Main Problems Related to Billing For Services

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Many ethical issues arise in health care related services for patients, including physical therapy. One main issue is in regard to billing for services. There has been evidence of up-charging and down-charging costs of services in physical therapy practice. Although, there are not many credible sources that discuss this topic. The reason behind this is because fraud is illegal, and there are not many people who will actually admit to performing this act. Also, some physical therapists may not be realizing they are doing it because of lack of education on the subject. Therefore, this discussion will mostly pertain to the ethics behind fraudulent activity with billing. The first peer-reviewed article selected for analysis is “Ethical Issues in Physical Therapy.”

It discusses the various ethical issues that physical therapists must encounter every day, with specific attention to billing integrity and what situations may arise that threaten ethical decisions. Physical therapists’ decisions are influenced by their own ethical beliefs, the patient’s beliefs, rules and regulations for their workplace, along with possible third party factors from Medicare, Medicaid, and other carriers.1 Questions may arise regarding the care that the patient may need against the insurance coverage and their ability to pay for that care. One specific case is provided where the patient’s insurance will only allow an initial evaluation, however, the physical therapist’s plan would involve follow up visits twice a week for four weeks.1 The main ethical question here is whether to provide pro bono care to implement this plan or to discharge the patient without further follow ups.

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The best option in this case would be to discharge the patient with very explicit home exercise program instructions that could most likely correlate with the plan of follow up appointments.1 Comprising the proper educational program would be extremely important to allow the patient to understand how to follow the physical therapist’s instructions. The next peer-reviewed article is “Fighting Fraud and Abuse In Physical Therapy.” This article focuses on fraudulent activity that physical therapists may or may not be aware of but must be educated on. It specifically discusses many situations where Centers for Medicare and Medicaid Services (CMS) audited various physical therapist practices. Also noted was the fact that in 2007, “Medicare and Medicaid made $23.7 billion in payments for health care services that did not comply with one or more coverage, coding, billing, or other rules.”

There were other reports showing intentional abuse of billing or manipulating ICD codes in order to gain profit. These occurrences have led to the overall increase in regulations and audits. Intentionally and unintentionally, regulations have been broken, with many health care providers, including physical therapists, being unaware of the policies and the mistakes are making. President of the APTA’s Home Health section states that she wishes Medicare would spend more time enforcing the regulations, rather than adding new ones, which only make things more complicated.

Physical therapists must take responsibility to understand the policies that are in place and know how to follow them, but adding more may not be helpful. In depth documentation is a huge contribution to evidence that can effectively back up a physical therapist’s plan of care and reasoning behind services, especially if an audit occurs. At most times, physical therapists will mistakenly provide pro-bono work to patients who have insurance or they will try to manipulate the system by falsely justifying a patient’s status in order to get them into certain facilities.2 To help avoid this, physical therapists should educate themselves and their staff through continuing education and proper documentation. I agree that ethical and economic issues are a huge concern for all health care providers, including physical therapists.

Some of the mainly detected mistakes are providing unnecessary testing, treatments, and increased sessions for patients who do not need them, coding for patients who do not have corresponding illnesses, and providing procedures solely for higher reimbursement from third party providers.3 With all of these intentional and other unintentional mistakes being made, we as physical therapists must be educated on the current regulations and policies that characterize insurance providers if we are to treat patients. There may be mistakes that physical therapists make regarding pro-bono services and manipulation of patient statuses for the good of the patient because they believe it would be ethical thing to do. However, these are policy violations and can result in further burdens and possibly audits. Following guidelines while also adhering to our code of ethics is the best way to apply optimal care for our patients and avoid fraudulent activity.

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Main Problems Related to Billing For Services. (2022, Apr 14). Retrieved from

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