Private Practice

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March 2004

By Stuart H. Platt, PT, MSPT

When I first graduated from physical therapy school in 1989, I felt ready to conquer the world as a practicing physical therapist. I could not wait to treat patients on my own. I wanted to learn a lot and be the best clinician I could be.

I started out, like many of my colleagues, in an acute care hospital, gaining exposure to all facets of patient care. I learned a lot from the experience and decided that I enjoyed most working with patients who had orthopedic injuries. I also became extremely curious as to what happened with my orthopedic patients after they were discharged from the hospital. Therefore, I transferred to the hospital’s outpatient orthopedic physical therapy area so that I could have a better understanding of the continuum of care for these patients.

Not only did I get a better sense of how patients with neuromusculoskeletal injuries move through the physical therapy system, I also got to experience the bureaucratic frustrations of a 600-bed hospital. Thus, I pursued outpatient orthopedic physical therapy in the private practice setting.

From Private Practice to Auditing

The private practice I chose had 10-outpatient orthopedic clinics. The facility I worked at had a staff of 14 people including two master clinicians. Within a year, I was promoted from staff physical therapist to clinical director. This meant managing the clinic’s personnel, treating a full caseload, and attending management meetings with the other clinic directors at our corporate office.

It was at these director meetings that I was able to interact with the other nine clinics to see how they were treating given patient conditions. Specifically, I was interested in their clinical outcomes, the number of visits that were utilized for those outcomes, as well as the modalities and procedures used during those visits. I thought it might be nice to share each of the clinics’ strengths with the others so we could all continuously improve quality of care. The owners of the company liked this idea too. Thus, I was assigned the role of auditing the company’s clinical charts on top of my regular clinical director duties.

Auditing charts from 10 clinics was no easy task, but the results turned out to be helpful. For instance, if clinic A’s charts showed a consistently good outcome in treating carpal tunnel problems and clinic B was not having as much success with similar conditions, we could turn that into a continuing education opportunity and more effectively utilize our company’s limited resources. For example, therapists in clinic B could make the most of the company’s limited continuing education dollars by attending courses focusing on carpal tunnel issues, shadow therapists in clinic A to develop more expertise in treating patients with carpal tunnel problems, or transfer to another one of our clinics where carpal tunnel referrals were minimal. Thus, we used our documentation to learn from each other. Before long, I found myself working more than 65 hours a week. I also became known for my knowledge in internal chart audit. Then, in 1995, a national corporation bought our small 10-clinic private practice. The acquiring company was interested in having me perform similar chart audit activities for their clinics along the eastern seaboard. It was a position that had appeal but required a lot of travel.

Ironically, at about the same time, I was approached by a chiropractor who owned his own utilization management company performing chiropractic reviews for third-party payors. The chiropractor’s organization was expanding to do physical therapy reviews and they wanted a physical therapist in charge. Up until then, I had been treating patients every day and doing internal peer reviews within one company (to enhance patient care, facilitate clinician development, and assist in the efficiency of the practice’s operations). However, I was intrigued by the idea of doing external reviews for many insurance companies (even if this would take me away from daily direct clinical practice). The chiropractor’s company provided peer-to-peer reviews making recommendations to insurance carriers and the job did not involve travel. So, I was on my way to a different perspective of utilization management for more than 4 years.

Utilization management

Concurrent with this work experience, I also did a lot of nonglamorous reading in the areas of documentation, CPT coding, insurance, and health care delivery. While these voluminous articles were not particularly racy, I did find myself intrigued with utilization management opportunities that were happening in our health care system (with or without physical therapists). This further fueled my desire to pursue this career path. Besides, who would be better to review physical therapy than a physical therapist?

By being a clinician and interacting with many colleagues throughout the country (in part by staying actively involved in the American Physical Therapy Association [APTA]), I learned that we all shared similar frustrations with our craft. We were frustrated with third-party payors (eg, for denying treatments), frustrated with physicians (eg, for not referring patients to physical therapy earlier and/or continuing to refer a patient not benefiting from physical therapy), frustrated with patients (eg, for not actively participating in their care), frustrated with other therapists (eg, for continuing to treat patients with a failed regimen), and frustrated with other providers (eg, athletic trainers, chiropractors, etc) who performed modalities and procedures similar to physical therapy but were not, in fact, skilled physical therapy.

Starting a New Business

While I enjoyed the cerebral gymnastics of performing peer reviews for the insurance industry, I certainly did miss seeing patients’ individual successes on a daily basis. Therefore, I set out to open my own utilization management firm with a couple of partners. Our goal was to be a national utilization management firm specializing in the physical medicine and rehabilitation (PM&R) arena with a focus on patient advocacy. Specifically, we wanted to be “the objective resource” on rehabilitation issues for providers, payors, attorneys, and regulators. In addition, we wanted to assure personalized attention, quick turnaround times, expertise, and the highest quality of reviews for our customers. And, of course, we wanted the ability to treat patients regularly. Thus we set out a business plan.

For providers, the chart audits give impartial opinions (backed by resources) on their files. Also, by participating in a chart audit/peer review process, our customers could “test” their facilities with professional standards, identify areas that lead to common denials, identify missed revenue opportunity trends (eg, bill and utilization analyses), facilitate decision-making processes by identifying strengths and weaknesses in the practice (eg, suggestions on PM&R coding, forms, and/or documentation to optimize justified reimbursements), help appeal illegitimate denials, help triage claims for common denial areas prior to submission (clean claim), assist with staff training, and enhance continuous quality improvement programs.

For payors, the review reports augment their existing utilization management structures. We offer clinical analyses of PM&R cases by reviewing the patient’s file and monitoring the patient’s therapy care (often speaking with the treating provider). This helps ensure that the patient’s therapy is reasonable, necessary, effective, and related to the insured event. The reports provide valuable information in a succinct, understandable format enabling our customers to be more productive and to produce an overall cost savings (by making sure patients receive all the care that they need). In addition, the reports are highly useful in settlement negotiation and litigation.

For the lawyers and regulators, we emphasize that physical therapists have a unique “body of knowledge” in rehabilitation and can apply it cost-effectively to their cases. This “body of knowledge” saves them time (and their client money), prepares them for deposition/court, increases their visibility as an attorney/regulator using cutting-edge innovative resources, and strengthens their cases.

While an inherent distrust has developed between providers and payors over the years (sometimes resulting in litigation), peer reviewers (who speak both their languages) are able to bridge that gap—hopefully fostering a better understanding between the two groups. Now, besides treating patients regularly, I am making a difference from a bigger perspective—viewing patients through the continuum from acute care to outpatient care. And, just as I educate patients, I have the opportunity to educate third-party payors, lawyers, and regulators about what physical therapy is and what a physical therapist can do. The tools I use for this education include the APTA’s Standards of Practice and the Guide to Physical Therapist Practice. I also educate physical therapists about the perspectives of third-party payors in an effort to help them see the bigger picture within the health care system, and in doing so, ultimately ensure that patients get all the skilled care they need and none they don’t.

Conclusions

Just like any other practice, starting a consulting business requires: a theory or area of expertise (having a product or service); relationships and networking (for potential clients); a passion and belief in what you do (for marketing/selling); good communication and organizational skills (for business operations); expert resources for business advice (eg, attorney, accountant, mentors, information technology professionals); minimal start-up cash and office equipment; and a family/friend support system.

Providers, payors, and patients all need to work together in order to make the rehabilitation system work optimally. Our company attempts to fill this niche by serving as patient advocates and creating win-win-win situations among the players involved. With hard work, you too can develop a niche practice like this one. Good luck.

Stuart H. Platt, PT, MSPT, is a principal with Appropriate Utilization Group, LLC, Atlanta. His practice focuses on chart audit, peer review, utilization review, and expert testimony in the rehabilitation arena. He can be reached at (404) 728-1974 or appropriate@mindspring.com.

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March 2004