Compliance within the physical therapy industry is a beast in its own right. Whether you are a one-physical-therapist-stop-shop or practice within a larger physical therapy group, these five tips to increasing compliance will help you keep up with the constantly changing landscape.


  • Set Realistic and Transparent Expectations

The first step to increasing compliance is to be sure that you and your team are 100% clear on what the industry standards are including all local, state and federal regulations which impact PT compliance and how you are going to achieve them. Annual training for compliance should always include a focus on HIPAA and HITECH requirements. Reference materials should be readily available specific to your practice, outlining all operational procedures that therapists need to perform in order to remain compliant. 


For example, when it come to protecting PHI (protected health information), your document might detail the following:


HIPAA provides rules for protecting personal health information held by covered entities. 

  • Passwords may NOT be shared with others
  • All patient identifying paperwork must be properly secured and locked at night  
  • Computers must password protected and properly logged off if you step away from your desk 
  • Specific operational front desk procedures such as an AM/PM checklist to ensure all electronic and paper PHI are properly maintained


Once you have customized a policy and procedures document, you must share it with your team! Hold a team meeting to review the document you created and why it is imperative the procedures are followed. Discuss implications if procedures are not followed, but also how the procedures will create a secure and efficient environment within the facility.  Consider making the meeting fun by hosting lunch one day or a Friday happy hour so therapists feel excited and open to some potentially new changes and document those in attendance. Emphasize the purpose for the procedures and where the reference material will be located.  Generally, if procedures and the why are clear, people are happy to jump onboard. 


And keep it going….


Don’t forget to require annual compliance training for all of staff members. This allows for a routine process to update any regulatory changes and to ensure that everyone is knowledgeable of those updates. Concurrently, review your policy and procedures each year to account for operational and modifications that impact your practice. 


The best way to empower licensed skilled physical therapists is by demonstrating the value of life-long learning. State licensure renewals are different throughout the country (and legally required to complete in order to treat patients), but complying with CEU requirements don’t have to be painful. Assisting with the cost or even hosting courses in-house are a great way to encourage your team to select relevant and meaningful courses.  


  • Assign a Compliance Officer


Having a go-to individual to answer all of your compliance questions is not only a good idea, but part of the US Sentencing Guidelines and enforced by the Office of Inspector Generals’ (OIG) for implementation of a compliance program. One can assign a staff member or hire an expert to help support the complicated details necessary. The designated compliance officer is required to perform risk assessments, HIPAA breach investigations and reporting, quality assurance and auditing functions and a knowledgeable individual who understands the therapy profession and your practice setting. 

  • Audit Charts on a Regular Basis


No therapist enjoys documenting, period! Reviewing documentation is even worse as PT’s want to treat patients and provide skilled and medically necessary therapy services. Documenting is often learned outside of traditional educational DPT programs, which creates a challenge for what the standards should include in each note. A knowledgeable compliance officer will be able to assist with the guidelines and standards, but who should perform the routine chart reviews?


Internal auditing and quality assurance are also part of the US Sentencing Guidelines compliance program which can demonstrate more than just “an ounce of prevention is worth a pound of cure”. Fines, penalties and enforcement of non-compliance are greater reduced if one can demonstrate that a compliance program includes a meaningful auditing system for documentation. This can be completed with staff members reviewing charts, hiring certified healthcare auditors to randomly select a sample or use an AI Compliance tool.   


Transparency and bias are the primary variables between the listed options above. Employed staff typically view themselves favorable when critiquing each other. Vendors are limited by sample size and bandwidth, but industry leading AI documentation audits created just for PT’s is a game changer.    


PredictionHealth’s AI Compliance tool can help reduce the cost, expand the scope and dramatically improve in real-time the knowledge for documentation standards for each therapist. Making operational decisions based on a review of only a handful of charts is now history. AI-automated compliance checks ensure that 100% of charts are being audited. Never has this level of insight, data analytics and educational power been available for PT’s. 


  • Create a Positive Compliance Culture


When most of us think about compliance, we generate mental images of loads of paperwork and being severely disciplined for an innocent mishap. But it doesn’t have to be this way! Consciously create a culture that empowers therapists to make quality decisions while adhering  to all operational procedures. If you work on a larger team, it might be fun to implement a ‘Compliance Star’ during the annual compliance and ethics week (November 7-13, 2021) who is recognized for their good practices and wins a small prize. Compliance can be fun! 


  • Utilize Technology to Streamline the Workflow


We are so fortunate to live in an age with incredible advances in technology. There are many software packages that help with patient adherence with HEP’s, billing and coding issues, templates and more. PredictionHealth offers the first of its kind AI Documentation and Compliance tools to enhance the consistent quality of documentation by each therapist, every time. Integrating technology into the clinical workflow saves all staff members valuable time, headaches and preventable audits which can improve the overall patient experience! .  


Embracing these five tips to increase compliance can do more than just help you meet your KPI’s, benchmarks and other metrics; but also helps your business and profession grow. We all need every advantage possible in the current healthcare environment, so now is the time to prepare for 2022.  Happy planning!

Topics: Product, Technology, Physical Therapists

Daniel Hirsch, DPT

Daniel Hirsch, DPT

Stay up to date on the latest from PredictionHealth

Leave your comments