New on PTManager Blog

[Guest guest]

Your Daily Posterous Spaces Update October 14th, 2011 Medicare

Advantage scam crackdown hits Fresno business |

abc30.com<http://ptmanagerblog.com/medicare-scam-crackdown-hits-fresno-business>

Posted about 22 hours ago by [image: _portrait_thumb] Kovacek,

PT, DPT, MSA <http://posterous.com/people/1l1oCkDWEWjv> to

PTManager<http://ptmanagerblog.com>

[image: Like this

post]<http://posterous.com/likes/create?post_id=75297611>

Medicare scam crackdown hits Fresno business

Thursday, October 13, 2011

Corin

Hoggard<http://abclocal.go.com/kfsn/bio?section=resources/inside_station/newstea\

m & id=5772038>

<http://abclocal.go.com/kfsn/story?section=news/local & id=8389624/newsteam>

FRESNO, Calif. (KFSN) -- State agencies are cracking down on Medicare fraud

and a Fresno business is one of their top targets.

/*Hussein Osman Ali*? is a convicted felon who's accused of using deceptive

practices to sell Medicare Advantage plans and collect big bonuses. Ali told

Action News he's never sold the plans, he just manages people who do, and he

says the government hasn't told him about any sanctions.

Behind the closed door at /*Brawley Insurance Services*/, Ali leads a team

of insurance sales people.

The company's website says it offers a full menu of Medicare Advantage plans

-- a relatively new type of policy offering Medicare insurance plus extra

coverage. State agents say the plans also offer an in for crooks.

" These plans can be very beneficial for consumers, but unfortunately they

have also given an opportunity for those who would take advantage of elderly

or vulnerable consumers, " said Brent Barnhart, the head of California

Department of Managed Health Care.

Insurers pay agents hundreds of dollars in incentives to sign up new

Medicare Advantage patients. State agents say that often leads to

unscrupulous sales methods.

In Manteca, Hoot fell victim to the hard sell, then found herself

sinking into debt as bills stacked up that her old policy would've paid.

" I was getting thousands and thousands of dollars in bills and I was calling

this lady, " Hoot said. " She said it was all a mistake and she'd take care of

it. She didn't. "

State investigators are looking into Hoot's complaint and about 100 others

across the state.

A complaint about Brawley Insurance Services led to sanctions preventing the

company from selling any more Medicare policies. But some victims say that's

not enough to stop the scams.

" They get a slap on the wrist, but what about us? " Hoot said. " You know, our

credit's bad, some doctors won't see us because they didn't get paid. It's

been a nightmare. "

Open enrollment for Medicare Advantage starts on Saturday, so state agents

want seniors and their families on alert.

As for Ali, he says he's selling Brawley Insurance Services and getting out

of the Medicare business, but not until after the open enrollment period.

via

abclocal.go.com<http://abclocal.go.com/kfsn/story?section=news/local & id=8389624>

Huh? / No Benefit of Occupational Therapy After Wrist Fracture

--Doctors

Lounge<http://ptmanagerblog.com/huh-no-benefit-of-occupational-therapy-after>

Posted about 17 hours ago by [image: _portrait_thumb] Kovacek,

PT, DPT, MSA <http://posterous.com/people/1l1oCkDWEWjv> to

PTManager<http://ptmanagerblog.com>

[image: Like this

post]<http://posterous.com/likes/create?post_id=75327844>

No Benefit of Occupational Therapy After Wrist Fracture Last Updated:

October 13, 2011.

*Surgeon-directed independent exercises superior for volar plate fixed

radial fractures*

Share <http://www.addthis.com/bookmark.php?v=250 & username=doctorslounge> |

<http://www.doctorslounge.com/index.php/news/pb/23792#>

<http://www.addthis.com/bookmark.php?v=250 & winname=addthis & pub=doctorslounge & sou\

rce=tbx-250 & lng=en-US & s=myspace & url=http%3A%2F%2Fwww.doctorslounge.com%2Findex.p\

hp%2Fnews%2Fpb%2F23792 & title=No%20Benefit%20of%20Occupational%20Therapy%20After%\

20Wrist%20Fracture%20--Doctors%20Lounge & ate=AT-doctorslounge/-/-/4e973215b14f35f\

d/1 & frommenu=1 & uid=4e973215175117ff & pre=http%3A%2F%2Fnews.google.com%2Fnwshp%3Fh\

l%3Den%26tab%3Dwn%26ar%3D1318531528 & tt=0>

<http://www.addthis.com/bookmark.php?v=250 & winname=addthis & pub=doctorslounge & sou\

rce=tbx-250 & lng=en-US & s=google & url=http%3A%2F%2Fwww.doctorslounge.com%2Findex.ph\

p%2Fnews%2Fpb%2F23792 & title=No%20Benefit%20of%20Occupational%20Therapy%20After%2\

0Wrist%20Fracture%20--Doctors%20Lounge & ate=AT-doctorslounge/-/-/4e973215b14f35fd\

/2 & frommenu=1 & uid=4e973215e69d8d70 & pre=http%3A%2F%2Fnews.google.com%2Fnwshp%3Fhl\

%3Den%26tab%3Dwn%26ar%3D1318531528 & tt=0>

<http://www.doctorslounge.com/index.php/news/pb/23792#>

Comments: (0) <http://www.doctorslounge.com/index.php/comments/page/23792>

Tell-a-Friend <http://www.doctorslounge.com/index.php/site/recommend/23792>

------------------------------

*Related*

*For patients with an unstable distal radial fracture treated with open

reduction and volar locking plate fixation, surgeon-directed independent

exercises, but not those under supervision of an occupational therapist,

improve average motion and disability score of the wrist, according to a

study published in the Oct. 5 issue of The Journal of Bone & Joint Surgery.*

THURSDAY, Oct. 13 (HealthDay News) -- For patients with an unstable distal

radial fracture treated with open reduction and volar locking plate

fixation, surgeon-directed independent exercises, but not those under

supervision of an occupational therapist, improve average motion and

disability score of the wrist, according to a study published in the Oct. 5

issue of *The Journal of Bone & Joint Surgery*.

J. Sebastiaan Souer, M.D., from the Massachusetts General Hospital in

Boston, and colleagues investigated whether wrist function and arm-specific

disability six months after open reduction and volar plate fixation of 94

unstable distal radial fractures differed in patients who received

occupational therapist-supervised exercises or surgeon-directed independent

exercises. Combined wrist flexion and extension were measured six months

after surgery. Wrist motion, grip strength, Gartland and Werley scores, Mayo

wrist scores, and Disabilities of Arm, Shoulder and Hand (DASH) scores were

measured at three and six months after surgery.

The investigators found that the mean arc of wrist flexion and extension six

months after surgery was significantly improved in those patients prescribed

independent exercises. A significant difference was observed in mean pinch

strength, grip strength, and Gartland and Werley score at three months after

surgery, and in the mean results of wrist extension, ulnar deviation,

supination, grip strength, and Mayo score at six months after surgery, and

favored independent exercises. No differences were found in the DASH score

at any time point.

" Prescription of formal occupational therapy does not improve the average

motion or disability score after volar locking plate fixation of a fracture

of the distal part of the radius, " the authors write.

One or more of the study authors disclosed a financial relationship with the

biomedical industry.

via doctorslounge.com <http://www.doctorslounge.com/index.php/news/pb/23792>

Study: Direct Access to Physical Therapists Associated with Lower

Costs and Fewer

Visits<http://ptmanagerblog.com/study-direct-access-to-physical-therapists-as>

Posted about 16 hours ago by [image: _portrait_thumb] Kovacek,

PT, DPT, MSA <http://posterous.com/people/1l1oCkDWEWjv> to

PTManager<http://ptmanagerblog.com>

[image: Like this

post]<http://posterous.com/likes/create?post_id=75332950>

Study: Direct Access to Physical Therapists Associated with Lower Costs and

Fewer Visits

Download in Adobe

PDF<http://www.apta.org/uploadedFiles/APTAorg/Media/Releases/Consumer/2011/Press\

Release_IowaStudy_101311.pdf>

ALEXANDRIA, VA, October 13, 2011 — A new

study<http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2011.01324.x/abstra\

ct>suggesting

that " the role of the physician gatekeeper in regard to physical

therapy may be unnecessary in many cases " could have significant

implications for the US health care system, says the American Physical

Therapy Association (APTA).

The study, published ahead of print September 23 in the journal Health

Services Research (HSR), reviewed 62,707 episodes of physical therapy using

non-Medicare claims data from a Midwest insurer over a 5-year period.

Patients who visited a physical therapist directly for outpatient care (27%)

had fewer visits and lower overall costs on average than those who were

referred by a physician, while maintaining continuity of care within the

overall medical system and showing no difference in health care use in the

60 days after the physical therapy episode.

The study is noteworthy because services delivered by physical therapists

account for " a significant portion " of outpatient care costs in the United

States, according to the study, and some health insurance plans require a

physician referral for reimbursement of these services. In addition,

although 46 states and the District of Columbia now allow some form of

direct access to physical therapists, some of them nonetheless impose

restrictions if patients have not been referred by a physician.

" Physical therapists have long known that direct access to our services is

safe and effective, " said APTA President R. Ward, PT, PhD. " The

elimination of referral requirements and other restrictions has been a

priority of APTA for decades. This study provides further evidence that

direct access to physical therapists could go a long way toward helping to

make health care more affordable and accessible for all. We encourage

researchers and insurers to continue to further investigate this important

issue that could have a profound impact on patient care. "

" When patients choose direct access to a physical therapist, it does not

mean the end of collaboration with their physician, nor does it diminish

continuity of care, " added DiAngelis, PT, DPT, president of APTA's

Private Practice Section. " We believe the results of this study will support

our efforts to work with legislators and physician groups to establish

policies that reduce unnecessary regulations, improve access, and build

models of delivery that best serve the patient and the health care system.

Although this study focused on direct access, it is not about the provider.

It is about the patient. It means better opportunities to provide the proper

care to those who need it, when they need it. "

Led by Jane Pendergast, PhD, professor of biostatistics and director of the

Center for Public Health Studies at the University of Iowa, the study

retrospectively analyzed 5 years (2003-2007) of private health insurance

claims data from a Midwest insurer on beneficiaries aged 18-64 in Iowa and

South Dakota. A total of nearly 63,000 outpatient physical therapy episodes

of care were analyzed – more than 45,000 were classified as

physician-referred and more than 17,000 were classified as " self-referred "

to physical therapists. Physical therapy episodes began with the initial

physical therapist evaluation and ended on the last date of services before

60 days of no further visits. Episodes were classified as physician-referred

if the patient had a physician claim from a reasonable referral source in

the 30 days before the start of physical therapy. Researchers found that

self-referred patients had fewer physical therapy visits (86% of

physician-referred) and lower allowable amounts ($0.87 for every $1.00 of

physician-referred) during the episode of care, after adjusting for age,

gender, diagnosis, illness severity, and calendar year. In addition, overall

related health care use – or care related to the problem for which physical

therapy was received, but not physical therapy treatment – was lower in the

self-referred group after adjustment. Examples of this type of care might

include physician services or diagnostic testing. Potential differences in

functional status and outcomes of care were not addressed.

" Health care use did not increase in the self-referred group, nor was

continuity of care hindered, " the researchers write. " The self-referred

patients were still in contact with physicians during and after physical

therapy. Concerns about patient safety, missed diagnoses, and continuity of

care for individuals who self-refer may be overstated. "

According to Rick Gawenda, PT, president of APTA's Section on Health Policy

and Administration, the study should cause insurers and policymakers to

rethink the physician gatekeeper concept when it comes to physical therapist

services. " Evidence shows that, in the case of physical therapy, the

physician gatekeeper model is doing exactly the opposite of what it was

originally designed to do; it does not reduce ineffective and duplicate care

nor reduce health care costs, " says Gawenda. " It's time to end the physician

referral requirement in every state, and it's time for all payers to embrace

direct access to physical therapists. "

Earlier research has supported direct access to physical therapists, but the

new HSR study is the most comprehensive to date. A 1994 study analyzed 4

years of Blue Cross Blue Shield of land claims data and found that total

paid claims for physician referral episodes to physical therapists were 2.2

times higher than the paid claims for direct access episodes. In addition,

physician referral episodes were 65% longer in duration than direct access

episodes and generated 67% more physical therapy claims and 60% more office

visits. The HSR study looked at a far more extensive number of episodes than

the previous study, and also controlled for illness severity and other

factors that could have affected the patients' outcomes.

" In summary, " the researchers write, " our findings do not support the

assertion that self-referral leads to overuse of care or discontinuity in

care, based on a very large population of individuals in a common private

health insurance plan with no requirement for PT [physical therapy] referral

or prohibition on patient self-referral. We consistently found lower use in

the self-referral group, after adjusting for key demographic variables,

diagnosis group, and case mix. We also found that individuals in both groups

were similarly engaged with the medical care system during their course of

care and afterwards. "

The American Physical Therapy Association (APTA) represents more than 77,000

physical therapists, physical therapist assistants, and students of physical

therapy nationwide. Learn more about conditions physical therapists can

treat and find a physical therapist in your area at www.moveforwardpt.com.

Consumers are encouraged to follow us on Twitter

(@moveforwardpt<http://twitter.com/#!/moveforwardpt/>)

and Facebook <http://twitter.com/#!/moveforwardpt/>.

The Practice Practice Section (PPS) is the business section of APTA that

fosters the growth, economic viability, and business success of physical

therapist-owned practices to benefit the public.

The Section on Health Policy and Administration (HPA) is a specialty

component of APTA. The mission of the HPA Section is to transform the

culture of physical therapy through initiatives that enhance

professionalism, leadership, management, and advocacy to foster excellence

in autonomous practice for the benefit of members and society.

Coauthors of the study were A. Kliethermes, MS, a doctoral

candidate in biostatistics at the Center for Public Health Studies,

University of Iowa; Janet K. Freburger, PT, PhD, research associate and

fellow at the Sheps Center for Health Services Research and a scientist at

the Institute on Aging at the University of North Carolina, Chapel Hill; and

Pamela A. Duffy, PT, PhD, OCS, CPC, assistant professor, Public Health

Program, at Des Moines University.

The study was funded by a grant from APTA and its sections on Private

Practice and Health Policy and Administration.

*Reference*

1. Pendergast J, Kliethermes SA, Freburger JK, Duffy PA. A comparison of

health care use for physician-referred and self-referred episodes of

outpatient physical therapy. Health Services Research. Published ahead of

print September 23, 2011. DOI: 10.1111/j.1475-6773.2011.01324.x

via apta.org <http://www.apta.org/Media/Releases/Consumer/2011/10/13/>

HHS to Investigate 'Incident To' Billing in

2012<http://ptmanagerblog.com/hhs-to-investigate-incident-to-billing-in-201>

Posted about 16 hours ago by [image: _portrait_thumb] Kovacek,

PT, DPT, MSA <http://posterous.com/people/1l1oCkDWEWjv> to

PTManager<http://ptmanagerblog.com>

[image: Like this

post]<http://posterous.com/likes/create?post_id=75333023>

Thursday, October 13, 2011[image: RSS

Feed]<http://www.apta.org/rssfeed.aspx?blog=10737418615> HHS

to Investigate 'Incident To' Billing in 2012

The US Department of Health and Human Services (HHS) Office of Inspector

General (OIG) next year will conduct an investigation into how many office

visits, consultations, and other services are performed by unqualified

nonphysicians under Medicare's " incident-to " billing rules, says a *Medscape

* *Medical News* article.

Physicians have drawn much of their Medicare reimbursement through

incident-to billing. An OIG study in

2009<http://www.oig.hhs.gov/oei/reports/oei-09-06-00430.pdf>revealed

that when Medicare allowed physicians to bill the program for more

than 24 hours of service within a single day, nonphysicians had performed

half the services.

OIG finds no fault in that pattern, says

*Medscape*<http://www.medscape.com/viewarticle/751292?sssdmh=dm1.724913 & src=nldn\

e>.

OIG's concern is that 21% of the services were performed by nonphysicians

who lacked needed licenses or certifications, verifiable credentials, or the

appropriate training, to render the services. (Read APTA's press

release<http://www.apta.org/Media/Releases/Legislative/2009/8/10/>on

OIG's 2009 report.)

In its 2012 work

plan<http://oig.hhs.gov/reports-and-publications/workplan/index.asp#current>,

OIG says that incident-to billing " may be vulnerable to overutilization and

expose Medicare beneficiaries to care that does not meet professional

standards of quality. " OIG intends to determine whether incident-to claims

have a higher error rate than ordinary ones and assess the ability of the

Centers for Medicare and Medicaid Services to monitor incident-to services,

which are not identified as such on claims.

This is just 1 new investigation that the HHS plans to conduct next year.

OIG also will look into such diverse issues as the extent to which

physicians are opting out of Medicare, the safety and quality of care at

ambulatory surgery centers, and physician-owned companies that distribute

spinal implants, the article says.

via apta.org<http://www.apta.org/PTinMotion/NewsNow/2011/10/13/OIGWorkPlan/>

[image: Posterous] <http://posterous.com> Want your

own?<http://posterous.com> Change

your email

settings<http://posterous.com/email_subscriptions/hash/gspsqucxgqviGogjvCufJwAxB\

xkgmH>