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What is your full name and title?
When did you graduate from PT school, and from where?
I graduated from University of Utah in 2006
What did you do when you first graduated?
Initially, I worked in a therapist-owned private practice. I stayed there for five years, at which time I was approached by friends from PT school regarding an opportunity.
One of my PT school classmates had a family-owned clinic with his father, and another had started working there with him. The owner (my classmate’s father) wound up going on a service mission and was out of clinic for a few years, and my friends recruited me to work with them.
I happily joined that outpatient orthopedic clinic, which also saw a fair amount of workers’ compensation on-location.
This role I held was at a smaller company still trying to spread wings. I thought there would be lots of growth potential, but when the owner came back from his mission two years later, he wanted his job back, so I was let go.
That’s so frustrating! What did you do when you were let go from that job?
I spent a few months not working. I thought about starting my own PT clinic, but since I had three young children, I didn’t want to make my wife work full-time while I built my caseload, or leave my family without medical benefits.
Just a note, though…earlier, while I was still working with the first clinic after PT school, I had been elected as the Component Reimbursement Chair for the Utah Physical Therapy Association Board.
I ended up serving two full terms of two years. I believe that this experience helped me immensely in my future endeavors.
Before we get to your next job, what was involved in your role as Component Reimbursement Chair?
I served as the go-to between for Utah Physical Therapy Association members and the APTA regarding all things related to reimbursement.
- I prepared local reimbursement conferences for our annual UPTA meetings.
- I attended board meetings and completed additional assignments as given.
- I attended the yearly APTA Payment and Legislation Meetings.
At these APTA conferences, all of the Component Legislation Chairs are flown out to meet on a national level. The APTA does an excellent job of providing three days of content to help keep all states on the same page and get people involved in certain movements.
I would highly recommend it to anyone to run for their board!
What made you decide to run for a board position?
In Utah, we get ballot requests from our state association every year. Most positions only had one person volunteer to be on the ballot. I just kind of felt it was my duty to put myself out there.
I also had a supervisor where I was working who said it was dumb idea to run, because he had tried it any never got elected. I thought that was a silly reason not to run, and I figured why not volunteer my name.
I ended up on the ballot against one other person and I won.
This all happened during the time while I was still at that first job I held right out of PT school! I had been out of PT school only 4 years.
What did people think of a newish grad volunteering himself for this type of role?
As I said previously, one of my supervisors thought it was a dumb idea. However, after I won, the owner of the company was very positive about it. I was able to learn a lot of information that I could pass down first-hand to that company. So it certainly helped them.
Most others were supportive, too. Very few people volunteer for these roles, so those on the board are very grateful for those of us who step up!
It sounded like a good opportunity, and I’m glad I went for it. I held that position for four years (the maximum amount of time allowed per bylaws), and feel it is part of what helped me get my current job as a physical therapy reviewer.
So, getting back to what you did next. What happened when you were laid off?
After being laid off, I was considering two different jobs, but I went with one that was all workers’ comp, as I was used to that and the owner had indicated that he was looking for therapists to help join him and grow things.
The clinic was right near an occupational medicine doctor’s office. The role involved doing pre-employment screens, post-offer screens, etc., and sounded like it had growth potential. It also had better benefits.
Did you enjoy the workers’ comp role?
The population was varied. We got to work with people from all over. Many patients were refugees working in location plants.
We would get super busy during construction/summer season, as well as during hiring sprees.
I enjoyed it at first, but I did start to realize that things were heavily dependent on aides, who were doing all the screens. Some things started to look a bit unethical.
By this time, it was my second term on the board and I had learned a great deal about payment and reimbursement. I really started to feel the situation I was in, was not what I had visioned upon hire; and it was not going to change.
How did you make the leap from patient care and into utilization management (UM)?
I had arranged a local reimbursement conference with third-party payers for our state meeting. One of the people who arranged to come out was from a company called CareCore.
This person was very nice and gave a great presentation that helped many of those that attended understand how CareCore worked.
After the presentation, I wound up speaking with the team from CareCore. We chatted about what utilization review(UR)/utilization management(UM) was, and what a physical therapy reviewer would do in his or her daily life.
I wound up taking one of their business cards and said I would love to reach out to them.
After a bit more time at my workers’ comp job, I started to realize that I didn’t see a future there. Talks with the owner were going nowhere, and the promises made before I started the role were clearly not going to happen.
Some of my previous concerns about billing, referral sources, and such were making more sense as well. It was becoming clear that the clinic was partially physician-owned (by the occupational medicine MD who sent all the referrals), which did not make me happy.
When I was interviewing, the owner had made a point to tell me that the company was PT-owned, and he just had a good friendship with the referring physician. Frankly, had he been more upfront when I was hired, it would have been a different situation; however, in this case, I felt I could not trust him or the business setup.
So, I decided to reach out to my contact at CareCore again regarding utilization management.
My timing was perfect; she said they were actually looking for PTs to do utilization management. The best part? The role was work from home!
She said if I was interested, we should talk. Of course, I was, and within a month, I’d accepted a job with them.
How long have you worked there?
I’ve been here for three years now.
What is your physical therapy reviewer role like?
I enjoy my job most of the time. Currently, there is plenty of work. Getting to see clinical notes and courses of care from all over the nation is very interesting.
My primary role is a physical therapy clinical reviewer. Basically, it involves looking over information that a provider (PT/PTA) sends for pre-authorization or retro-authorization, and then deciding if their request is approved in full, in part, or denied.
My primary day-to-day work is reviewing these requests.
What is the difference between utilization review/management and case reviewing?
Physical therapy case/chart review is part of the “umbrella” of utilization management/utilization review (UM/UR). The primary goal is that we help manage the care the health plan member (patient) receives through their benefits so that they get back to normal daily tasks.
We watch that they get appropriate care; but not too much or care that is outside of their benefit.
I currently work doing utilization management 30 hours a week. That leaves me some time to pursue other side jobs.
And what is the difference between utilization review(UR) and utilization management(UM)?
These terms can often be synonymous. But in general, utilization management is the umbrella term that all others are part of. Some of the terms that fall under that umbrella include:
- Case review
All of those terms refer to managing a member’s PT benefit. Really, the primary goal is to see that a member’s benefit is not abused, and that it is used appropriately when it is really needed.
Are there any misconceptions about utilization management that you’d like to clear up?
There is so much of physical therapy that is yet to be “proven,” meaning there are a lot of PT treatments being performed that are not supported by best evidence or practice patterns.
I will admit that we case reviewers can make the process harder for many.
However, there are many providers that do not understand what a person’s health benefit really is for, and they try very hard to provide care outside of the contract that a patient signed with a health plan.
This is a whole other topic though…
You had mentioned CareCore, but you said you work at eviCore. Did you switch companies?
No, but since I began this role, the company has merged or been purchased a few times. With each merging, it has brought more work, which pleases me because there’s lots of job security!
How big is your team? Are they hiring?
There were initially 10 therapists when I started, and now we’re up to nearly 40. There are a few openings for weekend work currently. Rumors are that more health plans are looking to expand utilization review, so we keep being told that we will grow.
What is a day in the life like for you as a physical therapy chart reviewer?
Here’s a peek at my day-to-day work:
- I’ll start my day by logging into the computer system.
- From there, I check email messages and our team board for announcements.
- I check for scheduled provider calls.
- I then start pulling up cases and reviewing the information provided to support continued PT.
- I’ll look at the info that a provider sends to see if significant functional progress is being made from the skilled care. We base our decisions very heavily on a patient’s functional presentation and if it progresses. This is the primary responsibility of the PT benefit, so that is what we look for.
- Based on the information I can either authorize a full request, part of a request, or deny additional care.
- Several times a week, I also get assigned peer calls. This involves calling a provider and trying to address their questions. Generally, this is about a reduction or denial of visits.
- I go through many appeal reviews as well. If a PT’s claim is denied, they can appeal for reconsideration.
Some health plans also assign their providers to tiers. We do some case review to look for treatment patterns and utilization to see if a certain provider should be allowed to move up a tier.
Do you do anything else in your role?
As I’ve stayed on at the company, I’ve been pulled into really interesting internal projects.
- I’ve worked to create ways to certify that we’re either approving or not approving cases, based on best standards.
- A colleague and I also created all the clinical practice guidelines for orthopedics. We had to look up best peer reviewed treatment practices per diagnosis and create guidelines that would be used to support the reviews that we do. These are our backbone, so all that we reviewed had to be high level research. Think JOSPT clinical practice guidelines, Cochrane Database, Systematic reviews, etc.
As I continue to grow in the company, I continue to add more interesting projects. I’ve gotten to do:
- Internal education
- Tier reviews
- Webinars for internal use
- Mentor of new reviewers
What are some of the challenges of your role?
I still always get butterflies in my stomach when I have to have a peer conversation.
Honestly, these calls usually go well, but I do need to maintain calm and poise, even when the therapist on the other end of the line gets very frustrated. At times, providers can be down right rude and nasty. This is the minority.
Primarily these calls are to discuss when a request decision doesn’t quite go the way the PT wants. More often than not, it comes down to lack of quality functional information from the provider.
Working from home can be lonely. We use an instant messaging app to communicate, so I definitely have the camaraderie of working on a team, but it’s an adjustment getting used to working at home when you’re used to working closely with people as a PT. Spending more time sitting at a desk is certainly an adjustment; however, being at home, you are free to stand up, walk around at times, or grab a snack.
You work for a large corporation. So there are company politics and decisions that are often made by those outside of PT management. Sometimes these decisions come from different places at the same time and cause conflicts.
Health plan regulations get complicated. We contract work to many health plans in several states. Each health plan and each state have different rules and regulations. Trying to keep it all straight can be very difficult at times.
Are there any particular requirements to do the job of physical therapy reviewer?
There are some requirements in that you need sufficient internet quality to do the work. You need space to work, and will have to supply your own desk setup.
The company I work for does not provide money for APTA membership, nor do they pay for state licensing.
We are also required to maintain an active physical therapy license.
Do you have quotas?
We don’t have set quotas or required numbers of cases to review per day at this point, but the company does track productivity to make sure we’re not slacking.
A set number of cases per day or week doesn’t really make sense; some cases are more complex than others, depending on the provider and how much info they send.
How are you paid? Is it hourly/salary, and are what’s the pay like compared to patient care?
We are all paid hourly. We are not paid per case, and there no incentives to deny care or approve care. Pay is generally similar to working in a clinic per hour. For employees that work full time, there are typical benefits as well.
How is utilization management run? Do you work for a specific clinic? Or do you work for a company?
As far as eviCore is concerned, we are a third party manager. So health plans contract with us to take care of their utilization management for various benefits.
We have contracts with plans from most every region of country. This includes:
- Commercial plans
- Medicaid plans
Most of these health plans started with management of other medical specialties, and then added PT/OT later.
Basically, on the provider end, a request is submitted for care that is to continue. A review is made based on information provided about previous care to that point.
Some health plans allow auto approvals for first and second requests so patients can get some visits to start care and begin to show progress. Other health plans want us reviewing from the very first request.
Each authorization is valid for a certain time period. Typically 30-60 days for ortho and some neuro, and up to 120 days for developmental pediatrics. Once the visits are used, if the provider wants more visits over a new time period, they need to send a new request. That is the general idea anyway.
What would you recommend for someone interested in becoming a PT case reviewer?
First and foremost, you need to be passionate about physical therapy care being used appropriately, ethically, and at times minimally. If you are one of those PTs who think the more visits the better, this likely is not the job for you.
You need to understand the true value of a patient using a home program and taking ownership of his or her own recovery.
- It’s also vital to understand the difference between physical therapy for medical need and physical therapy just to feel better.
- An understanding of current best practice and recommended guidelines is important.
- Also, this is a job where experience really does matter.
In what sense do you mean experience matters?
I mean that just having letters after your name from taking a test is not enough. If you have a specialty, that’s certainly helpful. But if you’ve got a wide breadth of experience, that’s also great…maybe even better.
We see all sorts of cases come across our desks, so if you’ve worked in ortho, neuro, pediatrics, aquatics, etc., it’s great to have that background.
The ability to be in situations of conflict and resolving those is also very helpful. Everyone on the team is expected to make phone calls to providers. Being able to help them understand what we do and how to make things go smoothly are needed.
What are three things you’d recommend for anyone considering a physical therapy reviewer career?
Talk with your office managers and find out who the big UM players are and which health plans they deal with.
Most PT have filled out a form to request additional care. Who is asking for those forms? Do you understand why? Have you checked their website if they are hiring?
Also, if you get the chance to have a peer call about one of you patients, don’t be afraid to ask the PT on the other end about their job!
Expand your horizons
What are you doing outside of the clinic to help better PT? It was through my service with the UPTA board that I was able to get where I am now. What have you done to serve the profession? What have you done to really understand the issues in PT?
There are a lot of complainers out there who blame health insurance for all the problems. However, insurance is also highly regulated, and much of the complaining is due to not understanding what a health plan contract REALLY is there for.
It is NOT there to pay for myofascial release three times a week for someone who can work, drive, travel, sleep, and even do some exercise.
The main things I would recommend to study would be the most up-to-date clinical practice guidelines for the areas that work the most. Those are what make up the backbone of how we make decisions.
For example, in my review of the research it became clear that basically every clinical practice guideline (CPG) recommends the use of standardized outcome measures such as LEFS, DASH, or ODI.
This a reason we ask for those measures for our reviews (and no, many providers do not send them because they do not take them 🙁 )
Do you have any books, podcasts, or blogs you’d recommend to someone looking to become a physical therapy reviewer?
I don’t know of any books or CEUs specific to utilization review. This has actually been a thought of mine to create a CEU about how to navigate the utilization management process better, and why it is there.
Editor’s note: Feel free to pester Aaron about creating a course 🙂 🙂 Just kidding…kind of!
Primarily, you just need to understand what there really is out there to back up what we do as PTs. Unfortunately, much of our research is low-quality. We still have a long way to go to prove our worth.
Anything else you’d like to tell the readers about physical therapy reviewer jobs?
I would be happy to communicate with anyone that has additional questions about becoming a clinical reviewer (OT or PT or SLP). Feel free to contact me if a clinical review specialist role appeals to you. I would also be very interested in consulting with providers or clinics if they are having difficulties. I think this is an area where knowledge is greatly lacking, and I am happy to help.
Anything else you’d like to share? What’s next for you?
As I mentioned earlier, my 30-hour/week schedule allows me extra flexibility to explore other areas that interest me. In my additional time, I am slowly working on some corporate consulting for workplace injury and wellness.
I also work with adults with disabilities weekly at a day center run by a non-profit. I assess the progress of participants in a wellness program. It gets me out of the house one day a week, and I get to work with people that really need it.
One last new endeavor for now is using some art and design skills to create tongue-in-cheek t-shirt designs specifically for PT/OT and similar. I only have a few designs up, and have not started any major marketing yet, but it is fun to create the designs when I have spare time.
I am working under the name “AWittyPT,” and you can check out my designs on Threadless! Please check them out and weigh in on the designs! I would love to get comments back from the “non-clinical” following on the designs. Maybe if there was enough interest I would even create one specifically for us non-clinicals!
Beyond, that, I have a beautiful, fabulous wife of 16 years, as well as three boys (12,10,8) and four chickens. I enjoy garage workouts with neighborhood buddies, the outdoors, and walks at sunset (with my wife only!).
Thanks for your insight, Aaron!