“What is therapy?” sounds like a simple question, but it requires a separate and very complex answer for each discipline.
What is defined as our physical, occupational and speech therapy scope of practice is defined by the Centers for Medicare & Medicaid Services in the Medicare Benefits Policy Manual.
As a therapist or assistant, we have our long version and short version answers always ready at the tip of our tongues. So why is the answer so important? Well, I’ve been talking with a lot of colleagues about their experiences during the appeals process of claim reviews. Many of them have shared stories of not only having to defend the claim in question, but also explaining the basics of each of our disciplines — especially when the appeals are handled at the administrative law judge (ALJ) levels.
So to advocate for our industry, and get our claims paid, defining rehab has taken on a whole new importance level.
I like to think of all three therapies as “masters of training.” We train or retrain for gait, ADLs, cognition, swallowing, and many, many other areas. We use terminology, such as, “gait training,” or “ADL training” in our everyday vocabulary. And what we can’t train, we adapt, modify, or train/teach new compensatory strategies to enhance the patient outcomes.
As an occupational therapist, I’m not surprised when I meet someone new, unrelated to healthcare, who assumes I help people find jobs. I always love this opportunity to educate someone about my profession and the countless ways that rehab and OT impact patient lives.
What worries me, however, is when I’m having this conversation with a judge who is responsible for determining if my services were medically necessary and appropriate for the patient I treated.
As claim reviews and increased scrutiny continue to increase, I think it’s important for every PT, OT, SLP therapist and assistant to have a clearly defined, easy answer, ready to roll off the tip of our tongues. We used to assume that if we used our skilled terminology and objective measurements, it was enough to support our claims; I’m finding a growing need to add the basic definition of PT, OT, and/or SLP at the beginning of every appeals letter and conversation when submitting insurance appeals.
If you are dealing directly with insurance companies, and the appeal escalates to the insurance medical director, you might need to involve the patient’s direct care physician to educate the insurance physician on the importance and scope of therapy.
Our challenge is not only to educate about the basics of rehab, but also include evidence-based research to support our clinical interventions when attempting new treatment strategies or “state-of-the-art rehab approaches.” So, add “master of training” to your job descriptions and let your definitions continue to grow from there.
Shelly Mesure (“Measure”), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a veteran speaker and writer on therapy and reimbursement issues.