As a Physical Therapy Clinic Owner, Why Should I Care About Compliance?

Introduction

The laws and regulations around compliance, while challenging to deal with at times, are designed to ensure thorough and high-quality patient care and encourage communication between clinicians. This post aims to help you understand the myriad of ways compliance extends beyond the legal bounds and make adhering to compliance guidelines as easy and beneficial for your physical therapy practice as possible! 

Most physical therapy clinic owners, staff, and therapists understand that maintaining a legally abiding practice is paramount to avoid lawsuits and expensive audits and protect the viability of your practice. However, owners often overlook how compliance benefits employee engagement, patient outcomes, and the financial health of their practice. Let’s look at all the reasons you should care about compliance. 

Legal

The reigning regulations that dictate compliance are HIPAA and HITECH, as they require the security of protected health information. Specifically, HIPAA was designed to protect a patient’s sensitive health information from being disclosed without their consent. Under this law, any healthcare entity must have documented policies and procedures for how your practice handles PHI, and these policies and procedures must be outlined, accessible, understood, and implemented by clinicians and staff.

The HITECH Act was signed into law for two major reasons. The first is to tighten up some loopholes of HIPAA, and the second is to encourage the adoption of health information technology (specifically EMRs) to improve security protections of patient health information. It is important to note that both HIPAA and HITECH are laws, and if patients feel their rights have been violated or a practice is found to be non-compliant, they could face a lawsuit or hefty fine. 

In addition to HIPAA and HITECH, there are other laws and regulations you should be aware of as a business owner. Make yourself familiar with The Fair Labor Standards Act, the Civil Rights Act, the Age Discrimination in Employment Act, and the Americans with Disabilities Act. These laws determine how you hire, employ, provide benefits, and pay your employees and should be considered a vital part of remaining compliant.

Documentation

While a huge component of compliance is legal, it is also a fantastic way to maintain high employee standards. Ensuring compliant documentation is a must. When therapists are trained to write high-quality documentation, they become more efficient and effective in writing those notes. 

Many clinic owners and therapists are shocked to learn that over-documenting is a common issue in the physical therapy industry. Therapists intuitively feel that the more information they put in a note, the better when this is not true. In fact, by including too much information in the patient chart, therapists can inadvertently negatively impact the justification for continued skilled care. A note should be concise and address functional deficits (those that are a medical necessity), while over-documenting typically targets minimally skilled or redundant information. Additionally, having too much information in the patient chart creates more opportunities for error and can make a note less compliant. When therapists can consistently write compliant, succinct documentation, they spend less time on their documentation, more time with patients, and don't have to take charts home in the evenings and over the weekends. 

Clinical Practices and Patient Care

Compliant documentation is vital for legal reasons and time savings. It can also provide incredible insight into how a therapist treats a patient over an episode of care and patient outcomes. Understanding the variability of care amongst therapists allows for an in-depth look into why patients are or are not completing an episode of care, whether they are improving or declining, and how well a plan of care is being followed. Having compliant documentation makes for the most accurate data to track these trends and provides massive learning opportunities for therapists where they may be struggling to prove value to patients. Ultimately, these learnings lead to better patient care, outcomes, and retention.

Here's a good example: viewing data like the median number of visits per episode of care by ICD-10 code can help you understand how therapists are treating various diagnoses and can even help you direct your continuing education budget for diagnoses where the number of visits seems insufficient for a normal plan of care. 

Similarly, data like this "drop off" chart (number of visits per episode of care) can be helpful in monitoring when patients only stay for 1-3 visits. 

Financial Health

As a clinic owner, you should care about compliance because it can impact your bottom line. The cost of being non-compliant far exceeds the cost of maintaining compliance. Aside from lawsuits and fines for nonadherence to rules and regulations, lengthy audits that unearth poor compliance are very expensive and time-consuming (and your staff’s time is worth money!). 

Conversely, achieving and maintaining compliance carries a small cost but saves time, energy, and money. In addition, having high-quality, compliant documentation at your clinic can actually help increase revenue. Documentation is key to how your practice can code and, therefore, bill. Understanding where therapists are inaccurately coding and under-billing allows you to explain the nuances to your therapists and dramatically improve reimbursements. 

Three Cheers for Compliance!

As a physical therapy practice operator, you should really care about compliance! While maintaining processes and gathering all the information needed to let compliance work for you rather than against you sounds like a lot, PredictionHealth can help. Practice Intel uses AI to analyze every word in every sentence across 100% of therapists’ notes to generate dashboards and reports from structured and unstructured data. Sidekick, our AI documentation assistant, turns patient conversations into compliant SOAP notes and documentation and offers real-time CPT coding feedback. Ensure compliance, drive revenue, and improve clinical practices—now that’s a compliance win!