is exciting, dynamic, engaged, and evolving as our health care system evolves. Physiotherapists ARE experts in exercise prescription and using exercise as an intervention. Maintaining wellness is every bit as valuable as managing disease or injury. The case above could be talking about a patient with osteoporosis who wants to maintain bone density, or a patient with osteoarthritis who wants to maintain their current level of function. Both of these patients would be best managed by physiotherapy, and exercise alone would be an appropriate intervention. Should physios not be doing "prehab" before a joint replacement surgery? Above all else, we need to provide exercise and education, and even if we do nothing else, we have provided physiotherapy. Maintaining function or losing weight are appropriate goals - they reduce orthopaedic and cardiorespiratory complications, and using exercise to do so is the mainstay of our scope of practice. 

It is the responsibility of our Association to promote and defend our scope of practice. If our Association does not believe we are experts in using exercise as an intervention, they cannot promote us as such to the Canadian public. This series neglects many important and exciting issues in Canadian health care that affect physiotherapy, such as our role in primary prevention of chronic disease and disability, pain management in the face of the opioid crisis, and as partners in the obesity epidemic. While I agree that fraud in our profession is an issue, it would warrant maybe one article in this series, but certainly not more than that. We have provincial Colleges, after all, to regulate professional conduct and standards. Our Association's role is to promote the physiotherapy profession, which this series neglects to do. 

I have been reading this series and getting progressively more irritated, but I was moved to respond when I read  the comment above from a PT student. I think that student's interpretation of the situation is correct - it is within our scope to design, supervise, and progress an exercise program, whether we deliver it in person or delegate it to support personnel. As he or she says, "If the PT is part of the communication and performing the reassessments" I also don't see why exercise can't be billed as physio treatment. 

 

Apparently the association we pay excessive fees to be part of believes we are repleat with fraudulent members and we need no less than 7 out of 24 of the REPS to address fraud or unethical behaviour.  

Perhaps it is time to remind the CPA that we are not required to be members.  The educational curriculum offered is old and unsupported by evidence and way overpriced, the insurance policy can be obtained through no less than 7 different insurers at the same level and price, the webinars often do not deal with anything in the realm of actual practice, and the "support" for members seems to be "don't be a criminal" and "you can't use your skills unless someone is injured or has a disease...don't prevent injury, treat it."

I and a lot of others are seriously looking hard at why we spent upwards of $1000 being a member each year.  It is NOT required and your existence is dependent on us.

These REPS are discouraging, demoralizing and, flat out, biased and wrong.  If renewals hadn't already been processed, you would be 50 people smaller at this point, as many of my working group and colleagues have discussed mass exiting the CPA.  

I agree with the comment. At this point, my feeling is that I will never want to renew my membership again, after supporting the association for over 30 years.

 

Some of the most important conversations are the ones that are truly difficult to have. This is why I want to thank you for raising your concers regarding the content of #30Reps. As Director of Practice and Policy I believe there is value in sharing the good, the bad and the ugly as part of this campaign, but I didn't consider the negative impact it might have on the value of a CPA membership.

In conceptualizing the #30Reps project we wanted to bring forward some of the concerns we hear from members, partners, patients and other health system stakeholders. As the saying goes, "Sunshine is the best disinfectant", but as I read through some of the comments I realize that there is also the risk of getting burned.

At CPA we wholeheartedly agree that the majority of our members and the profession as a whole are good clinicians in terms of their skill and ethics. I also think it is clear from this campaign that we need to take more time to celebrate excellence in the profession. Over the last three years we've come under increasing pressure to address issues regarding reputational risk. A lot of thought and consideration was given to how we can best engage members in the discussion of fraud, abuse and waste. We felt a traditional approch to education might not address the scope of issues that clinicians and clinic owners face, which is why we decided on this model of framing issues. 

In hindsight I see the fatigue of the campaign and the risk of alienating or losing members. This certainly never factored into the decision making for #30Reps, but I would like to acknowledge the members who are questioning the role or value of their membership. I hope that anyone with concerns will reach out to me directly at koconnor@physiotherapy.ca to engage is a dialogue about how we can better serve the membership and demonstrate leadership for the profession. 

Thank you to everyone who has taken the time to comment on this blog series. Your feedback in invaluable for us at the national office.

Taken from the CPA Website:

"CPA's Mission: CPA’s purpose is to ADVANCE the profession of physiotherapy in order to IMPROVE the health of Canadians."

That being said, the content of the 30 REPS is definately not doing this and in fact it is doing exaclty the opposite. It is questioning and undermining the role of physiotherapists in health prevention and promotion. The discussion of fraud, abuse and waste is not what CPA should be focusing on. As someone said earlier, membership in CPA is voluntary and we are not getting value for our dollars here. The Regulatory bodies should be addressing these issues as ALL PT's need to be registered and the PT's can be briefed about these issues (of fraud, etc) through them. Those of us who pay extra money to be members of the 'Association', because we believe in the value of promoting our profession and improving our skills, are not being helped by this demoralizing and damaging campaign.

CPA seems to have lost sight of it's role here. 

I would be interested in learning more about your working group. Please email me at physioconnexion@gmail.com if you would be willing to communicate off line. Thanks
 

Having been en executive member of the OPA and a Practice Assessor for the CPTO, I don't know why you feel "under pressure" to deal with "repuational risk."  That is not your mandate, nor should it be.  That is the College of Physiotherapists mandate.  It is the CPTO's job to protect the public, and address these kinds of issues.

CPA is solely responsible for supporting it's members.  That's it.  End of sentence.  You have no other mandate.  Even education programs such as the Ortho Div courses are really not in your mandate.  But at least those are something offering some meaning.  

If members are being fraudulent, that is up to the CPTO to educate, assess and discipline.  We (CPTO) has an entire division for that--Practice Enhancement.  CPA has no training, ability or authority to delve into that realm.  CPTO Assessors are thoroughly trained and update their training every 2 years.  

CPA are the profession's cheerleaders.  pump us up, motivate us, keep people like me from wanting to leave the profession and association.  Make me WANT to be a PT again.  My daily life is filled with hearing about people's pain, dysfunction, frustration, anger and illness.  I need my association to help me not get depressed and discouraged, to tell me there are great things happening and things I can do to refresh my weariness, to share other PT successes and detail how I can have those same successes.

I DO NEED MY COLLEAGUES!  And I'm sure I am not the only one!

This time, you have failed me and I am disheartened, discouraged and unmotivated.  Please don't fail me again.

I am not sure how come there is so much negative feedback related to learning about physiotherapists who are not ethical. All we need is one, highly advertised fraud (or other) case and that affects all of us! Even if 99.99% of the physiotherapists only do good, the public generally remember the one bad case. Does that one case affect CPA members? Of course it does. Even if the "bad apple" is not a CPA member, the negative consequeces can affect all of CPA members (hence a role in reputational risk).

I personally think that CPA bringing forward these discussions is good. OK, maybe one (or two) too many bad stories... but overall this stimulates discussion that is never easy to have.

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