Major changes in healthcare delivery systems in physical therapy followed the creation of Medicare and Medicaid in 1965 and the introduction of Diagnosis Related Group (DRG) Codes in 1982. Physical therapists must also be aware of the Physician Quality Reporting System (PQRS).3 Fiscal intermediaries, such as commercial insurance companies and the Centers for Medicare and Medicaid Services, publish rules and regulations, with associated payment criteria, that can affect patient care and need to be a component of the therapist’s playbook.
All of these stakeholders in physical therapy have different and sometimes conflicting values and priorities. Physical therapists often identify high-quality patient care, professional values and self-fulfillment as motivators in professional growth and satisfaction. Conversely, an organization managing or paying for healthcare services may prioritize fiscal viability, institutional efficiency and competitive positioning in the marketplace. These differences and potential loyalties may cause dilemmas in arriving at acceptable patient care outcomes based on evidence-based practice standards.
Physical therapists can also face Medicare audits and are accountable for compliance issues associated with documentation, coding and billing procedures. Changes in regulations without ethical content complicate the way healthcare is now being organized and financed. This changing environment places the patient and healthcare provider in a difficult position, as illustrated by the above scenario.
Understanding the rules and regulations so you can avoid mistakes that might be considered fraud is paramount.
The Objective
What are the driving forces, principles and guidelines that shape professional behaviors and ethical standards?
The short answer comes from the Code of Ethics adopted by the American Physical Therapy Association (APTA). It states, in part, “Physical therapists shall … act in the best interests of patients/clients over the interests of the physical therapist.”4
In physical therapy, the literature is rich with texts and publications that address ethical issues.5-8 And physical therapists can rely on The Guide to Physical Therapist Practice and state-directed practice laws in their quest to act ethically and provide the best care for their patients.4,9
However, not knowing the applicable laws, rules, ethical codes and practice guidelines is not an excuse for a lapse in judgment.
Back to Our Scenario
The opening scenario poses both an ethical dilemma (i.e., Do you provide the optimal care even if the insurance won’t cover it?) and a regulatory dilemma (i.e., Medicare regulations require that all patients be billed in accordance to the CMS fee schedule without consideration to patients’ ability to pay).2 If you offer the service for free or at a discounted rate, you could be in violation of Medicare regulations and face fines or be dropped from the program.
