Physical Therapy Contract. Reference guide to understanding your contract

Transcription

1 Physical Therapy Contract Reference guide to understanding your contract Revised February 2011

2 HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 2 of 13

3 PHYSICAL THERAPY PROVIDER EXPECTATIONS PHYSICAL THERAPY OBJECTIVES The goal is to deliver the right interventions at the right time to achieve safe, timely and sustainable return to work, at a reasonable and sustainable cost. To support this objective, Providers are expected to use best efforts to achieve a minimum 65% off-td01 rate - 7 days post discharge. PHYSICAL THERAPIST RESPONSIBILITIES: In fulfilment of their obligations under the agreement the Physical Therapist is expected to undertake a number of activities: 1. Initial Physical Therapy Assessment to identify: a) any objective clinical impairments that restrict the Workers ability to perform usual work tasks; b) the Worker s readiness to safely perform usual work tasks; c) the presence of barriers for return to work (appendix B ); and d) any other factors, both compensable and non-compensable that may impede or delay the Workers return to work. 2. Active Physical Therapy treatment that: a) promotes early reactivation and timely return to normal activity; b) promotes safe and timely return to work; and c) use symptomatic relief modalities on a time-limited basis. 3. Worker Education and Self-Management that: a) includes education regarding their injury; b) includes self management and home exercises; and c) includes strategies to reduce the risk of future injury. 4. Return To Work Planning that: a) discusses, with the Worker, return to work as a goal of Physical Therapy treatment; b) determines any work restrictions based on objective clinical impairment; c) includes contacting the employer where appropriate to determine job duties and the availability of modified work; d) provides the Case Worker with a specific return to work date including functional abilities and physical restrictions; and e) communicates the return to work plan (verbal or written) with the Worker, the Case Worker, and where possible, the Worker s Physician, and employer. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 3 of 13

4 ADMISSION 1. What are my responsibilities as a contractor when I see a new WCB patient? Confirm if injury occurred at work. If work-related, ask Worker if a Worker s Report of Injury has been submitted to the WCB. If one has not been submitted, provide the Worker with a form and make reasonable efforts to have the Worker complete it. You may obtain a Worker's Report of Injury form by logging onto and clicking onto WCB for Workers and then Resources and then 'Publications and Forms' tab and scrolling to the Worker injury reporting form. Try to confirm if the Worker is receiving treatment for the same injury elsewhere (e.g., another physical therapy clinic, chiropractor). If already receiving treatment, have the Worker contact their WCB Case Worker for authorization before providing service beyond the first assessment and treatment. The WCB does not normally support concurrent care. If the Workers have attended without a Doctor s referral, advise the Worker to see their Physician within the next five days. Make the Worker aware of his/her responsibility for payment in the event treatment is not authorized. You may wish to consider having the Worker sign an agreement to ensure payment is secured if treatment is not authorized. 2. What if someone is hurt at work but doesn t want to go through the WCB? Under the Workers Compensation Act (WCA), when you have knowledge that a work-related injury has taken place, you are obligated to report to the WCB within two business days. It is unlawful to bill treatment that is the WCB s responsibility to another payment source. Failure to report work-related injuries could result in termination of your contract. You may wish to post a notice in your office indicating that you are required, under the Workers Compensation Act (WCA), to report any work-related injuries. AUTHORIZATION FOR SERVICE 1. How will authorization be given? Once the Case Worker determines that the Worker is entitled to Physical Therapy treatment and has received the assessment report, the Case Worker will send a letter authorizing service as well as the treatment period dates. In the event verbal authorization is given, ensure the following information is clearly recorded in the Worker s file: o Date and time authorization was given; o Name and telephone number of the Case Worker providing the authorization; and o Nature/duration of services authorized 2. Why is authorization sometimes delayed? Although Case Workers will make reasonable efforts to provide authorization in a timely manner, the following factors can cause a delay in the process: o Not all reports have been received, e.g., Employer Report, Worker s Report of Accident, Physician s Report. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 4 of 13

5 o Certain cases (e.g. re-opens, RSIs) require more information/investigation and may take longer to process. 3. Will WCB pay for an assessment and one treatment? The WCB will pay for an assessment and one treatment while waiting for an entitlement decision regardless of whether the claim is ultimately accepted or denied. The initial treatment can be on the same day as the assessment. 4. If a Worker knows he may not be covered, and he wants to go ahead with treatment and pay himself, is that okay? Yes, but you must immediately reimburse the Worker for all money paid to your clinic if the claim is accepted and you have received authorization from the WCB. You must then invoice the WCB for authorized dates of services at WCB contract rates. 5. If we provide an assessment or treatment, and then have to wait two weeks for authorization, do we still have up to six weeks to treat from the date that we receive treatment authorization? No, the time frame starts from the date of the initial assessment. 6. How can I find out if a claim is entitled and therapy is authorized? Call the WCB Contact Centre providing the Worker s name and claim number, if available: Edmonton: Tel: Toll-free in Alberta: Toll-free fax: (in Alberta) Calgary: Tel: Toll-free fax: (in Alberta) 7. What if the Physical Therapist and the Worker want to continue treatment beyond that approved by the WCB? No additional treatments may be provided while the Worker s claim is still active. Once the WCB has stated that responsibility for ongoing treatment has ended and the claim is closed, the Physical Therapist must now enter into a separate payment agreement for the additional treatment. The Physical Therapist has a professional obligation to discuss payment before providing these treatments. The Worker must understand that the costs of these treatments are to be paid personally, and that the WCB will not be responsible for reimbursement to either the Worker or the provider. The Worker must also understand that the WCB does not allow the Worker to pay privately for any additional treatment not authorized by the WCB while their claim is still active. The WCB requires that Workers with an active claim to comply fully with all treatment recommendations made to the WCB. Failure to do so could impact their claim. Any dispute regarding payment for any additional treatment after the claim is closed must be resolved privately between the Physical Therapist and the Worker. You may wish to consider having the Worker sign an additional payment agreement to ensure payment is secured for any treatments beyond those approved by the WCB. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 5 of 13

6 8. What if the Worker or third party has paid for treatment? i.e. the Worker or 3 rd party has paid for treatment and the claim is later accepted. If the WCB accepts the claim, the WCB will take responsibility for the full cost of services you provided to the Worker from the date of claim acceptance. You will be asked to reimburse the Worker or a third party all payments made and bill the WCB at the WCB contract rate applicable at the time that those services were provided. No other party shall be billed any amount for the Services rendered after the date of claim acceptance. COMMUNITY PHYSICAL THERAPY TREATMENT: 1. What is the maximum number of weeks allowed to provide treatment and how many treatments can I provide? The standard authorization period is up to six (6) consecutive calendar weeks. Services will consist of one initial assessment and up to a maximum of twenty-one (21) treatments. The first treatment can be provided on the date of assessment. Only one treatment per day can be provided. 2. How do I determine if a Worker qualifies for treatment under the Surgical/Fracture Protocols? Workers qualify for Surgical/Fracture treatment if: a) The surgical or fracture protocol is specifically listed in Appendix A of the contract Any other post-surgical or fracture conditions not meeting the conditions above should be treated under the standard treatment authorization. 3. Can the Surgeon write his protocol on a prescription? No, the WCB will only accept formal, typewritten protocols or specific instructions documented in the post-operative report. 4. What if the Surgeon has a protocol that is not listed in the contract? Send a copy to the Physical Therapy Consultant fax line for review at (780) HOW DO I CONTACT THE WCB CASE WORKER? Contact the WCB s Claims Contact Centre at: Identify which claim you are contacting them about and ask for a note to be placed on the Worker s file with the following information: your name and clinic the issue you are calling about your recommendations and/or course of action the urgency of a response back a request for the Case Worker to call back, and the best time to call back when you are available HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 6 of 13

7 Do not call, fax, or the Case Worker directly as there is no back-up to ensure messages will be responded to if the Case Worker is away, on vacation, etc. TREATMENT ISSUES: 1. How do I deal with Workers with poor attendance? It is important to record all cancellations, no shows, or absences on the reporting form. You must notify the Case Worker immediately by leaving a note on the file as per the above protocol if the Worker misses three appointments or earlier if there is a concern. Upon discussion with the Physical Therapist, the Case Worker will decide on an appropriate course of action. The WCB will not fund cancellations or no-shows. The WCB does not allow for extra treatments to be added to the treatment program to make up for missed appointments. 2. What should I do if I believe the Worker needs further medical investigation? If such a condition is identified, immediately contact the Case Worker and the referring Physician. If the medical condition contraindicates Physical Therapy treatment, the program will be discontinued and the Worker discharged; otherwise, treatment can be provided concurrently. 3. If a Worker is not responding to treatment as expected, what other avenues are available? Contact the Physical Therapy Consultant to discuss treatment or the Case Worker to request a referral for a Return to Work Assessment if the Worker is not progressing as expected or if you have identified other barriers for return to work. 4. Can I assign certain interventions to other clinical staff? You may assign tasks to support staff such as Exercise Therapists, Kinesiologists, etc. in accordance with the Practice Standards for Physical Therapists and any position statements or guidelines issued by the licensing authority. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 7 of 13

8 RETURN TO WORK: 1. If a Worker returns to work before the authorized treatment is completed, should I continue to treat? You should discuss the continuation of treatment with the Case Worker. The WCB s responsibility is to return the Worker back to pre-accident duties. The need for ongoing treatment after return to work depends on whether the Worker is at full duties, modified duties and/or the clinical status. 2. If a Worker has a sedentary job, but has a severe sprain (e.g. ankle) and he can do his job, is he/she still entitled to treatment? Yes, the Worker still needs support to perform work duties. 3. If I feel that treatment is complete but the doctor keeps sending the Worker back for additional treatment, what should I do? Clearly communicate this to the Case Worker and Worker s physician. The Case Worker may refer the Worker for a RTW assessment. 4. If the Worker is not progressing and the doctor keeps sending the Worker back for additional treatment, how do I get a second opinion? If you determine that further Physical Therapy treatment will not help the Worker get back to work, clearly communicate this to the Case Worker and Doctor. Request a referral to a Return to Work assessment centre. TRANSITIONAL RETURN TO WORK (TRTW) VISITS: 1. What is the purpose of the Transitional Return-to-Work visits? The purpose is to assist Workers during their return to work, whether in a modified or pre-accident capacity. You may provide two (2) Transitional Return-to-Work visits within three (3) consecutive calendar weeks of discharge without additional authorization. 2. What should I do during TRTW visits? The intent of the visit is to coach, problem solve, and review the return-to-work plan, not to provide additional treatment. 3. What do I do prior to communicating the TRTW visits? Submit a Discharge report including your recommendation for two (2) transitional return-to-work visits. Phone the Case Worker to discuss, if appropriate. Submit the Additional Treatment Invoice upon completion of the Transitional Returnto-Work visits. EXTENSION REQUESTS: 1. How should I submit an extension request? Extension requests must be sent on a completed Physical Therapy Status report. Click 'Yes' to the question 'Is this a request for extension of treatment?' and your request will be sent directly to a Physical Therapy Consultant. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 8 of 13

9 2. When should I submit an Extension request? Submit your request at least 3 Business days (no more than 5) prior to the last date of authorized services. The Physical Therapy Consultant will make best effort to respond by fax within 3 business days. 3a) What if I know at 3 weeks that an extension will be required? You may indicate this in your report; however, wait until the last week of treatment. This way the Physical Therapy Consultant will have the most up-to-date status on the Worker 3b) Can we ask the Case Manager for a decision on an extension? No, only the WCB Physical Therapy Consultant has authority to approve an extension. No approvals obtained from any other person shall be binding on the WCB. 4. If the surgical protocol is 16 weeks and only three weeks have been authorized, do we fax our Status Report to the WCB Physical Therapy Consultant? No, if the protocol is identified in the contract, request the proper authorization from the Case Worker. 5. Under what circumstances is the extension likely to be granted? Extension of Physical Therapy treatment may be considered where the Worker presents with examples of the following injuries and there is evidence that the Worker is making measurable objective improvement with treatment: a) CRPS; b) Co-morbidities; c) Fractures; d) Partial, non-surgical rotator cuff tears; e) Low back pain with radicular symptoms, non-surgical, with or without neurological deficits; f) Severe sprains requiring either casting, air cast, or bracing; g) Non-surgical grade II/III ligament tears requiring either casting or bracing; h) Multiple diagnosis, defined as follows: i) Involves two or more separate body parts (e.g. separate limbs); ii) Involves two or more separate diagnoses which cannot be treated at the same time (e.g. upper extremity crush iii) i) Motor vehicle accident injuries; and j) Other exceptional injuries injury); and Where a Worker has more than one WCB claim, they shall be treated and funded as separate claims; Extensions will normally be approved if the Worker is making measurable objective improvement with treatment, has a return to work plan in place, and will likely achieve a successful return to work outcome with an additional period of treatment. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 9 of 13

10 6. Under what circumstances is the extension likely to be denied? Requests will normally not be granted if the Worker: a) has returned to pre-accident job duties; b) initially sustained a no time loss injury that regressed to a time loss injury; c) has demonstrated no measurable objective signs of improvement with Physical Therapy; d) sustained soft tissue injuries and either did not return to work or has no definite return to work date in place; e) has conflicting diagnoses; f) requires a referral for a RTW assessment; g) has a history of poor attendance or non-compliance. REQUESTS FOR EXTRA BILLING: 1. When a Worker has two or more body parts injured, can I bill for two visits per day? All requests for multiple body parts or extra treatment time/duration must be faxed to the WCB Physical Therapy Consultant at (780) on the date of assessment and include the assessment and cover sheet with rationale and time frame requested. Authorization for double billing will not be given once treatment has commenced. Requests will be reviewed on a case-by-case basis. 2. If I assess multiple body parts on the same day, can I bill for two assessments? No, only one assessment will be paid by the WCB 3. Under what circumstances will the request be considered? Requests will normally be considered when it is not reasonable to manage all injuries in alternate or daily treatment sessions. Requests will not be considered for Workers with soft tissue injuries and nonspecific pain involving multiple body parts. REPORTING REQUIREMENTS 1. When do I have to file my reports? Physical Therapy Assessment Report to be submitted within 2 business days of the initial assessment. Physical Therapy Status Report to be submitted at the end of the third week of treatment and at 4 week intervals for surgical/fracture protocols. Physical Therapy Discharge Report to be submitted within 2 business days of discharge from treatment. 1 1 A specific stand-alone Discharge Report is not available. Instead a Discharge Report is generated from a Status Report by clicking Treatment Complete in Section 5. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 10 of 13

11 2. What should I include in my reports? Provide detailed reports with functional status. For example, a Worker may be fully functional without having perfect range of motion. Objective measurements are fine but function is critical. Clear reporting on objective measures Specific information on the use of walking aids 2 Progression of treatment program Functional tolerances for walking, sitting, standing, lifting, carrying, etc. PAYMENT: 1. What is the turnaround time on payments for invoices and sundry items? Provided you have obtained proper authorization and the invoices are complete, you should get paid within 30 days. 2. Can I prescribe and provide orthotics? No, you are not authorized to provide orthotics. The WCB has contracted providers to provide this service. The WCB will not pay for orthotics provided by nonauthorized providers. If you determine orthotics are needed as a result of the compensable injury, contact the Case Worker for a referral to a WCB-authorized prosthetics or orthotics provider. 3. Can I charge additionally for acupuncture? Not when acupuncture is performed within a physical therapy treatment. It is considered a modality, whether performed by you or an acupuncturist in your clinic. To be paid separately for acupuncture, you must be a WCB authorized Acupuncturist and can perform only stand-alone acupuncture that is not concurrent with physical therapy treatment. 4. Can I charge additionally for IMS? No, it is considered a physical therapy modality and is paid at the same physical therapy treatment rate. 5. If I am doing iontophoresis, can I be paid extra for the electrodes? No, it is considered a physical therapy modality and is paid at the same physical therapy treatment rate. 6. Can a Worker pay for massage therapy on their own? The WCB does not fund massage therapy as a stand-alone treatment. If a Worker wants massage, it should be made absolutely clear that WCB will not cover the cost of massage and will not reimburse the Worker. (With this full knowledge, the Worker may be billed for massage therapy.) If massage is recommended as part of the physical therapy treatment, then it is considered a modality and cannot be billed to the Worker. Massage that is provided by a Physical Therapist as part of, or in conjunction with, a physical therapy treatment, is billed as a regular treatment. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 11 of 13

12 7. If I forget to bill for some services, how long do I have to submit an invoice? The WCB may deny payment of an invoice where the Contractor has not billed the WCB within one year of the Service being provided. REVERSAL OF A WCB CLAIMS DECISION 1. If I am treating an individual whose WCB claim was initially denied and then accepted, how is the billing handled? The WCB is solely responsible for the payment of all assessments and treatments which it determines were necessary as a result of a compensable injury. That responsibility may not be determined until after Services are provided due to delays in reporting claims to the WCB, adjudicating claims and the appeal process. In the event that the WCB or an appeal decision determines that PT Services provided to an individual were the WCB s responsibility, the WCB will reimburse the payer once written confirmation from the Contractor of the fees charged to the payer is obtained. 2. What if the WCB initially accepted a claim and then denied it? The WCB will only pay for treatments you provided prior to receiving notice that the claim has now been denied. PERFORMANCE METRICS AND EXPECTATIONS What is the TD01 measure? Return to work and duration of claims are key metrics measured by the WCB to indicate the success of health care and disability management strategies. Specifically, the WCB uses the TD01 Status as a measure for return to work. TD01 is a wage replacement benefit paid to Workers who are totally disabled from all forms of work. Workers who return to work either in a modified or full capacity should not receive TD01 benefits. Workers who are unable to return to their preaccident work but are deemed Fit to Work at a full or modified level may be eligible to receive vocational benefits and should not receive TD01 benefits. How is the TD01 rate calculated? The TD01 rate is measured using the WCB Total Temporary Disability benefit status on the 7 th day after the last paid treatment date of an episode of treatment. Workers who are not receiving TD01 benefits on the 7 th day after the last paid day of treatment are considered off of TD01 and are considered a success in the TD01 rate. How is the overall rate calculated? The overall TD01 is calculated for all time loss claims that have a completed episode of Physical Therapy treatment. Claims that are excluded are denied claims. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 12 of 13

13 PERFORMANCE EXPECTATIONS What are my performance expectations? Your performance is measured on whether or not a Worker has stopped receiving TD01 benefits from the WCB no more than 7 days post discharge from Services with a minimum acceptable benchmark standard of 65%. Should your performance statistics fall below the standards outlined for two or more consecutive reporting periods, the WCB will take into consideration the adjusted TD01 rate prior to determining if you will be required to participate in quality improvement initiatives including service evaluation, action planning and follow-up. Failure to comply with recommended quality improvement activities or failure to achieve acceptable benchmark standards may result in contract termination. HC-429 REV FEB 2011 Copyright 2009 at WCB Health Care Services Page 13 of 13