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Toni Talks about PT Today

You Can't Discharge Her, the Family Will Complain

Published March 19, 2014 4:08 PM by Toni Patt

We've all had patients we've kept on caseload longer than necessary. Sometimes it's just one more day until discharge. I've occasionally kept patients on caseload because they wouldn't get out of bed unless I did it. When I worked in the ICU, I'd keep patients because I thought they were waking up.

I can't say I've ever kept someone on caseload because the family demanded it. I have of one those right now. The patient and her husband have learned the louder they complain, the more a facility will acquiesce to their demands. At least it's understandable when a family wants to continue therapy because they're convinced the loved one will get better. This couple simply likes being in control.

Yes, getting out of bed is therapeutic. She gets up twice daily with a sling lift, which nursing can do without us and therefore is not a skilled service. She refuses to exercise and will never ambulate due to orthopedic problems. A slide board is out of the question due to sacral wounds. She's been doing this more than two weeks so orthostasis isn't a problem. Yet she's still on caseload and we are still charging for the service.

I brought this up with the other therapists. They have no problem with keeping her on caseload because the couple is difficult to deal with. Difficult to deal with or not, by keeping her on caseload we're charging for a skilled service that isn't skilled. And that's the problem. I don't care about getting her out of bed. I care that we're calling it a skilled service when it isn't.

One of the biggest complaints PTs have is being referred to as a lifting service. Nursing calls therapy to get up anyone who's somewhat difficult or overweight. The only skill required is body mechanics to prevent ourselves from getting injured in the process. We might complain but still get the patients up, thus becoming a lifting service.

Thus we come full circle. We're not providing a skilled service. She should not be on caseload. This doesn't mean therapy won't help with getting her up if needed. That both the patient and her husband complain loudly shouldn't enter into the equation.

I don't care if we've been doing it this long so what will a few more days matter. In theory we're providing skilled services, not simply lifting patients. In reality she'll remain on caseload because I need to pick my battles and won't win this one. What's disappointing is that my coworkers don't see anything wrong with the situation.

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2 comments

I agree with Mike. I know you've gotten burned, badly, in the past from raising issues at work, but if you really are billing for unskilled care, admin will point the finger at you if it comes up.

I think the risk management approach is best. It shows that your concern is reduction of risk for the organization as a whole.

Good luck with this one!

Dean Metz March 20, 2014 12:26 PM
Sunderland UK

Great post Toni.  We deal with this a good amount at my hospital as well.  Luckily our supervisor is very understanding of the ethical and legal ramifications of billing for unskilled and unnecessary services.  This may be an issue to talk about further with your staff and maybe even get supervisors or risk management involved.  As a worse case scenario, you can always paint the picture that you are intentionally billing for services that you know are unskilled and unwarranted.  That to me sounds like insurance fraud.  Apart from that being ethically wrong, the legal issues you could face could be even more damaging.  You are putting your license on the line and also opening up your facility and employer to further investigation about their practices.  Again, it's a worst case scenario, but sometimes bringing up the "L" word (legal) scares some people into doing what is actually right.

Mike Kelley March 19, 2014 10:24 PM

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