Observations from a Utilization Reviewer

[Guest guest]

Forwarding an email that I shared with HPA.

Alan Petrazzi, MPT, MPMPittsburgh, PA

Subject: Observation from a Utilization Reviewer

To: hpa-list

Date: Sunday, October 9, 2011, 7:29 PM

All,

I recently reviewed several hundreds of initial evals & POCs from PT providers

in three states.  For your consideration, these are the

unfortunate trends that I see in way too many cases.  Doesn't matter if it is a

BS, MPT, or DPT.  Doesn't change with setting or years of experience.   

I hope this generates discussion and is meant to bolster our profession through

quality improvement.  Nationwide, third party payors are looking with more

scrutiny and this will only get more meticulous.

Better to hear it from a PT in the profession than someone else.

My observations in no particular order:

Superficial exams.  If the patient comes in with neuro radicular complaints, why

don't I see a neuro based

exam?  No DTRs, dermatomal/myotomal screening, etc.  Infrequently they will

comment on absence of b/b changes.  

Too many blank spaces.  If you didn't evaluate it, then acknowledge this with a

NT or NA.  When you leave huge blank spaces through the PT evaluation form you

look lazy.

PT diagnosis.  Why do therapists list an accumulation of symptoms instead of a

true PT diagnosis?  I see " decreased strength, decreased ROM, increased pain. "

 This is not a PT diagnosis and doesn't permit our profession to demonstrate our

skill with differential diagnosis which can often be more refined than the MD

diagnosis for " R shoulder pain. "  I would love to see more PT's discern that it

is a subscapularis strain with bicipital tendinitis...

Limited manual therapy.  We are physical therapists.  Physical.  Hands-on is our

forte.

 What is the love affair with piling on the modalities

and having them do supervised therex?  Please add manual therapy when

appropriate.  It tells me that you are not too busy to care for my patient.

Failing to keep abreast with the evidence based literature.  Chronic pain x 30

years probably won't respond to MH, TENS, interferrential, biofreeze,

phonophoresis, etc.  We need to be honest with ourselves and our patients and

know our limitations.  

Why do I see requests for 30 visits on an initial eval?  Nothing that far into

the future is predictable.  I question your judgment when you do this.  

When therapists request 2-3 visits per week x 4-6 weeks (8-18 visits), they are

signaling that they feel capable of achieving goals within 8 visits.  

Is every diagnosis 2-3 x 4-6?  I see this 99% of the time.  When you vary the

frequency and duration from case

to case it indicates that you have considered the patient's

availability and adjusted your requested visits based upon the diagnosis.  Sort

of like 'Name that Tune'... " I can treat this diagnosis in 6 visits. "  You have

more credibility than the 2-3 x 4-6 therapist and I may look favorably on future

authorizations.

Absence of objective measurement tools.  I rarely see the Oswestry, DASH, and

the others you can name.  And when they are used, it often doesn't become tied

to a goal.

Use age matched cohort ROM considerations.  Don't list a goal for 180 degrees

shoulder flexion for a 89 year old farmer and then request more visits because

you're only at 175.

Limited evidence of healthy education teaching.  I wish I saw more documentation

and goals that spoke to education re: energy conservation, symptom

self-management, avoidance of aggravating factors, joint conservation, caregiver

education, offering the patient

information on community support groups for their

chronic diagnosis, etc.  We seem to be stuck on resolving the immediate problem

and haven't yet ventured into connecting the dots with healthy living and other

support systems post therapy d/c.

Irritation with the authorization reviewers.  When we call for more information

on a case we are paying you for, provide the information we seek without a chip

on your shoulder.  It is unbecoming.

Daily notes are blah.  Cut and paste from the previous day just updating the 3#

to #3.5.  An assessment is an assessment and shouldn't be " tolerated session

well. "  A parakeet can ascertain this.  Give me a bona fide assessment or don't

write anything.

Similarly, when I don't see skilled therapy progression from session to session

I begin to wonder if you are squandering visits.  And chances are often that you

are.  You should've been able to reach the

goals within 12 visits but you are on 19 and want

12 more.  I will remember you.

Respectfully,

Alan Petrazzi, MPT, MPMPittsburgh, PA