Just for Fun, What Would Happen If You Had a Therapist and a Physician in Your Practice? Consider how your facility might benefit from partnerships with other health-care professionals By Thomas F. Fise, JD
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&P practitioners talk all the time about things like: “Why can’t we get paid for our time in patient training, gait analysis, and instruction, like the therapists do? It’s unfair—don’t we do the same thing they do?” Or, “The prosthetist/orthotist understands the patient’s mobility needs much better than the physicians do, yet our getting paid is dependent on the exact words in the physician’s order, and Medicare won’t even let us help the doc clarify what should be in his or her notes.” First, be careful what you ask for. Is everybody ready for CMS to restructure the L-code system so that they begin paying for everything on the basis of the amount of time you spend, rather than paying a set price—a global fee, if you will—for the finished device? Medicare did just this type of restructuring of physician fees in the early 1990s. They hired a Harvard public health expert to go to physician practices, and also to review physician calendars/logs to pinpoint exactly how much time—in minutes and seconds—the doctors actually spent, on average, with the patient. They also factored in actual practice expense costs for gauze, bandages, paper used on the examining table, etc., and added in factors for malpractice costs, and the
10 O&P News | February 2018
intensity of the time the doctor spent and training required—minutes spent performing heart surgery were more intense minutes than those spent taking a history and physical. The result was what became known as the ResourceBased Relative Value Scale (RBRVS), and around 1993, physicians started to be paid based on a set number of dollars for each relative value unit (RVU)—that is, they got paid primarily based on the actual average minutes for each service, and they didn’t much like this result. As we ponder the payment to the O&P professional versus that paid to the therapist or the physician, recognize that the latter get paid under the Current Procedural Terminology (CPT) coding system (based on RVUs), while O&P gets paid from a subset of the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) fee schedule. That said, like so many things in life, there is more than one way to skin a cat. For example, you probably have observed that hospitals have purchased a bunch of physician practices, but did you know that the fee paid to the physician practice can be significantly higher if the visit occurs on the premises of the hospital (viewed as more intense time, almost like time in the emergency
room)? To qualify for this higher reimbursement, the office actually needs to be no more than a set number of feet from the hospital itself—if it is that close, it is considered on premises. You also may know that surgeries/procedures of modest complexity can be performed either in the hospital or in a separate ambulatory surgery center (ASC). The truth is that the amount Medicare pays for practice expenses is generally significantly higher if the patient is treated in the hospital’s outpatient department, rather than if the very same procedure is provided in a free-standing ASC. So, when a physician practice is purchased by a hospital, you can expect that more of its procedures will be done in the hospital outpatient department (even though, in order to keep the “wheels of medicine turning,” a decent volume will continue to occur in the ASC, which the hospital likely bought from the physicians when they purchased the practice). The point of the above is not to make you an expert on physician payment under Medicare, but rather to demonstrate that practices, even hospitals, are often set up on a structure that takes all the rules into account in order to generate the most generous total reimbursement from Medicare and other payors.
