The College of Physiotherapists of Alberta often receives questions about fees and billing from patients, third-party payers, physiotherapists and physiotherapy business owners. This article will address some of the frequently asked questions, with the aim of providing physiotherapists and others with guidance when establishing their fees and billing practices.
Does the College of Physiotherapists of Alberta have a set of fee guidelines or a fee schedule that physiotherapists must follow? If not, how are fees set?
The answer is NO, the College of Physiotherapists of Alberta does not have a fee guideline for physiotherapy services.
The last such schedule was published in 2009 by the Alberta Physiotherapy Association. In accordance with the Health Professions Act, the College of Physiotherapists of Alberta does not have the legislative authority to provide guidelines for professional fees. As such, Council has stated that physiotherapists need to establish their fees based on their business model, services offered, and market forces.
Given that operational costs, demand and competition can vary widely depending on the location or type of practice, the fees charged can vary considerably from clinic to clinic. Understanding the marketplace where services are being provided should also guide fee decisions. Patients and payers often call to question a fee that appears to vary greatly from other clinics providing similar services in the area. The Fees and Billing Standard of Practice1 requires that fees charged be justifiable. In other words, a physiotherapist must be able to explain why they charge what they do.
How should physiotherapists or physiotherapy business owners communicate their fees for services?
Every physiotherapist or physiotherapy practice must establish and make available a fee schedule of their own that includes all the fees a patient may be subject to (i.e., fees for assessment, treatment, chart copies, reports, interest charges, cancellation fees, etc.). The Fees and Billing Standard1 requires that clients be made aware of any fees that may apply before they incur them. The fee schedule should be publicly posted, either in your clinic or on your website, or communicated at the time of booking.
How are fees for chart copies set?
A fee often forgotten is the fee charged for providing chart copies to the patient or third parties such as lawyers. The Personal Information Protection Act (PIPA)2 permits professionals to charge “an applicant who makes a request (for chart copies) a reasonable fee for access to the applicant’s personal information or for information about the use or disclosure of the applicant’s personal information.”
The operative word is reasonable. Patients have a right to access their own information and should not face financial barriers to do so. The fee charged is intended to cover the costs related to collecting, compiling and producing the chart copy. It is not intended to be a profit generator. An estimate of the costs must be provided to the requester in writing before providing the service and a deposit may be requested prior to initiating the process.
Although PIPA does not establish explicit fees for chart copies, the Health Information Act Regulations (HIA)3 does have a set of fee guidelines that can be used as a starting point when setting individual clinic fees for chart copies. The allowable fees for chart copies under the HIA are $25 plus 0.25 for every page beyond first 20 pages for provision of paper copies. Notably, chart copies related to Diagnostic and Treatment Protocols (DTPR) cases are governed by the HIA and these fees apply to patient records related to the DTPR program. Review the HIA Regulations for more details on allowable charges.
Are there situations when there are prescribed fees?
When a clinic signs a contract with Alberta Health Services or WCB or provides treatment under the DTPR, they are subject to fees established under the relevant contract or legislation. These fees are often lower than what a clinic charges for non-contracted assessments and treatments.
Can a clinic offer discounts for different populations?
A clinic owner or practitioner must develop and adhere to a fee schedule. If the clinic wishes to offer a specific population or group a discounted fee, the discount must be clearly identified on the fee schedule for all to see. There must be clearly defined inclusion criteria and these criteria must be consistently applied to any individual who fits the definition. Examples where this might apply are:
- Seniors (a defined age must be identified and applied)
- Members of the military or emergency services
- Members of a local sports team
The point being that everyone who fits within that defined group will be able to identify that they qualify for the discount. A second effect is that other groups may question why there isn’t a similar discount for them. If you plan to offer a discount you need to keep in mind that the Advertising Standard of Practice prohibits incentives and inducements including time limited pricing, meaning that a discount offered may not be tied to a specified time period.
Can a clinic set a fee for a group of services?
At times it may make sense to offer an intervention as a series or bundle of treatments. An example would be a set of exercise classes aimed at managing low back pain. When setting fees for a group of services, the clinic owner must ensure that they meet all the expectations of the Fees and Billing Standard. The fee must be reasonable and justifiable and must be fully transparent to the client.
You may be tempted to offer a pre-payment plan for these programs. The College of Physiotherapists of Alberta recommends owners carefully consider the consequences before doing so. The fee schedule must clearly define when a refund could be requested, how the amount would be determined, and how it would be refunded. The receipt for services provided must identify the dates the interventions occurred and would be provided at the conclusion of the episode or program of care. Physiotherapists considering these types of plans need to consider the risks of insurance fraud and take measures to mitigate against this risk.
Can physiotherapists bill for acupuncture?
Physiotherapists provide physiotherapy. Although some physiotherapists are trained in the use of acupuncture, when a physiotherapist uses acupuncture they do so as a component of a comprehensive physiotherapy treatment, not as a stand-alone intervention. Physiotherapists are expected to bill this type of treatment as “physiotherapy services.”
When extended health benefits programs have funds set aside for both physiotherapy and acupuncture, they typically include a statement requiring that acupuncture benefits be reimbursed only when a registered acupuncturist is providing the treatment and that physiotherapy services be reimbursed only when provided by registered physiotherapists. Third party payers typically check the registration status of the clinicians accessing these funds.
The expectation that the patient receives a “clear, transparent, accurate, and comprehensive invoice/receipt” requires that the physiotherapist should indicate “physiotherapy using acupuncture or dry needling” rather than simply “acupuncture” on the receipt. Again, the physiotherapist is authorized to use needles within the context of a larger physiotherapy plan and approach to care, not as a stand-alone modality. Physiotherapists cannot switch to billing for acupuncture to assist a patient access further benefits when their available physiotherapy benefits have been used up.
The College of Physiotherapists of Alberta regularly receives calls from patients who have had their claims denied as the service was not provided by an acupuncturist. The lack of transparency can be frustrating for the patient.
How to avoid Billing Conflicts
Conflicts can arise with 3rd party payers and patients. Billing conflicts can results in frustrated patients, conduct allegations or even delisting physiotherapists or entire clinics from insurers. Physiotherapists can be audited, and can be delisted if your billing practices are questionable or determined to be fraudulent. Insurers do audit and monitor billing practices and will ask questions of providers related to the accuracy and appropriateness of care being provided and of bills submitted. If a pattern of unexplained, excessive or inappropriate billing is uncovered, the insurer has the right to decline to pay for services delivered by a physiotherapist or by an entire clinic. If an individual provider or a clinic is delisted by an insurer, any bills submitted by the clinic or patient will be declined. This leads to very angry patients as they will be required to pay for their physiotherapy services out of pocket.
Insurance providers have also at times delisted specific services (such as the prescribing or dispensing of orthotics) provided by specific providers when the value of those services has not been clear relative to the cost to the third-party payer. It is important that physiotherapists providing these services are aware of individual insurers expectations and ensure only allowable services are claimed.
Physiotherapists should also be aware of the value proposition for services and make efforts to clearly communicate the benefit of their services on patient outcomes and quality of life.
Physiotherapists can avoid billing conflicts by:
- Maintaining clear, transparent, fair and ethical business and billing practices.
- Ensuring that only authorized services are provided to a patient who will be making a claim to an insurance provider.
- Protecting your registration number! (It’s not a billing number). Watch to make sure bills submitted under your registration number are accurate. Ensure you have access to any billing submitted on your behalf. This is you and your reputation at stake. You are responsible for all billing done under your registration number.
What about billing for non-traditional services?
More physiotherapy services are being offered using different practice models such as telerehabilitation. Physiotherapists are also providing services in a variety of clinic settings such as Pilates studios, gyms or wellness clinics. The College of Physiotherapists of Alberta often fields questions about whether the service can be billed as physiotherapy or not. Just because a service is provided by a physiotherapist, does not make it physiotherapy. Some examples would be offering Pilates or yoga classes. Using yoga as an exercise-based modality to address low back pain, as part of a comprehensive physiotherapy program of care would be physiotherapy, whereas offering a community yoga class would not be.
The practice of physiotherapy is broadly defined, but all physiotherapy services also have certain hallmarks:
- The patient presents with a problem.
- There is an assessment appropriate to investigate that problem
- The physiotherapist develops a treatment plan and goals to address the problem, in collaboration with the patient.
- Treatment is delivered.
- Patient response is monitored.
- Treatment is adjusted or discontinued depending on the patient’s response.
When a service does not include these components, it is not physiotherapy and should not be billed as such.
How do I bill for services provided by a Physiotherapist Assistant?
The College of Physiotherapists of Alberta’s Supervision Standard of Practice outlines multiple requirements that the supervisor must fulfill, including providing appropriate monitoring and reassessment of the patient condition and progress, communicating the role of supervisees, and obtaining consent for the supervisee’s involvement in the patient’s care. The College of Physiotherapists of Alberta’s perspective is that when appropriate supervision is provided and the requirements of both standards are met, the physiotherapist may bill care provided by a support worker or student as physiotherapy services.
If doing so, it is essential that the physiotherapist communicate this plan to the patient and obtain their consent. The College of Physiotherapists of Alberta often hears from patients concerned about services provided by a physiotherapy support worker and billed as physiotherapy and when this occurs, it quickly becomes clear that the patient did not understand and agree to this approach.
The practices you follow when setting fees and establishing billing practices for services is important to you, your clinic and the reputation of the profession. To avoid angry patients, formal complaints or problems with third-party payers, make sure you set reasonable fees and that you can justify the fee if/when you are asked. Fairly apply fees to all your patients, do not make “exceptions” to the rules for those special individuals. Ensure you review and understand the Fees and Billing Standard and are in compliance with the expectations contained in the standards. .
- Physiotherapy Alberta College + Association. Standards of Practice: Fees & Billing. Available at https://www.physiotherapyalberta.ca/files/practice_standard_fees_and_billing.pdf
- Government of Alberta. Personal Information Protection Act. Available at http://www.qp.alberta.ca/documents/Acts/P06P5.pdf
- Government of Alberta. Health Information Act Regulations. Available at http://www.qp.alberta.ca/documents/Regs/2001_070.pdf