Advocacy

How can insurance authorizations for PT be rendered by non-PTs?

I have always had an issue with the insurance authorization process.  In many instances, a non-PT, reviews a PTs notes, and authorizes an amount of care dependent upon the individual patients presentation.  While I accepted this as “part of the process” in the past, I began to question the process when a family member entered a skilled nursing facility.


Upon entering the facility, my family member was assessed by clinical staff, as well as a care coordinator that works for NaviHealth.  Upon discussing the potential length of stay (for serious medical complications), the clinical staff reported that they have little say in the duration of care, and that a non-PT, non-OT, non-SLP (you get my point), determines the actual length of stay.   I asked the clinical staffs opinion of this, and they simply answered “that’s they way it is“.   They reported my family member would likely have two weeks approved for rehabilitation (again, he has serious medical complications).


So I immediately went to the Pennsylvania Board of Physical Therapy’s practice act, to determine the potential legality of a “non-PT” determining such an important aspect of my family member’s long-term plan (Below is what I found).


Are insurance companies (and the post-acute management organization which they contract) in legal compliance with state practice acts?   Shouldn’t insurance companies be utilizing the review services of a licensed-Physical Therapist as they are the only individuals who can truly determine a diagnosis, prognosis and plan of treatment for physical therapy care?  


Let’s discuss and hold insurance companies responsible for providing the appropriate individuals in determining authorization for our care (as anyone not licensed cannot make a clinical decision related to physical therapy).

“Physical therapy” means any of the following:

(1) The evaluation, examination and testing of individuals with mechanical, physiological and developmental impairments, functional limitations and disabilities, other health-related or movement-related conditions, performed to determine a diagnosis, prognosis and plan of treatment intervention within the scope of this act or to assess the ongoing effects of intervention.


Section 4. Training and License Required; Exceptions.–(a) It shall be unlawful for an individual to practice or hold himself out as being able to practice physical therapy in this State in any manner whatsoever unless such individual has met the educational requirements and is licensed in accordance with the provisions of this act. The board shall determine standards, by regulations, regarding qualifications necessary for the performance of such tests or treatment forms as the board shall determine require additional training or education beyond the educational requirements set forth by this act, as such relates to the practice of physical therapy in accordance with law. Nothing in this act, however, shall prohibit an individual trained and licensed or certified to practice or to act within the scope of his license or certification in this State under any other law, from engaging in the licensed or certified practice for which he is trained.


b.1) It shall be a violation of this act for an individual or business entity to utilize in connection with a business name or activity the words “physical therapy,” “physical therapist,” “physiotherapy,” “physiotherapist” or similar words and their related abbreviations which imply directly or indirectly that physical therapy services are being provided, including the billing of physical therapy services, unless such services are provided by a licensed physical therapist in accordance with this act: Provided, however, That nothing in this section shall limit a physician’s authority to practice medicine or to bill for such practice nor limit a chiropractor’s authority to practice chiropractic or to bill for such practice.

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7 replies »

  1. Joe, I feel you and I have had a very hard time accepting that someone else can completely undercut my clinical decision for prognosis and frequency/duration of care. I especially feel for you as this involves someone near and dear to my heart. If there is something that we can all do as a grassroots effort to get them in compliance, I’m on board!!

  2. Hey Steve,
    I have no objection to a licensed PT auditing my evaluation and questioning a recommendation for care. I do have a huge objection to a non-PT making a clinical assessment and determining a duration of PT care. I will be contacting my state board to determine if these individuals are practicing PT without a license. This is obviously, illegal.

  3. Joe, this is a huge issue across the country. Just yesterday my partner and I had a lengthy discussion about neuromuscular re-education with a non-clinician at an insurance company. He was denying our charges because “in his opinion” NMR can only be performed and billed by a physician. When asked how he came to that conclusion he simply stated “everyone knows that”. It seems so simple now that you’ve pointed it out as a practice act issue. Brilliant!

  4. So I contacted our State Board and here was the reply (I suspect we can start issuing complaints to our state board based upon non-PTs, making clinical assessments based upon our info):

    “Neither I nor the Board may pre-approve or pre-disapprove specific conduct, that would be providing an advisory opinion, which the Commonwealth Court has deemed a “legal nullity.” Similarly, the only time that the Board can issue a “ruling” on specific conduct, determining whether or not that conduct violates the law, is when a formal disciplinary matter has been brought before the Board.

    The Bureau of Professional and Occupational Affairs is a complaint-driven organization. In order for the Bureau to conduct an investigation, a complaint must be filed. The complaint form is available on the Department’s website, http://www.dos.pa.gov. If you file a complaint, it will be processed by the Professional Compliance Office and Office of Prosecuting Attorneys for the Department, who will determine whether formal charges should be brought.”

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