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  • Delisted: Make Sure it Doesn’t Happen to You

    May 24, 2018

    Fiona Campbell, Senior Physiotherapist Advisor

    Guest Blogger: Fiona Campbell, Senior Physiotherapy Advisor 

    What is Delisting Anyways?

    Recently, a few PTs have called me shocked and embarrassed after discovering they’d been delisted by one, or more, of the major insurance providers. 

    Delisting of a physiotherapist by an insurance provider means the costs for services from the PT are no longer covered. Patients may be left to cover their own treatment costs and may go elsewhere for care. In many cases neither the PT nor the patient are notified of the delisting—not a pleasant surprise when you’re expecting a reimbursement. 

    Why are insurance providers delisting health professionals?

    Fraud or abuse of benefits is big business, so it’s no surprise insurance companies have reacted by employing teams of investigators to gather data, conduct audits of health care facilities and use analytics to identify irregular billing patterns and potential fraud. 
    Fraud is an intentional deception that can result in unauthorized benefit. For example, submitting claims for services never given, falsifying claims or patient records, and frequency or description of services rendered. 

    Abuse, on the other hand, is defined as actions that are improper, inappropriate, outside of acceptable standards, or clinically unnecessary. Common examples of abuse include bad billing practices, failure to maintain accurate records and a pattern of claims for services not medically necessary. 

    I spoke with representatives from the insurance industry and they said audits that show evidence of the above examples, or a discipline history may trigger their decision to delist a PT. Audits of health facilities are increasing so there’s a good chance that if you’re working in, or own a private practice, you have or soon will participate in an audit. New grads or anyone new to physiotherapy should be careful when looking for work as there are some employers who make it difficult to follow the rules. Don’t get caught in someone else’s poor business practices and end up paying the price. Even if you change employers, there’s a chance you will remain delisted. 

    While the College has no power over insurance agencies and their decisions, we can increase your awareness. So, are you at risk of being delisted? 

    Ask yourself these eight questions:

    1. Do I document in each patient file a correct physiotherapy diagnosis based on subjective and objective measures?
    2. Do I develop and document a clear treatment plan?
    3. Do I use outcome measures to support my rationale for treatment?
    4. Do I document the dates a patient attended and the name of the person who provided the treatment?
    5. Am I really supervising the care being delivered by PTAs or are they practicing independently?
    6. Do I routinely check and document the accuracy of billing using my name and registration number?
    7. Do I have an agreement with my employer as to the appropriate use of my name and registration number for billing purposes?
    8. If I stop working at a clinic, do I have an agreement that no further invoices/claims will be made with my license after my date of departure?

    Don’t get delisted. Follow the rules and standards, provide safe, effective patient care and routinely check the accuracy of billing done using your billing number. 

    If you have questions, please get in touch with the Practice Advisor team at 647-484-8800. It’s free and anonymous and our job is to help you get the information and answers you need. 

    Fees, Billing and Accounts Standard

    Questions? Contact the Practice Advisor

    A blog by Fiona Campbell, Senior Physiotherapy Advisor at the College of Physiotherapists of Ontario, explaining how and when a physiotherapist may be delisted by an insurance company.
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