Compliance - a word that makes most cringe. While most clinicians have a general dislike of the word compliance, it is absolutely necessary to have a vital, organized, and legally abiding practice. 


Of course, compliance is crucial in all aspects of healthcare, but physical therapists have their own set of requirements and challenges when it comes to remaining compliant. This fact, along with the ever changing regulatory landscape, makes the process for ensuring a physical therapy practice remains compliant practically a nightmare for all staff members. But fear not! We’ve put together a list of the most current compliance issues in physical therapy and some of the greatest tools and processes out there to help you tackle the world of compliance head on. 


Protecting Patient Records (PHI)


Securing protected records should be simple, but since the majority of therapists are not information technology experts, we rely on others who are to ensure all HITECH and HIPAA privacy and security rules are being maintained. Below, we outline the must-do checklist to meet the requirements of protecting patient records.

  • Each therapist must have a unique login/password which is updated on a routine basis. Experts recommend changing passwords every 60 to 90 days as well as avoiding dictionary words. 
  • Practices must secure the IT equipment in a location that is not easily accessible to the public.
  • All patient email communications containing PHI must be encrypted.
  • Confirm fax numbers prior to routing the information out of your system.
  • Maintain a process for tracking and releasing authorized medical records.
  • All marketing materials and patient releases must not violate practice act standards.


Incomplete Documentation


A necessary evil; documentation. So how does one know what is required to be documented during different types of visits (evaluation, daily, progress notes, etc.) in therapy? How can one differentiate between nice to have vs. must have? Finally, since we all learned from someone during school, clinical affiliations and on-the-job training, consider if these educators influenced your documentation and where gaps and biases might exist. 


One should follow these steps in order to assess whether they are documenting correctly: 


1) Have a trusted source. Just like knowing where to look for post-op protocols or screening complex neurological patients with co-morbidities, you need to have a guide. This can include individual insurance company guidelines, Medicare benefit policy manual, the APTA, and each state’s practice act.


2) Internal references need to be well known. Where are the facility policies, procedures and manuals that can be used to reference company standards? Off-the-shelf products are frowned upon by enforcement agencies and should really be customized for your specific practice. At a minimum, revise and edit your reference materials on an annual basis.


3) Leverage technology. EMR systems offer excellent templates to get started for benchmarking basic documentation requirements. Internal controls and other functions can enhance the strength of these templates.


Liability Exposure 


Therapists have a reputation for being a generous group of professionals who are movement experts and work to improve the health of the general population. Even with the best of intentions, errors occur, accidents happen and mistakes are made during the career of a therapist. The best way to protect oneself is to assess all anticipated (and unforeseen) areas of exposure to that hard earned license. The following are prudent examples of what every therapist and company should consider:


  • Maintain company professional liability. Not all professional liability products are created equal. Shop this product around each year as premiums are recalculated annually. Avoid low rated carriers (not referring to social media ratings) since an insurance company’s credit rating indicates their solvency, financial strength, and ability to pay policyholder claims. 


  • Where is your cyber policy? One may think that cyber coverage is already included in another business policy, but please read the fine print. Attorney fees, ransom payment language and other valuable product limits vary widely, so take time to understand how comprehensive each product is written. The trend of large and small companies receiving cyber attacks is on the rise. 


  • Read your state practice act. Claiming to not know this information is not a defense. You have an obligation to understand your practice act which dictates what a licensed therapist is allowed and more importantly, not allowed, to do in the practice of treating patients. Supervision requirements, continued education credits, telehealth standards and other details which are all located in your state’s practice act should be clearly understood by each therapist in your practice. 


This brief compliance information is just scratching the surface of the beast that is compliance. However, many components of documentation, internal audit, and quality assurance standards can easily be delegated to PredictionHealth. The industry gold standard PT Practice Intel product offers documentation compliance, operational and financial optimization, and clinical practice excellence. Automatically analyze every note, reduce administrative chart review by hundreds of hours, and identify billing inefficiencies. Dashboard analytics allow for 100% transparency across therapists and clinics, offering simple to use but meaningful insights of how therapists are performing. PredictionHealth’s PT Practice Intel is a game changer for compliance and a product you as a therapist cannot afford to be without!


The material in this blog does not constitute the rendering of legal advice in any manner by the author or company. This blog shall only be interpreted as general information in nature and not contractually binding professional advice.


For more on compliance in the Physical Therapy industry and new solutions to help your therapists, clinic, and patients thrive, check out our webinar here!

Daniel Hirsch, PT, DPT, CHA, OHCC, COCAS

Daniel Hirsch, PT, DPT, CHA, OHCC, COCAS

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