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Just for Fun, What would happen if you had a Therapist and a Physician in your Practice?

Just for Fun, What Would Happen If You Had a Therapist and a Physician in Your Practice?

Consider how your facility might benefit from partnerships with other health-care professionals

By Thomas F. Fise, JD

O&P practitioners talk all the time

about things like: “Why can’t we get paid for our time in patient training, gait analysis, and instruction, like the therapists do? It’s unfair—don’t we do the same thing they do?” Or, “The prosthetist/orthotist understands the patient’s mobility needs much better than the physicians do, yet our getting paid is dependent on the exact words in the physician’s order, and Medicare won’t even let us help the doc clarify what should be in his or her notes.”

First, be careful what you ask for. Is everybody ready for CMS to restructure the L-code system so that they begin paying for everything on the basis of the amount of time you spend, rather than paying a set price—a global fee, if you will—for the finished device? Medicare did just this type of restructuring of physician fees in the early 1990s. They hired a Harvard public health expert to go to physician practices, and also to review physician calendars/logs to pinpoint exactly how much time—in minutes and seconds—the doctors actually spent, on average, with the patient. They also factored in actual practice expense costs for gauze, bandages, paper used on the examining table, etc., and added in factors for malpractice costs, and the

intensity of the time the doctor spent and training required—minutes spent performing heart surgery were more intense minutes than those spent taking a history and physical. The result was what became known as the Resource- Based Relative Value Scale (RBRVS), and around 1993, physicians started to be paid based on a set number of dollars for each relative value unit (RVU)—that is, they got paid primarily based on the actual average minutes for each service, and they didn’t much like this result.

As we ponder the payment to the O&P professional versus that paid to the therapist or the physician, recognize that the latter get paid under the Current Procedural Terminology (CPT) coding system (based on RVUs), while O&P gets paid from a subset of the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) fee schedule. That said, like so many things in life, there is more than one way to skin a cat.

For example, you probably have observed that hospitals have purchased a bunch of physician practices, but did you know that the fee paid to the physician practice can be significantly higher if the visit occurs on the premises of the hospital (viewed as more intense time, almost like time in the emergency

room)? To qualify for this higher reimbursement, the office actually needs to be no more than a set number of feet from the hospital itself—if it is that close, it is considered on premises. You also may know that surgeries/procedures of modest complexity can be performed either in the hospital or in a separate ambulatory surgery center (ASC). The truth is that the amount Medicare pays for practice expenses is generally significantly higher if the patient is treated in the hospital’s outpatient department, rather than if the very same procedure is provided in a free-standing ASC. So, when a physician practice is purchased by a hospital, you can expect that more of its procedures will be done in the hospital outpatient department (even though, in order to keep the “wheels of medicine turning,” a decent volume will continue to occur in the ASC, which the hospital likely bought from the physicians when they purchased the practice).

The point of the above is not to make you an expert on physician payment under Medicare, but rather to demonstrate that practices, even hospitals, are often set up on a structure that takes all the rules into account in order to generate the most generous total reimbursement from Medicare and other payors.

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So, back to the “just for fun” question: Suppose for a moment that you had negotiated an arrangement with a local physician to spend one afternoon every week or every two weeks in your practice, and similarly that you had an agreement with a physical therapist to spend one or one-and-a-half days a week in your practice. Consulting with your experienced health-care attorney, you negotiate a contract that assures each of these professionals a minimum billing/ income flow—under their own CPT fee schedule—during the time they are at your practice to see (and bill) your patients. Your agreement would specify terms for rent, staff, etc., ideally in a way that some portion of amounts over

your guarantee would come back to your practice. This is the tricky part, and you would absolutely need to engage experienced help from experts in crafting the terms—there are rules from the Office of Inspector General (for example, “Questionable Rental Arrangements for Space in Physician Offices”), contractual agreements with private-sector payors, etc., which must to taken into account, but such agreements can be crafted. The outcome might look something like this:

• You could easily schedule your prosthetic and some more complex orthotic patients to see the physician about their mobility needs, assessment of K levels, and generation of

sufficient documentation on their visit. At the same time, your patients could see the physician for primary care-type needs like routine prescriptions, allergy injections, flu shots, or other assessments, or referrals for minor services requiring a specialist—such as minor surgeries, etc. The fees would be generated by, and belong to, the physician, but you’d also have valuable new cash flow, at the same time making your practice more valuable to your patients.

• Your patients who needed gait assessment, education, and adjustments beyond the basic routine could be scheduled for a visit with the physical therapist—you, as an O&P

professional, can’t deliver and be paid for those services, but the therapist is permitted to bill them under the CPT schedule (assuming they are not duplicative of the precise services you are obliged to deliver in the global fee under the L-code/DMEPOS fee schedule). As with the physician, having the physical therapist available will have them generating bills under the CPT codes for their own services, but you’d have both valuable new cash flow (rent, referrals to you for new O&P services, and better physician and therapist records), at the same time making your practice more valuable to your patients.

• Your practice would start to look and act more like a multipurpose healthcare facility—patients may routinely have blood pressure, temperature, or even an EKG or an X-ray performed on site by health professionals as ancillary services to the physician practice.

• You may not be able to bill for the above services yourself, but if you bring the professionals who can bill for them to your practice location, you and others may benefit. (Some of these might be billable by a licensed practical nurse in carrying out physicians’ orders, even at times when neither the physician nor the therapist is in the office.) It’s something to think about. A lot of this will depend on the numbers and availability of the right health professionals. But thinking about your practice this way is how medicine is provided in our complicated health-care system today.

Does your local CVS or Walgreens have a “minute clinic” or “urgent care clinic,” and are they providing inoculations to patients? It’s interesting that CVS is in the process of purchasing one of America’s largest health insurance companies. Is that a captive audience? When those patients have a prescription provided by a physician in that miniclinic, where do they get the prescription filled? The pharmacy clinic can become something of the primary care “go to” for those patients. Think about it.

Look at your practice through a different lens—patients come to your facility for health care. Does it make sense to be able to offer them more things than can be billed for under the O&P fee schedule, and to bring into your office other part-time health professionals who can deliver and provide other needed services, rather than send them away to another location to have their needs met?

Thomas F. Fise, JD, is executive director of AOPA and publisher of O&P News.

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