RE: Re: So we can use techs or aides to perform part of our treatment? (Not medicare)

[Guest guest]

Group,

On a slightly different note, we know PT students are treated as an aide

when it comes to treatment of Medicare Part B patients in that they cannot

provide any treatment, and bill for it. Does anyone know if this is the

case as well for Medicare Part A? Or, (at least for now) is it still left

up to individual state practice acts?

Reuben Jessop, DPT

Provo, UT

_____

From: PTManager [mailto:PTManager ] On Behalf

Of s

Sent: Tuesday, May 06, 2008 9:05 PM

To: PTManager

Subject: Re: So we can use techs or aides to perform part of our

treatment? (Not Medicare)

The other thing that seems to be missing from this conversation is

any concern for the wants and needs of the PATIENT. The patient

comes to us to be evaluated and treated by a Physical Therapist.

They are paying cash towards their deductible and or large co-pays

to see a Physical Therapist, they are using a portion of their PT

cap to see a Physical Therapist, there perception is that whomever

is treating them should be and will be a liscensed Physical

Therapist, they have heard all of the wonderful things happening in

the world of Physical Therapy, that the local university is now

offering the first docotorate in the school's history in PHYSICAL

THERAPY. They take time out of there busy day to come see a

Physical Therapist with high hopes that he or she might return them

to their pre-injury state and teach them how to prevent further

injury in the future, they do all of this and halfway through their

first visit you introduce them to Joe and say nice to have met you,

this is Joe, he is our " exercise specialist " , I've told him what I

want you to do, I'll check on you later. Would you stand for this?

Would you pay 50 bucks per visit to see Joe? Not me. Maybe this is

why we are losing patients to the personal trainers, massage

therapists and chiropractors, they are just as good as Joe but they

are not just as good as you, let your patients have you, the

Physical Therapist they are paying for!

E. s, PT, DPT

Orthopedic Clinical Specialist

Fellow American Academy Orthopedic Manual Physical Therapists

www.douglasspt.com

> > > >

> > > > Why does the Florida practice act appear to allow us

> > > > to delegate portions of treatment to aides and bill

> > > > for it? This is the " excemptions " section, please not

> > > > excemption (3). If an employer references this and

> > > > argues that an athletic trainer, or even a PT aide can

> > > > be trained by a PT to assist in the clinic for

> > > > non-medicare patients, how does a PT manager or PT

> > > > counter this point?

> > > >

> > > > 486.161 Exemptions.---

> > > >

> > > > (1) No provision of this chapter shall be construed

> > > > to prohibit any person licensed in this state from

> > > > using any physical agent as a part of, or incidental

> > > > to, the lawful practice of her or his profession under

> > > > the statutes applicable to the profession of

> > > > chiropractic physician, podiatric physician, doctor of

> > > > medicine, massage therapist, nurse, osteopathic

> > > > physician or surgeon, occupational therapist, or

> > > > naturopath.

> > > >

> > > > (2) No provision of this chapter shall be construed

> > > > to prohibit:

> > > >

> > > > (a) Any student who is enrolled in a school or course

> > > > of physical therapy approved by the board from

> > > > performing such acts of physical therapy as are

> > > > incidental to her or his course of study; or

> > > >

> > > > ( Any physical therapist from another state from

> > > > performing physical therapy incidental to a course of

> > > > study when taking or giving a postgraduate course or

> > > > other course of study in this state, provided such

> > > > physical therapist is licensed in another jurisdiction

> > > > or holds an appointment on the faculty of a school

> > > > approved for training physical therapists or physical

> > > > therapist assistants.

> > > >

> > > > (3) No provision of this chapter prohibits a licensed

> > > > physical therapist from delegating, to a person

> > > > qualified by training, experience, or education,

> > > > specific patient care activities, as defined and

> > > > limited by board rule, to assist the licensed physical

> > > > therapist in performing duties in compliance with the

> > > > standards of the practice of physical therapy.

> > > > Specific patient care activities, as defined and

> > > > limited by board rule, must be performed under the

> > > > direct supervision of the licensed physical therapist

> > > > or physical therapist assistant in the immediate area,

> > > > if the person is not a licensed physical therapist

> > > > assistant.

> > > >

> > > >

> > > >

> > > >

> > > >

> > > ____________-_________-_________-_________-_________-_________-

_

> > > ____________-___

> > > > Be a better friend, newshound, and

> > > > know-it-all with Yahoo! Mobile. Try it now.

> > > HYPERLINK

> > > " http://mobile. <http://mobile.

> > <http://mobile.

> <http://mobile.

<http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

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> > yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ

> > > >

> > > yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ " http://mobile.

> > > <http://mobile. <http://mobile. <http://mobile. <http://mobile.-y> -y>

-y> -y> -y

> > > ahoo.com/-;_ylt=Ahu06i62sR-8HDtDypao8Wcj9tA-cJ

> > > >

> > >

> > > ---------------------------------------

> > >

> > > In ALL messages to PTManager you must identify yourself, your

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> > > Visit the NEW and IMPROVED www.InHomeRehab.-com.

> > >

[Guest guest]

Dean,

If there are activities that are NOT defined highly valuable by a PT- in some of

the examples that are used prior, then it is worth considering other sources of

delivering them.  Yes, exercise and or modalities are best done by use and

personal trainers are not even in the same league of our knowledge, but my point

isn't to use this a means of replacing or circumvent PT services.  PT services

should always be provided as a valued service and should also be distinct in its

process.  The point of my discussion has encouraged PT's to gain control over

the other services (as we are senior to them in knowledge) and use them (if

deemed valuable) to guide or direct client/patient interventions.  If you feel

that your service as a PT is the only quality service that can be provided for

your patients then that is then determined by you and the patient.  However,

ancillary services are NOT meant to replace or qualify as a PT service.   

The question you asked about prescribed ther-ex- there are alternative means for

clients to carry out ther-ex after PT is over.  Wouldn't you want the client to

have your prescribed exercises in the hands of a possible personal trainer than

his ther-ex.  The last time I looked around the PT's weren't training people in

gyms, then personal trainers are and they haven't a clue.  Also you can't

expect to see that patient for more than 6 weeks and then what happens

then.......The point is for PT's to oversee this process either way (PT or

non-PT)....unless you want to start training patients after dysfunction is

cleared.  We all know (and the patients as well) that exercise is helpful. 

I'd love to see the number unused gym membership in the US based on the

notion/goodwill of health and exercise.  

The last part.  If you feel the ancillary service is helpful for your clients

and covered under your malpractice then their is reason to worry about

liability.  It isn't a PT service that is delivered by a personal

trainer.  If your client base is heavy into gym based activities wouldn't you

rather them be under your roof than at a gym.  I want to point out that in my

example personal trainers falls under the scope of nutrition, child weight

loss, sport based training, pilates yoga.....the list goes on.  I'm sure I

struck a cord on personal trainers....and there that is very reasonable.

This post is in reply to help along the question you posed on extended help. 

It is a real issue and one that we have to confront.  Using non-PT's to perform

PT services is against our practice criteria and we shouldn't have to push the

issue.  Coming up with alternatives that work is the goal.  Ultimately, it is

up to the clients to be educated, by us and differ the value of a

service.     

Vinod   

RE: Re: So we can use techs

> > > or aides to

> > > perform

> > > > > part of

> > > > > our treatment? (Not medicare)

> > > > >

> > > > > It's feather ruffling time...You know guys, I

> > > completely agree

> > > with

> > > > > the

> > > > > comments made on this posting with regards to

> > > delegation

> > === message truncated ===

> >

> > __________________________________________________________

> > Be a better friend, newshound, and

> > know-it-all with Yahoo! Mobile. Try it now.

> http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ

> <http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

> >

> >

> >

> >

> >

> >

[Guest guest]

Hi everyone,

Let’s not forget to include that, for most insurance contracts, you cannot

bill patients separately for services that can be provided under the

contract. The line between what is considered therapeutic exercise,

neuromuscular retraining etc has enough gray areas that you could run into

serious breach of contract issues if you are trying to steer people to a

personal training type situation.

To reiterate one of my earlier points: I can be the personal trainer when I

work with my clients one-on-one and it is a skilled service and it is

reimbursable. Why would I want to risk all the problems associated with

delegating the service to someone else?

Tom Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, ID

howellpt@...

_____

From: PTManager [mailto:PTManager ] On Behalf

Of deanpt1

Sent: Wednesday, May 07, 2008 6:17 PM

To: PTManager

Subject: Re: So we can use techs or aides to perform part of our

treatment? (Not medicare)

--

Vinod,

I'm all for value-added cash-based services!

As you pointed out, PTs are/should be the primary care provider for

musculoskeletal conditions. Why then " prescribe " an exercise

treatment plan for the patient to go to the personal trainer/tech to

carry out?

Also, I may be misunderstanding what you have described, but if the

client is a PATIENT (has a musculoskeletal problem), would it not

seem imperative for the treatment plan/monitoring/updating to be

carried out by a licensed therapist?

Lastly, even if it is a separate service (personal training) and cash

based, if you have evaluated and formulated a plan of care, then

referred them to your (employed or contracted) personal trainer/tech,

you would assume all liability. Is this something that you feel

comfortable with? Personal Trainers do not have the depth or breadth

of knowledge a PT or PTA has, particularly when pathologies and

health issues are involved.

I like your ideas of finding additional cash-based services, but feel

personal training for musculoskeletal issues is one you might wish to

reconsider.

Dean, PT

- In PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com,

vteam44@... wrote:

>

>

> Dean,

>

>

>

> With techs and US and ES I'm not a huge fun of that idea simply due

to the implications of client injury (ES-mainly). Do we have techs-

yes and have they done the above at busy times-yes. We have

thoroughly train techs on this so they have a firm ability (in cause

it is needed). As far as ancillary help we're having our techs

trained as personal trainers so they can help out as needed. Now we

can't bill for PT services for a personal trainers help in the

service and we don't, but the patients are comfortable and the PT's

know that a tech can help as needed and when needed.Â

>

>

>

> As mentioned in may last post, we are the (in my opinion) the

primary care provider for Musculoskeletal conditions and we will have

to incorporate ancillary services to contribute to our PT services.Â

By all means this doesn't mean that the PT services should be done

by a non PT. I'll give you an example. Lets say you treat a

patient for 30min, 15-20 manual and some ther-ex presciption. Then

call it a session and " sale " them on going over to your wellness

program and seeing a personal trainer or personnal that follows your

prescription and adds a service (cash)Â that the patient may want

(watching them do the exercise -personal trainer). It isn't a PT

service, but we are heading it up and doing it correctly. Yes, we

are the best ones to do it all and we can.  Again, a qualified

personal trainer, under your educational model can help you as a

ancillary service and love the fact that he is learning and getting

that education and you are providing the client 2 services that are

valued by them. One may be cash based and the other insurance-

but it is diversified. That's an example and it can go in many

directions.  What we are going to do in our office

is certify the techs- and train them ourselves so they can become

good service providers under their own scope. As we know

any personal trainer that has a PT background can have a nice effect

on client service and the personal trainer would cherish the

opportunity. It can be done with massagee, weight loss.....the list

goes onÂ

>

>

>

> Vinod Somareddy, DPTÂ

>

>

> RE: Re: So we can use techs

> > > or aides to

> > > perform

> > > > > part of

> > > > > our treatment? (Not medicare)

> > > > >

> > > > > It's feather ruffling time...You know guys, I

> > > completely agree

> > > with

> > > > > the

> > > > > comments made on this posting with regards to

> > > delegation

> > === message truncated ===

> >

> > __________________________________________________________

> > Be a better friend, newshound, and

> > know-it-all with Yahoo! Mobile. Try it now.

> http://mobile.

<http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ

> <http://mobile.

<http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

> >

> >

> >

> >

> >

> >

[Guest guest]

Group,

You utlimately have a choice in determining if our services are deemed valuable

by another party and if that party is worth agreeing with.  Although I take

insurance (and moving towards not), there are plenty that don't and have made

significant strides in autonomous practice.

Tom, I would drop those insurance' that limit your choices in practice.  You,

not them, should make that decision . Again, I'm not telling you to practice

(like the insurance company is) I'm offering a visual on what is going on

(personal trainers are seeing a lot of our clients-more than ever) and should

make choices.....not allow others to make them for us.  Its a simple thing. 

If you choice not to use a personal trainer, PTA, LMT, whatever......that your

decision based on the service you feel your client needs.  But when the fees

and paperwork for some insurance companies become larger than closely

acceptable, I'd like to see how we are going to make a buck (while that personal

trainer charges 60 per hour).    

Vinod

RE: Re: So we can use techs

> > > or aides to

> > > perform

> > > > > part of

> > > > > our treatment? (Not medicare)

> > > > >

> > > > > It's feather ruffling time...You know guys, I

> > > completely agree

> > > with

> > > > > the

> > > > > comments made on this posting with regards to

> > > delegation

> > === message truncated ===

> >

> > __________________________________________________________

> > Be a better friend, newshound, and

> > know-it-all with Yahoo! Mobile. Try it now.

> http://mobile.

<http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ

> <http://mobile.

<http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

> >

> >

> >

> >

> >

> >

[Guest guest]

Guys,

We can't have it both ways! In many prior posts, it has been stated that you

can not bill for watching a patient perform exercises as this is not a " skilled "

service. Now you are saying that we can't offer this in our clinics under the

supervision of a " trainer " that we have trained on a cash basis because we

should be the ones who are providing this service. If this is a valuable

service to the patient/client and we won't offer it to them because it is not

reimbursable as a " skilled service, " then what do you think these patients will

do? They will find themselves a personal trainer (most likely not knowledgeable

about their condition), pay them cash (likely more than we are getting from the

insurance company for our " skilled " service), and probably end up dropping our

of PT because the trainer is giving them the personal attention that we

can't/won't with their exercise. I'm not sure if I totally understand and am

comfortable with what Vinod is suggesting, but if

we are restricting ourselves from billing for ther-ex that is " non-skilled "

because it can be part of a home program, then our only options are to not

provide this service, do this for free, defer this to someone else, or provide

this within the scope of our practice on a cash basis. Either it is billable or

not. If not, then we are not breaching our contract by providing this service

on a cash basis. The gray area is when does ther-ex become " non-skilled " , thus

not billable as a covered service under an insurance contract. My point is that

this is not as black and white as it looks on the surface.

Judd, PT, MPT

Texas

thomas m howell wrote: Hi

everyone,

Let’s not forget to include that, for most insurance contracts, you cannot

bill patients separately for services that can be provided under the

contract. The line between what is considered therapeutic exercise,

neuromuscular retraining etc has enough gray areas that you could run into

serious breach of contract issues if you are trying to steer people to a

personal training type situation.

To reiterate one of my earlier points: I can be the personal trainer when I

work with my clients one-on-one and it is a skilled service and it is

reimbursable. Why would I want to risk all the problems associated with

delegating the service to someone else?

Tom Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, ID

howellpt@...

_____

From: PTManager [mailto:PTManager ] On Behalf

Of deanpt1

Sent: Wednesday, May 07, 2008 6:17 PM

To: PTManager

Subject: Re: So we can use techs or aides to perform part of our

treatment? (Not medicare)

--

Vinod,

I'm all for value-added cash-based services!

As you pointed out, PTs are/should be the primary care provider for

musculoskeletal conditions. Why then " prescribe " an exercise

treatment plan for the patient to go to the personal trainer/tech to

carry out?

Also, I may be misunderstanding what you have described, but if the

client is a PATIENT (has a musculoskeletal problem), would it not

seem imperative for the treatment plan/monitoring/updating to be

carried out by a licensed therapist?

Lastly, even if it is a separate service (personal training) and cash

based, if you have evaluated and formulated a plan of care, then

referred them to your (employed or contracted) personal trainer/tech,

you would assume all liability. Is this something that you feel

comfortable with? Personal Trainers do not have the depth or breadth

of knowledge a PT or PTA has, particularly when pathologies and

health issues are involved.

I like your ideas of finding additional cash-based services, but feel

personal training for musculoskeletal issues is one you might wish to

reconsider.

Dean, PT

- In PTManager@yahoogrou <mailto:PTManager%40yahoogroups.com> ps.com,

vteam44@... wrote:

>

>

> Dean,

>

>

>

> With techs and US and ES I'm not a huge fun of that idea simply due

to the implications of client injury (ES-mainly). Do we have techs-

yes and have they done the above at busy times-yes. We have

thoroughly train techs on this so they have a firm ability (in cause

it is needed). As far as ancillary help we're having our techs

trained as personal trainers so they can help out as needed. Now we

can't bill for PT services for a personal trainers help in the

service and we don't, but the patients are comfortable and the PT's

know that a tech can help as needed and when needed.Â

>

>

>

> As mentioned in may last post, we are the (in my opinion) the

primary care provider for Musculoskeletal conditions and we will have

to incorporate ancillary services to contribute to our PT services.Â

By all means this doesn't mean that the PT services should be done

by a non PT. I'll give you an example. Lets say you treat a

patient for 30min, 15-20 manual and some ther-ex presciption. Then

call it a session and " sale " them on going over to your wellness

program and seeing a personal trainer or personnal that follows your

prescription and adds a service (cash)Â that the patient may want

(watching them do the exercise -personal trainer). It isn't a PT

service, but we are heading it up and doing it correctly. Yes, we

are the best ones to do it all and we can.  Again, a qualified

personal trainer, under your educational model can help you as a

ancillary service and love the fact that he is learning and getting

that education and you are providing the client 2 services that are

valued by them. One may be cash based and the other insurance-

but it is diversified. That's an example and it can go in many

directions.  What we are going to do in our office

is certify the techs- and train them ourselves so they can become

good service providers under their own scope. As we know

any personal trainer that has a PT background can have a nice effect

on client service and the personal trainer would cherish the

opportunity. It can be done with massagee, weight loss.....the list

goes onÂ

>

>

>

> Vinod Somareddy, DPTÂ

>

>

> RE: Re: So we can use techs

> > > or aides to

> > > perform

> > > > > part of

> > > > > our treatment? (Not medicare)

> > > > >

> > > > > It's feather ruffling time...You know guys, I

> > > completely agree

> > > with

> > > > > the

> > > > > comments made on this posting with regards to

> > > delegation

> > === message truncated ===

> >

> > __________________________________________________________

> > Be a better friend, newshound, and

> > know-it-all with Yahoo! Mobile. Try it now.

> http://mobile.

<http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ

> <http://mobile.

<http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

> >

> >

> >

> >

> >

> >

[Guest guest]

Hi Vinod,

And when a client needs exercise services that are not covered by their

insurance, we also offer cash based fitness services BUT they are still

done by my wife or myself (both PT’s). We market ourselves as fitness

experts, as musculoskeletal experts but we then hand patients over to those

that aren’t. I just don’t see the logic in that (so we don’t hand them

off). We are the experts, we enhance our insurance-based services with

cased-based programs. Having full direct access is the real key. It allows

us to compete against massage therapists and personal trainers however we

want. The point is to offer ourselves as experts and let our quality care

and superior service market our clinic. And that is what has happened. Our

biggest referral sources are word of mouth, family members and community

referrals.

Just trying to let you know that I am frustrated as everyone about insurance

and have thought about cash only practice but it is also good to let

everyone know that you can have a practice, follow the insurance rules, the

code of ethics and APTA policies AND still have a successful practice.

Tom Howell, P.T., M.P.T.

Howell Physical Therapy

Eagle, ID

howellpt@...

_____

From: PTManager [mailto:PTManager ] On Behalf

Of vteam44@...

Sent: Thursday, May 08, 2008 6:54 AM

To: PTManager

Subject: Re: Re: So we can use techs or aides to perform part of

our treatment? (Not medicare)

Group,

You utlimately have a choice in determining if our services are deemed

valuable by another party and if that party is worth agreeing with.

Although I take insurance (and moving towards not), there are plenty that

don't and have made significant strides in autonomous practice.

Tom, I would drop those insurance' that limit your choices in practice.

You, not them, should make that decision . Again, I'm not telling you to

practice (like the insurance company is) I'm offering a visual on what is

going on (personal trainers are seeing a lot of our clients-more than ever)

and should make choices.....not allow others to make them for us. Its a

simple thing. If you choice not to use a personal trainer, PTA, LMT,

whatever......that your decision based on the service you feel your client

needs. But when the fees and paperwork for some insurance companies become

larger than closely acceptable, I'd like to see how we are going to make a

buck (while that personal trainer charges 60 per hour).

Vinod

RE: Re: So we can use techs

> > > or aides to

> > > perform

> > > > > part of

> > > > > our treatment? (Not medicare)

> > > > >

> > > > > It's feather ruffling time...You know guys, I

> > > completely agree

> > > with

> > > > > the

> > > > > comments made on this posting with regards to

> > > delegation

> > === message truncated ===

> >

> > __________________________________________________________

> > Be a better friend, newshound, and

> > know-it-all with Yahoo! Mobile. Try it now.

> http://mobile.

<http://mobile. <http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ

> <http://mobile.

<http://mobile. <http://mobile.yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

yahoo.com/;_ylt=Ahu06i62sR8HDtDypao8Wcj9tAcJ>

> >

> >

> >

> >

> >

> >

[Guest guest]

Tom,

I do agree with your points.  I'd like to point out that my posts have moved to

the idea of opening up other practicioners as a ancillary service to compliment

PT services.  If you are providing PT services via a ancillary service then it

is less of a PT service.  That really is completely different then having

another provider that can service your clients in addition to PT.  The topic of

ancillary services in PT for PT services will always led to a lesser quality

service, compared to one completely delivered by a PT.  But as mentioned

before, once we determine what services our clients want then we can better

service them, in many cases it goes beyond PT services.  Personally,  I

wouldn't (after PT care is completed) personally train a client nor should any

PT.  I'm probably the best person to do so, but its not my interest and

shouldn't be mixed.  But I have a ton of clients that beg for us to service

them this way since they hate going to a gym and paying the fees to a corporate

gym that doesn't have any background in their health.  

Since we will run into this subject (techs etc.) more and more as reimbursement

decreases and paperwork increases, we (I'm sure you know this) will have to

find a way to prosper and get clients to pay for our services.  The truth is,

we have the best clinical insight to do this.  As mentioned before, we should

have the ultimate say (with the client) in how this level of healthcare is

determined.  

This also goes into the piece on promotion.  Increased promotion would

increase the demand for our services and distinctively seperate what we are to

a LMT, personal trainer etc.  That is the key because patients will know it and

they will demand it.  

I'll keep you posted on our transition.  Take care

Vinod      

RE: Re: So we can use techs

> > > or aides to

> > > perform

> > > > > part of

> > > > > our treatment? (Not medicare)

> > > > >

> > > > > It's feather ruffling time...You know guys, I

> > > completely agree

> > > with

> > > > > the

> > > > > comments made on this posting with regards to

> > > delegation

> > === message truncated ===

> >

> > __________________________________________________________

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> >

> >

> >

> >

> >

> >