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Now displaying: March, 2020
Mar 30, 2020

Social Distancing for Rehab Therapists

Leveraging Part-B In-Home Care and Telehealth in Your COVID-19 Response


Recorded Thursday, March 26, 2020  |  2:00PM EST


In light of the recent COVID-19 pandemic, the CDC has recommended ‘social distancing’ as a key tactic to help reduce the spread of the virus. In this webinar, our guest speakers will discuss two options to help rehab therapists continue delivering care during COVID-19.

Hilary Forman, PT, Chief Clinical Strategies Officer for HealthPro-Heritage, a leading consulting and therapy management firm, will share best practices for effectively and safely delivering care through Part-B in-home care. Additionally, consultant Rick Gawenda, PT, President of Gawenda Seminars & Consulting, will discuss telehealth legislation now in effect, which supports the practice of ‘social distancing’ while continuing to deliver necessary outpatient rehab care.

Included in the webinar are details related to:

  • COVID-19 pandemic and CDC recommendations
  • Risks associated with traditional therapy ‘clinic’ settings during COVID-19
  • Benefits and best practices associated with delivery of Part-B in-home care
  • Telehealth legislation and application for rehab therapists


The continuation of outpatient rehab care plans during this unprecedented time requires careful thought as to how we adhere to new recommendations while providing the quality of care traditionally delivered in public locations such as outpatient clinics and gyms. This webinar is designed to help you as you seek ways to adapt your care delivery in today's new environment.



Gawenda Seminars Website

Healthpro Heritage Website

Rick Gawenda Twitter

Hilary Foreman LinkedIn


For more information on Hilary:

Hilary is an experienced, sought-after health care reform expert with a dynamic approach to advising providers within the post-acute care industry. As a solutions-oriented leader and consultant, she meets the challenges of a rapidly changing health care environment with innovative clinical and financial strategies. With more than 15 years of experience in rehab management, Hilary has worked with hundreds of clients to optimize marketplace strategy, clinical program development, and compliance integrity.

Hilary has presented at several association meetings to share up-todate information and insights as well as her thought- provoking approach to meeting the challenges of health care reform initiatives.

She has established a reputation for facilitating meaningful partnerships between post-acute care (PAC) providers and upstream and downstream cohorts. Hilary’s philosophy encourages open collaboration, proactive communication, and honest dialogue regarding outcomes, safe care transitions, and financial opportunities/pitfalls.

With a keen sense of humor and a no-nonsense approach to solving problems, Hilary has the ability to assist groups in thinking strategically, challenge the status quo, and ultimately succeed in leveraging positive outcomes.


For more information on Rick:

Mr. Gawenda has presented nationally since 2004 and currently presents approximately 100 dates per year around the United States.

He has provided valuable education and consulting to hospitals, private practices, skilled nursing facilities, and rehabilitation agencies in the areas of CPT coding, ICD-10 coding, billing, documentation compliance, revenue enhancement, practice management, and denial management as they relate to outpatient therapy services.


Read the full transcript below:

Tannus Quatre (00:00:02):

Welcome everyone. My name is Tannus Quatre and today I'll be kicking us off with our webinar on social distancing for rehab therapists. Before getting into our topic I'd like to take a moment to acknowledge and appreciate each of you that are on the call today, as well as the teams that you work with to serve patients in your communities. As a physical therapist myself and as part of an organization that proudly serves rehab therapists, this is a really heart wrenching time as we watched this coronavirus pandemic unfold and impact lives across the world, including the interruption of the care that you provide to your communities. As part of our effort to help rehab professionals continue to deliver care in your communities during a time of putting my hands in quotes here, social distancing and sheltering in place, phrases that are new to us, we've assembled a team to present for you two business models today, part B in home care and e-visits.

Tannus Quatre (00:01:03):

And we hope that these will facilitate the continuation of the care that you provide while helping your patients and your staff adhere to guidelines that require that during this time we limit our physical exposure to one another. We've got an amazing speaker lineup for you today. Starting off with Rick Gawenda, physical therapist, compliance and billing expert and president of Gawenda seminars. Rick's going to help us understand some recently expanded legislation regarding telehealth and e-visits for rehab therapists. We have Hilary Foreman, physical therapist and chief clinical strategies officer with HealthPRO heritage. Hillary is going to walk us through health pros, part B in home rehab model and how this model is uniquely positioned to help protect her patients and her team during a time of social distancing. And we have Sheila Cougras, registered nurse and director of compliance at net health, who together with Sarah Irey, also a physical therapist will be setting the stage for us today by introducing us to COVID 19 and considerations that impact us as rehab professionals.

Tannus Quatre (00:02:12):

Now, today's webinar represents our best efforts to help rehab therapists adapt to a very unique circumstance. We're working right alongside you to adjust and learn as things change and I know for all of us things are changing hour by hour at this point. So in our webinar today we'll be sharing some information that is both fairly broad in nature and then we're going to be zooming in to discuss details that are really pretty technical. So we hope that the information will help you stimulate thoughts and ideas that you can use to continue care for your customers, but please do know that the information is changing rapidly and you're going to need to verify if and how this information applies to your particular business. Now finally for me on a housekeeping note, we're going to be pretty fluid with this webinar today and we're going to take the time needed to cover the information that we have planned as well as time for Q and A at the end.

Tannus Quatre (00:03:06):

If you have questions that come up during the presentation, please use the Q and A function that you'll find on your desktop or your phone and we'll get to as many of your questions as we can. At the end of the webinar, we have about a thousand attendees on the call today, so we probably won't be able to get through all questions. So we'll be providing our contact information following the webinar so you can reach out to us for followup if and where that that is needed for you and for those that cannot attend, that may be within your organization or colleagues that you'd like to have attend this webinar after the live version. We will be sharing a recording following the live presentation today, so expect that in your inbox. So with that, I'm going to hand it over to Sheila Cougrass and Sarah Irie to introduce us to COVI- 19 and clinical considerations that apply to rehab therapists.

Sheila Cougras (00:04:00):

Thank you, Tannus. As Tannus mentioned, I'm a registered nurse and a certified wound care nurse that is certified in healthcare compliance. I have been at net health for the past 12 years and serve as the compliance subject matter expert for our products. But before I even get started, I really sincerely want to thank all of you on the front lines who are caring for our patients and communities. What you're doing is really, really appreciated and very much noticed throughout the world. I'm going to also first state that we recognize that all of you are being inundated with a lot of information for COVID-19 that's coming in through, you know, firehoses a lot of information and it only seems so appropriate though that we open with a high level of information we're receiving every day from the CDC to other regulatory and professional agencies across the country. It's also important to note the information is being updated every minute. Even as we speak. I'm reading and learning that new regulations and legislation is introduced at us at a startling pace. We already have over 500 bills and 250 regulations that have been introduced and proposed across the States and the use of the executive order has skyrocketed.

Sheila Cougras (00:05:17):

So we also recognize that this information varies for all of you. Depending on where you provide services, you may be in a home health, you may be in a SNF, acute hospital, private practices, assisted living facilities and with that said you may have a lot of variations with your facility and local policies and federal guidelines. So we want to keep that in mind. As we know, corona virus has been around for a long time. It is a group of related viruses such as SARS that causes disease in humans, in animals, the world health organization, they recently identify COVID-19 is a new virus group, Corona virus which typically respiratory illnesses and most will recover as we know without special treatment. As we've heard, it mostly impacts our elderly population and those that have specific underlying conditions or immunocompromised. We are also hearing about many of the treatments that are off label that are now being made available being introduced today for treatment. But currently there is no vaccinations and treatments are just now starting to be introduced off-label. It is active in all 50 States and I guess it's also active within our surrounding four jurisdictions of our country. And the last we seen reported I know that this is obviously probably updated since, but the last reported by the CDC is 27 are reporting community spread.

Sheila Cougras (00:06:46):

We are hearing that it is also being noted by the new England journal of medicine that COVID-19 is also stable in aerosols and on surfaces that can last from several hours to several days. So we want to keep that in mind when a person sneezes or coughs without proper coverage into their elbow or their sleeve, it creates a bubble of air that contains the virus. It could be suspended for hours and so with that said, if someone walks through that area an hour later, they could potentially pick up the virus.

Sheila Cougras (00:07:23):

So this slide is not only to share with you common recommendations from CDC and the world health organization, but also think about setting up competencies for your staff and educating your patients. We obviously want to maintain that good hand hygiene as being occurring washing for at least 20 seconds with soap and water and hand sanitizer with at least 60% alcohol reasoning is because those soaps we use contains surfactins which neutralizer removes the germs from the pathogens such as COVID-19 that has a crown like structure and outer membrane made of lipid molecules and protein that is then runs down the drain. Do not touch your face. We hear that a lot with unwashed hands is specifically your eyes, your nose in your mouth where there's much entry into your system. Where if face mask, if indicated by your facility policy protocols, we know there's a lot of uncertainty in this area due to the limitation of supplies.

Sheila Cougras (00:08:21):

So please check how and when you are to utilize face mask and the type of mask you should be wearing Disinfect your common touched surface areas. Often whether it be tables or knobs, countertops, desk, phones, keyboards in any other equipment that has commonly touched you. It's also helpful if you increase ventilation by opening windows or adjusting the air conditioning and we also want you to limit food sharing, stay home if you're feeling ill or have an ill family member and most importantly is you're going to hear threaded throughout this presentation and as Tannus mentioned is social distancing maintaining a safe distance three to six feet between you and others. It's so important given how this virus is transmitted. Sarah will speak to this further but before I hand it off to her, I want to share that a I have been listening to other professional organizations speak about ideas and best practices they're sharing.

Sheila Cougras (00:09:14):

I was on a call a couple of days ago with American hospital association in CMS with Sima Burma where she was encouraging the physicians to share ideas. Some are setting up tents outside of their offices to do the screening conducted prior to allowing the patients or staff to enter the building. Some are calling the patients prior to their appointments and asking a series of questions provided by the CDC to triage those patients. And many of you are hearing utilizing telemedicine and you will hear more from our other panel speakers on that topic. Additionally, I heard that in HPCO, which is a hospice professional organization just yesterday. They're getting so creative that they're providing care through windows and standing outside of the patient's home and looking at the patient through the window and addressing the needs with the caregiver at the door. So as we know, this is the time to really get creative and treat your patients safely as much as you can.

Sarah Irey (00:10:07):

Thanks for that great information Sheila. Before we start, I'll let you know a little bit about me. I'm a clinical liaison for net health, but my background is as a physical therapist with nearly 20 years of experience working in various settings including private practice, hospital outpatient and acute care and skilled nursing facilities. I'm lucky enough to use my clinical experience here at net health, but I do some clinical work still now and then. Let's continue to build on what you learned from Sheila. An important part of social distancing includes being able to identify patients and staff who have COVID-19 or who may be a risk of carrying or contracting the disease. Many facilities are now using screening protocols, as Sheila mentioned, to identify these individuals. If you're part of a larger organization, check your organization protocols to determine the process for screening patients and staff and know how to refer them for additional testing if they're possibly infected.

Sarah Irey (00:11:12):

If you don't have a formal protocol, you might want to consider creating one using sources from the CDC website as well as checking with your state. The CDC outlined some recommendations such as using your clinical judgment. Clinicians should use their judgment to determine if a patient has signs and symptoms of COVID-19 and should be tested so the signs and symptoms that you've heard about include fever, cough, and difficulty breathing. Other risk factors are having contact with someone who has or is suspected to have COVID-19 or pneumonia of an unknown cause within the last 14 days. Someone who's recently traveled outside of the United States or in an effected area and someone who has residents in an area with community spread of COVID-19. Like Sheila mentioned, your screening can actually begin before your patients arrive at your clinic. When you're making appointment reminder calls.

Sarah Irey (00:12:09):

You might want to consider asking screening questions and making recommendations for exposure risks in mildly ill or high risk patients to stay home per social distancing guidelines. We realized that many of you may still need to see patients in a clinical setting. So let's consider some ways to keep you and your patients safe while keeping social distancing in mind no matter where you treat your patients. First, follow the screening guidelines we just discussed to decrease your risk in your clinic. You also may want to ask patients to wash their hands prior to starting the treatment session and after you could even maybe consider having them stand on one foot to practice balance while they wash if it's safe, right? Wash your hands as well. Always follow standard precautions and use PPE per your organizational protocols. Be mindful to follow the six foot social distancing guideline in the waiting area and your treatment space.

Sarah Irey (00:13:09):

So you might need to modify your waiting area seating setup or your schedulings practices to support this model. Maybe use private treatment rooms for patient visits instead of the gym area. Avoid group and concurrent therapy treatment and consider treating patients in their rooms if they reside in a skilled nursing or assisted living facility. Also think about if you can change treatment and treatment plans to decrease physical contact with your patients, but still provide quality care. Examples of this might include instruction and self mobilization techniques instead of manual adjustments or mobilization or instructing the patient in use of tools for soft tissue mobilization such as foam rollers and trigger point release balls rather than direct therapist to patient touch. Also consider keeping your patients with one provider per visit instead of sharing care to decrease contact. So you may need to change your scheduling and staffing practices there. Finally consider educating patients on alternative treatment options such as part B in home rehab and eVisits. So let's learn more about part B in home rehab with Hilary foreman from HealthPRO heritage.

Hilary Foreman (00:14:22):

Thank you so much Sarah. And as Sarah said, my name is Hilary foreman. I am the chief clinical strategy officer at HealthPRO heritage. I am a PT by background and I've been lucky enough to be with HealthPRO for about 18 years now. I'm moving from operations into our clinical role. I have the honor of being in charge of our clinical and consulting business lines over our rehab services that span across the post-acute continuum. So as Sarah said, I wanted to talk to you about our first business model, which is part B in home rehab. Though HealthPRO heritage did not start this model in light of the current COVID-19 situation, it now more than ever in this era of social distancing has become one of our standards as it makes more sense as a consideration. This model can be used by both rehab companies and home health agencies to better meet the needs of some of our seniors.

Hilary Foreman (00:15:19):

So let's start with what is part B in home rehab. Very simply, it's the concept of the traditional outpatient therapy model being provided in a patient's home as opposed to a free standing clinic or the gym of a senior living community. Services still remain covered under Medicare part B. They may also be covered by managed B or some commercial payers as well. By being able to deliver this service in a patient's home, it provides a lot less anxiety for a patient and a much happier person. Patients in this scenario are not home bound, but due to other circumstances prefer to stay in their home, whether it be convenience, safety, or cost. One caveat to this model is that because patients aren't home bound, they can also not be receiving any part a benefits as this is a part B benefits. So those two insurances do have to be separated.

Hilary Foreman (00:16:27):

So why would we do part B in the home first? As I said, it would be convenience of care. According to some recent AARP statistics, over 89% of patients over 50 years old would prefer to receive these type of services in their home for many of their own reasons, but now in the era of social distancing, this can be a more protected setting. This can also be a great solution for protecting some of our most vulnerable patients, but continue to provide those essential rehab services with reducing the risk of illness or injury to those patients.

Hilary Foreman (00:17:14):

As we continue down the path of why we would do this, one of the other has to do with a lot of the regulations going into place. Many of us are looking to expand our referral base, so whether you're a rehab company or a home health agency, chances are you're looking for different partnerships in your community. In light of changes with PDPM on the skilled side and PDGM on the home health side and changes and just the level of competition in many markets, you may be looking at different ways to partner with other people in your community. Whether you're looking to expand with physician services, many outpatients we think of as partnering with orthopedic physicians. We all know that orthopedic physicians tend to use their own clinics or hospital based rehab settings. In this model. Healthpro heritage chose to partner more with primary care physician groups in order to better expand into the community.

Hilary Foreman (00:18:17):

These primary care physician groups, we're community-based or we're already partnering with many of the senior living and assisted living communities in the areas. This paired nicely with their house calls programs, so we just like the physicians would start making house calls. It became a very good word of mouth referral source for us as well as a network between different senior living communities who wanted to partner their therapy across all their levels of care. So having therapists provide services through the home health agency as well as part B in the home. This helped the therapist become a standard part of the community, whether it be on that campus or in the greater community. Another reason you may consider why we would do part B in the home is just to reduce overhead for providers. This model reduces costs associated with brick and mortar clinics and the costs associated with keeping those running or even dedicating space within an assisted living or independent living community for patients.

Hilary Foreman (00:19:27):

This reduces a lot of their anxiety. It may also save time, money and effort for them traveling, worrying about parking and worrying about keeping all their appointments straight by having us go to them. It is a lot of their worry. And lastly, in order to follow any of the trends in healthcare, we all have to change, diversify and grow. Most importantly, meeting people where they are and where they want to be. Chances are that is going to be in their homes. We wanted to be able to offer more alternatives to where they could get the essential rehab they needed. Now again, in the era of social distancing, we were able to meet them in their homes and it was a great new business model for us as well. So killing two birds with one stone, but now as Sheila shared in the era of COVID-19 we did have to take some additional rehab considerations.

Hilary Foreman (00:20:28):

So we at HealthPRO heritage, decided to do a few things before we ever entered someone's home. First, we implemented a very strict policy of staff monitoring where staff self-monitor temperature checks twice a day, attest to whether or not they have any signs or symptoms. We even instituted a smell check. Some of the more recent literature indicated that people ahead of coming down with the symptoms of COVID-19 had actually lost their sense of smell. We also reviewed contact or exposure history, looking at what would be a low or high risk exposure and choosing whether or not therapists would see some of our most immunocompromised patients in their homes or not. We also instituted patient screening calls as Sarah suggested, making sure that we not only asked about the patients themselves, but anyone else that might be in the home at the time of the visit.

Hilary Foreman (00:21:28):

So many of our seniors have their spouses or older children home with them. They may be caregivers for grandchildren, so we did want to make sure that in addition to asking just about the patient, we knew about them as well. We did follow the CDC guidelines on what we could and couldn't ask, but it also helped us explain to our patients what infection control steps we would take prior to coming into their home. We did focus a lot on our staff and making sure that they understood what those infection control steps were. We did add additional steps in light of the current situation, especially when it came to clean bag and equipment technique. We wanted to take extra care of everything we did or did not take into a patient's house and how we were able to take care of that.

Hilary Foreman (00:22:19):

The other issue we have run into, and I'm sure many of you on the call have as well, is the availability of PPE. In cases where we do have low risk or high risk situations, patients still may have required care and we did have to make sure that people had the correct availability of PPE and understood proper use and retirement of that PPE well in the home. We did ask our therapists to continue to maintain social distancing rules from others in the house, in the apartment or in that senior living community. We did see that there was a lot of opportunity there as well. We were able to be another set of eyes for our seniors in the community or in the senior living community. Looking for other needs they may have. Being able to address things such as medication that may need to be delivered, additional signs and symptoms of other issues outside of COVID-19 that may increase a patient's risk of rehospitalization and we were able to work better with our senior living communities in that way.

Hilary Foreman (00:23:29):

So now that you know a little bit about our model and now it's time to look to see if this is the right model for you as you're possibly considering this as part of your growth and diversification strategies. There are a few things both pro and con you should consider if you are a home health agency, there are differences between billing part a and part B. You still do have a homebound requirement. You have to look at what those billing differences as well as what the different therapy documentation rules might be because this is part B and the home. It does follow traditional part B documentation and billing guidelines with all of the modifiers attached. A benefit to this is for the home health agency. Being able to provide additional rehab services after perhaps nursing services have ceased as a need, gives you the ability to divert those critical nursing visits to more high risk patients that may be elsewhere in the community. In this case, rehab would focus mostly on safety in the home and basic ADLs. If you're a rehab company, there's a little bit more to consider here. We were able to, in different parts of the country operate this model either under a group practice or a rehab agency. These both models have specific regulations by state that vary and we did need to look into all of those different rules and regulations and setting up the different practices and different locations.

Hilary Foreman (00:25:05):

The other challenge we had was looking at our therapists and their skill sets. This is a unique model because you do blend the skillsets of a home health therapist by being in the home, being more innovative and looking at what you have available to you in a home to provide therapy while mixing it with true outpatient skills. So looking at our therapists being able to work at the top of their license and looking at things from medication management all the way down to manual therapy. As Sarah shared, we did have to make some alterations in the care we've provided recently in light of some of our infection control procedures. But to our patients still receiving that essential therapy was still most beneficial in some cases in making this decision, you may have to actually look for additional consulting services in your area to help you either set up this program or work through the regulations. I hope this gave you a good overview of this possible new business model. And now to talk about our second alternative business model, I pass to our next speaker, Rick Gwenda.

Rick Gawenda (00:26:16):

Thank you very much. My name is Rick Gawenda. I am a physical therapist. My wife, I and another business partner do own two clinics here in Southern California. And then also for the past 17 years I have been a national speaker and national consultant in outpatient physical occupational speech therapy as relates to documentation, CPT coding, diagnosis, coding, payment reimbursement compliance. And all stuff nobody really likes to talk about. So with that, we're going to talk today about telehealth and e-visits. As we go to the next slide. This information I'm going to share with you is current as of 2:00 PM Eastern time today. Cause obviously I used to say things, you know, change weekly or monthly things are changing hourly. We're seeing many state governors mandate insurance plans in their state cover telehealth. We're seeing insurance companies doing this on their own saying they're adding PT OT SLP as telehealth providers. And we are waiting patiently for updates from these centers for Medicare and Medicaid services. So again, everything is current as I speak today. Most likely things would change either tomorrow or early next week. We are in the Medicare program as well as maybe other insurances in many States.

Rick Gawenda (00:27:47):

So speaking with the Medicare program first, so CMS, the centers for Medicare and Medicaid services issued a document over a week ago and they talk about three types of virtual services that you see here on this slide. And the commom mistake I'm hearing people make is they're using the terms eVisits and Telehealth interchangeably synonymously, the same as, and they're not the same. They're completely different. So again, three types of virtual services per the Medicare program right now. Medicare telehealth visits, which we're going to give you the current status of that coming up, virtual check-ins, which were not apply right now to PTs, OTs and or SLPs. And then we're going to talk about eVisits that will apply to PTs, OTs and SLPs.

Rick Gawenda (00:28:45):

So as I speak to you today, now about, I believe it's around 2:30 East coast time, March 26, the Medicare program still does not pay for tele health services for outpatient, physical, occupational and or speech therapy services. They consider this a non-covered service because the Medicare program does not pay for these services for therapy and they consider it non-covered. You right now today can provide tele health services to your Medicare part B beneficiaries and charge them your cash rate for the telehealth services. And an ABN, an advanced beneficiary notice of non-coverage would not be required to be issued to the Medicare beneficiary. You can issue a voluntary ABN to the Medicare beneficiary if you want to and I do recommend you do that but it's not mandated. You issue an ABN to the Medicare beneficiary and the reason why it's not required is an ABN is only issued when normally the services are covered by the Medicare program, but under the circumstance you think Medicare is not going to pay or since right now today, March 26 telehealth services provided by PT OT SLPs or statuary, non-covered and ABN would not be required.

Rick Gawenda (00:30:24):

Also, if you are familiar with the ABN form in section G there's three boxes and the patient's supposed to select one of those three options in section G since your issue in a voluntary ABN, you are not going to ask the patient to choose an option. The patient does not need to sign and date the ABN because you're not going to be submitting the claim to the Medicare program. So people haven't been asking me, well, Rick, what CPT codes do we bill to Medicare for telehealth? You're not going as I speak today, you will not submit a claim to Medicare if you are providing telehealth services for outpatient PT, OT SLP to a Medicare part B beneficiary because it's statutorily non-covered. And since these services are non-covered, the mandatory claim submission is not required. Now I will say there is a barrel that we expect the house to vote on tomorrow called the creating opportunities now for necessary and effective care technologies.

Rick Gawenda (00:31:32):

The acronym is connect, C O N N E C T act, the connect act and in section three seven zero three of that bill. If it gets passed by the house passed by the Senate, everything stays in president Trump signs it. It's going to broaden the authority of the secretary of health and human services to wave tele-health requirements as they currently are. So we're hoping that once the house is supposed to take a voice vote on that sometime tomorrow followed them by the Senate. My opinion only, it should pass pretty easily. Hopefully the president signs it, then hopefully then the secretary of health and human services would then waive the current restrictions house for Medicare beneficiaries and allow PTs, OTs and SLPs divide those services and build the Medicare program for that. Also, as we speak today in the office of management and budget, there is an interim final rule regarding COVID-19 and some updates in that interim.

Rick Gawenda (00:32:43):

Final rule. Unfortunately we have no clue what's in that interim final rule. It could be some things way too. What I'm still going to talk about here today about E-visits could be about tele-health, could be about easing restrictions and supervision, requirements of assistance, could talk about certifications recertifications it could have nothing about therapy and you know, we don't know again, it's still in the office of management budget to OMB. Hopefully it leaves there either later today or tomorrow and then gets published in the federal register. But that's why I add that disclaimer. We expect things to change with the Medicare program here shortly. We expect clarification to come out from CMS on some things we're talking about right now during today's presentation.

Rick Gawenda (00:33:38):

Let's talk about now e-visits. So again, e-visits and tele-health are not the same. The two are completely different things. So CMS did come out over a week ago and say that they would pay for eVisits provided by physical therapists, occupational therapists and speech language pathologists. I cannot stress enough that top bullet point, they must be initiated by the patient for each E visit, which means the patient needs to reach out to you, the provider, either via a phone call, via an email request. In this E visit. Now CMS did clarify you, the provider of therapy services can educate the beneficiary on the availability of this service. So you can send out an email to your current established patients about the option for ae-visit and all of that. So you can quote I guess like a better word, advertise this service. However the patient must initiate this visit now, but we don't know.

Rick Gawenda (00:34:42):

Here's this third bullet point says patient must be an established patient with the provider who is conducting the visit. And what we're hoping to get soon from CMS is clarification and the definition of an established patient. Because these G codes I'm going to talk about in a moment on the next slide, they actually are brand new this year just came out January 1st of 2020 and to be honest with you, they were not designed for what CMS is allowing us to use them for right now. This is not the purpose of these codes. Now these codes are kind of a, a knockoff, kind of a shoot off of the nine eight, nine seven zero CPT code nine eight nine seven one CPT code nine eight nine seven two CPT codes that are used by physicians for evaluation and management services for these visits done through an online patient portal.

Rick Gawenda (00:35:45):

Now when you look at the physicians and the definition of established patient for a position, this is somebody that has, you know, maybe seen that physician within the last three years. We don't know how CMS is using that definition of established as it pertains to PT, OT, SLP. I'll be honest, it could be established patient as in this is a patient that you were currently seeing for therapy services and now they can't come into your clinic right now you've shut down your clinic, you want to do an visit. Is that what they mean by established patient? Could established patient mean this is the patient you've seen sometime in the past three months, the past six months. Are they going to have to go back, you know, quotes three years like they do physicians. We don't know the answer right now. What we do know though is if you're going to do an evisit any Medicare beneficiary that that patient could not have been seen by you for a physical visit within the previous seven days for the same condition.

Rick Gawenda (00:36:48):

And then once you do this evisit they're not coming in to see you within seven days for that problem. Now, CMS does say that you must use an online patient portal. And I'm giving you the definition of an online patient portal by the office of the national coordinator for health information, which is a secure online website that gives patients can be it 24 hour access to personal health information from anywhere with an internet connection. And there's the URL link for you cause people, you know, if you read the CMS information that's come out, you know, you saw, CMS mentioned that they're the lax scene, they're kind of easing the HIPAA rules and regulations. You know, you saw CMS mentioned Skype and mentioned FaceTime, they mentioned Skype and FaceTimes for tele health services, not for E visits. So right now again we're trying to seek clarification from CMS and boy, can you do a phone call, can you use FaceTime, can you use Skype before we get that clarification.

Rick Gawenda (00:37:57):

I've got to, you know, talk here and say you have to use an online patient portal. And again, you can go on the worldwide web, go to any search and you want to go to, I just use Google and type in a search box, you know, types of online patient portals. You know, what is an online patient portal? You know, I know my physician, and again, I'm not endorsing this product. My physician uses the call it, it's called charm, C, H, A, R, M, all capital letters where she can send me my test results. You know, my lab results. She can give me updates on my medications. You know, I create an account, I log in, I see my test results, I see her email, I can respond to her, she gets notification and with things like that. But again, it must be initiated by the patient for each E visit.

Rick Gawenda (00:38:54):

Next slide. So here are the three G codes, G 2061 G 2062 G 2063 and I cannot stress enough those words that are underlined, assessment and management, and then shooting the tib time during the seven days. So let's talk about what are the seven days. When is day one? When is day seven so here's my example. Let’s say on Monday, March 23rd the patient reaches out to you either via a phone call or an email requests in any visit. You don't respond to them until March 25th. March 25th is going to now be day one, which means six days later that's going to end that seven day period. So, so say you know, March 23rd the patient's sent you an email requesting any visit and they had some questions for you maybe about their home exercise program or should I use ice or should I use heat or how many times do you want me to do my exercises a day?

Rick Gawenda (00:40:03):

Things like that. You respond to them on March 25th and as I say, I'm going to make math easy here today. You spend five minutes typing out the instructions, answering their questions. You send that to them on March 25th on March 27th the patient responds, requested another e-visit with additional questions on Friday, March 27th and you spend another five minutes, you know, answering their questions, whatever that may be, send it back to them on Tuesday. March 31st patient requests another E-visit with additional clarification. They want some information from you. You spent another five minutes on March 31st answering their questions via email or via that secure online patient portal. You send it back to them. That's, and that's it. There's no more other e-visits within that seven day period. So I kept math simple. So you did three separate eVisits spent five minutes each time answering their questions via email, sending it back to them.

Rick Gawenda (00:41:12):

When you add up five plus five plus five that is 15 minutes, that's going to fall between 11 to 20 minutes. So on that last day to service, during that seven day period on March 31st you're going to bill one unit of G two zero six two because the QM to time during that seven day period was 15 minutes. And the question I know you want to ask me is, Rick, can we do more than one seven day period? You know, can I bill G 2060 to say from March 25th to March 31st but that from say April 3rd to April 9th, I spend 27 minutes. Can I do G two zero six three and ms dancer, you hate for me today, we don't know. We're seeking clarification from CMS because again, these codes were not developed for this purpose. We did not know COVID 19 epedemic was coming when these codes became effective January one of 2020. So we're not sure if CMS as well as other insurance companies are going to allow us to build these G codes for more than one seven day period. Now you see it says underlying assessment and management as the go to the next slide.

Rick Gawenda (00:42:33):

People always want to know what is a qualified healthcare professional. And this definition comes straight from the American medical association. So if you have a CPT book, you know, especially or more current one, but if you have like a 2018 2019 2020 CPT books at the beginning of the CPT book, a Roman numeral number of pages explains how the book works, where the AMA provides this definition of a qualified healthcare professional. And in really the key is the words or the sentence who performs a professional service within his, her scope of practice in independently reports that professional service. Well, as a physical therapist, an occupational therapist, a speech language pathologist, you meet this definition because in a private practice you enroll with Medicare, you enroll with other insurance companies, you get an NPI number, you can report the CPT codes independently of anybody else that people was asked for.

Rick Gawenda (00:43:35):

Rick, what about a physical therapist assistant or an occupational therapy assistant? Can they report these G codes you just spoke on was to go to the next slide. You can now see the definition of a clinical staff per the American medical association. And you see in that first bullet point is a person who works under the supervision that'd be physician or other qualified healthcare professional that goes on to say, but who does not individually report that professional service. So that would include a physical therapist assistant and an occupational therapy assistant. So right now it's my interpretation. I know APTA interpretation that PT assistants, OT assistants, you know, can't provide the evisit. And also if you get a definition, if you go back to two sides from replays, you know it says assessment and management and really who's assessing the patient, who's managing and changing what's going on with the patient. And that's really within the scope of practice of the therapist, not the assistant. Now again, we're hoping to be CMS allows assistants do these G codes. We don't know waiting for clarification, but right now I don't feel comfortable saying they can do it based on the definition of a qualified healthcare professional as well as the words assessment and management. Because that is done by the therapist, not the assistant.

Rick Gawenda (00:45:09):

Now how about modifiers? Now, CMS did say if you are submitting a claim on a 1500 claim form and if your Smith claims on a 1500 claim from you are a private practice, the Medicare program did say to attach this CR modifier to the applicable G code. If you are a non private practice, you submit claims you be zero for claim form. You would not only attach the C R modifier to the G code but you also need as a condition code the R. So again that R is not a modifier that R is a condition code. Now we are hearing issues and concerns from households around the country that these G codes can't be submitted, can't be built on the UBS or four claim form. We are still waiting for clarification from CMS on this. You know, can hospitals, can facilities that submit claims any UBS four claim form? Can they bill the G codes? A part of me thinks yes, I'll be honest. Part of me thinks no because again, these G codes, a kind of a knockoff of the nine eight nine seven zero (989) 719-8972 CPT codes which are really the physician codes and typically physicians are only been at any 1500 claim form. But again, we are just waiting for clarification with CMS as well as other insurance companies. Can non private practices bill these G codes and get paid by that insurance company.

Rick Gawenda (00:46:56):

Now, documentation for an evisit extremely important that at minimum each E visit you do must have the following documentation. You must document that the patient initiated and or requested the visit. You must document the patient consented to the visit and then you must document these services, the education, the training that you provided during that e-visit. So an example I gave where you did visits one on March 25th one on March 27th one on March 31st you would have a note for each date of service that will contain at minimum these three bullet points, but the billing would not occur to a date service March 31st

Rick Gawenda (00:47:51):

Now let's talk about telehealth and tri care. You know Tri-Care, believe it or not does cover house services and they've done so since July 26 2017 and that top moral point, that sentence is right out of the tri care manual that they cover telehealth services if these services are otherwise covered. Tri care benefits, well since Tri-Care covers outpatient PT, OT, SLP services, this means that they would cover telehealth services for PT, OT and or SLP services and nicely my Tri-Care is they allow payment for telehealth provided both asynchronous and synchronous. Now non-Medicare, it's the answer you hate. You've got to go check with every insurance company. And when I say every insurance company, we estimate they're over 6,000 insurance companies in the United States. Whether they cover telehealth, it's all over the board. If they do cover tele-health, which CPT code or CPT codes they allow or want to see all over the board, which modifier or modifiers do they want and every CPT code all over the board.

Rick Gawenda (00:49:17):

You know, this is changing hourly because we're seeing many state governors issue declarations, issue orders mandating all insurance plans in their state that are overseen by their insurance commission, you know, cover tele-health. That's great. You know, we've seen some insurance companies like Michigan blue cross California blue shield of blue cross blue shield of North Carolina do this voluntarily where they now expanded telehealth for PT, OT SLP on a temporary basis. And again, the CPT codes, IMC and I'll all over the board which ones they want. Just, you know, when to kind of maybe give you some guidance here. The most common codes I'm seeing be and allowed for tele-health a PT and OT are nine seven one one zero 30 exercise nine seven one one two neuro re ed nine seven five three zero safety activities, nine seven five three five self care, home management and for speech is nine two five zero seven.

Rick Gawenda (00:50:30):

The treatment of speech, language, voice communication, Archway processing disorder. You know, don't try billing ultrasound for through telehealth. A manual therapy would also be a no through tele health cause your hands have to be on the patient. The other thing to ask when you check with these insurance companies is are they covering tele-health for only patients that were already established. You know, you've already seen them for therapy. There's already an active, you know, plan of care going on and now they can't come to your clinic. Or are they also covering tele-health for new patients as well? That's something you're going to want to check. If you're in a private practice setting they usually want to see for the place of service code for telehealth be a zero two. So again, extremely important to check with each insurance company and their coverage of telehealth services.

Rick Gawenda (00:51:34):

You know, how do you keep up to date with all this, you know, number one, stay current with your national associations. APTA. Also check your state associations website. You know, most of them now have a dedicated page for COVID-19 many of them are, you know, doing daily updates and information that they find out. You know, why not go bookmark your top four or five, six insurance companies that you deal with in your practice. You know, and again, go to Google and search box. Just type in for example, Georgia Medicaid provider page, tri West provider page, Nebraska blue cross blue shield provider page. In those last two words, stay the same provider page. That's what you want to get to on insurance company's website to provider page. And most of them now have a dedicated COVID-19 page and they've got dedicated page for, you know, quote, telemedicine, tele rehab, tele-health and those three terms don't all mean the same thing we've got. I think we're using them synonymously right now and I'm okay with that. But they are different. But get on those payers websites. If you're not on social media, get on social media, get on Twitter, get on Facebook. Many of us are putting out tons of information hourly on all of the changes.

Rick Gawenda (00:53:02):

Not to get too excited about these G codes. Just so you know, the Medicare program has about 112 different payment localities across the United States on just using each choice, Michigan. And you see the approximate payment amounts here. And before we go to get questions. And one thing I really want to say about tele-health. You know, normally if you're gonna start tele-health in your practice in your organization, it's usually about a four, five, six, seven, eight weeks start up. Yeah, I know a lot of people are trying to start tele-health in 24 hours and 48 hours. Be careful, you know, even though CMS has eased the HIPAA enforcement doesn't mean you can be careless. Just because CMS has eased HIPAA does not mean other insurance companies may not come after you. You know, you got to make sure you have your policies and procedures in place.

Rick Gawenda (00:53:52):

They're going to do telehealth, you know, have you updated your consent forms to include telehealth services, have you gotten your consent forms to your patients for them to sign, you know, how you document in the medical record and keep a track of, is the patient consenting to telehealth, have they consented to be videoed and have that recorded and saved in case they want to look back at it? You know what happens if you are doing a telehealth visit and you're doing it with Tannus and you see Tannus all of a sudden he grabs his chest, becomes short of breath, he falls off his chair, there's an emergency situation. You know, what's your policy? What's your procedure to address those kinds of things because you could have a liability. So again, you need to check with a healthcare attorney to make sure you got the proper policies and procedures in place. Because my hope is those of you that initiate tele-health, like right now when the COVID-19 pandemic is done, I'm hoping you're not done with telehealth. I hope you continue to do tele-health into 2021 2022 2023 as I think this is an important aspect of your business growth. Keep in mind, tele-health is not appropriate, not applicable for all of your patients.

Tannus Quatre (00:55:16):

Outstanding. Thank you so much Rick. Hilary, Sheila, Sarah wonderful presentation. We're going to get into some Q and a now and I will go ahead and moderate this portion of the webinar. And while we're doing this, we have our contact information up on the screen. So for those that would like to get in touch with us, if you have further questions or would like to learn more about what each of us and our organizations are doing to help rehab professionals adapt to COVID-19. We want to have this up on the screen. So with that we've got a lot of questions coming in and I know that we're right up against the hour. Like I said before, we're going to be kind of fluid with this, so if you're able to stay on, we're gonna answer as many of these as we can and then anything that we're not able to get to, we'll figure out a way to follow up with you independently afterwards. So I'm gonna start with I'm going to start with one here. For Rick, would encrypted organization based email be considered a secure patient portal for delivering he visits?

Rick Gawenda (00:56:23):

Yeah. Great question. And again, my opinion, my interpretation as it stands right now today is yes, because the email is encrypted, which usually requires a patient, you know, to create a username and a password to then access that encrypted email.

Tannus Quatre (00:56:24):

Perfect. Another one for Rick here. Are these codes billable by home health organizations or just outpatient organizations?

Rick Gawenda (00:56:54):

Well you know, when you say home health, if you're doing quote part B in the home which we believe you can bill the G codes. Again, we're just saying for clarification where if you're talking to home health under say part a under a home health agency plan of care, the G codes would not be applicable to that setting.

Tannus Quatre (00:57:19):

Excellent. Thank you. And we're going rapid fire here with Rick. I've got another one here for you. What POS code should be used for hospital-based outpatient clinics with any commercial insurers? Should it still be zero two or does it need to be different?

Rick Gawenda (00:57:33):

Yeah, great question. And again, if you are a private practice, and again some hospitals you've got offsite clinics that are set up as a private practice and you submit any 1500 claim form if you do in telehealth services, the place of service code would be a zero two. If you are a non private practice, which again could be, you know, as a hospital outpatient department, you know, hospitals can I have clinics ops site but they still fall under the hospital umbrella. You submit claims, NAU B zero four claim form in place of service codes are not used, most likely what you're going to have to use, which we didn't really talk about today. When you go to CPT codes you plugging up to put you to modify your GT or a modifier nine five on the CPT codes and that indicates that it was tele-health provided through a synchronous communication.

Rick Gawenda (00:58:32):

Now I know the follow up question is going to be which modifier do I use? It depends on the insurance company. You know, some insurance companies may tell you to use modifier nine five some may say to use GT if you're not a private practice. So again, unfortunately you just have to check with every insurance company you want to do tele-health with. And that's why I'm stressing so much to make sure you've got your policies and procedures in place and you've checked this through risk-management your attorneys to make sure you got your I's dotted, T's crossed and all of that.

Tannus Quatre (00:59:08):

Excellent. Thank you. Okay, so one here about part B in home. So Hilary if you can unmute. How is reimbursement different for part B in home versus in a free standing outpatient clinic? Right.

Hilary Foreman (00:59:21):

Great question. It is not that is why if a home health agency does choose to implement this program, they are going to have to look into a different way to do their billing. So it is still done by CPT code with modifiers just like a traditional outpatient setting.

Tannus Quatre (00:59:41):

Great. Thank you. Hillary. Another one about part B and home, how long does it take to launch part B in the home? If I only have done freestanding outpatient therapy?

Hilary Foreman (00:59:55):

It would depend on two things. One, if you were going to go a group practice or rehab agency route group practice is much quicker to get up and running, but there are some restrictions, especially depending on the state that you're in. A rehab agency is a much longer process and does require some additional filings. Some of them depending on the state you're in, you can do some retro billing in some cases. So you are able to start before everything is completed, but it's very state specific. If you, whoever asked if you want to reach out and let me know the state, I'd be happy to point you in the right direction for those answers.

Tannus Quatre (01:00:36):

Great. Thank you, Hillary. Okay. Another one here for Rick regarding eVisits. So per webinar a previous webinar or attended Medicare calls, e-visit a non face to face consultation, therefore Skype and such may not be required can be done via email or phone call. Is this accurate?

Rick Gawenda (01:00:57):

I'm sorry, what? I'm not understanding the question. Are they asking, is Skype and FaceTime allowed for a e-visit?

Tannus Quatre (01:01:03):

I'm interpreting this as is it required. So this, I'm going to go ahead and restate it. So Medicare calls e-visit and non face to face consultation, therefore Skype and such not required, can be done via email or phone call.

Rick Gawenda (01:01:21):

Well again, as I said during the presentation when CMS discussed Skype and FaceTime in that publication they released, they were using Skype and FaceTime for quote telehealth services not for an E visit. So right now an E visit needs to occur via email or a secure online patient portal. We are waiting for clarification with CMS regarding a phone call. You know what a phone constitute that cause right now as you know, a phone is not considered an online secure patient portal. So right now I can't tell you to use a phone to do an E visit. So right now I would say use encrypted email or use a secure online patient portal such as charm or you know, other online patient portals that are available to you.

Tannus Quatre (01:02:17):

All right, thank you Rick. Okay. Another one on E visits. When asking for an evisit do they have to, so the patient, does the patient have to directly address it as this or can they electronically ask a question? So for example, through a communication portal for us to then address outside of the clinic and we can count this as a patient contact.

Rick Gawenda (01:02:41):

Yeah, it's a great question because you know, again, this is like not what these codes are designed for. So obviously if a patient sends you an email asking a question I guess my recommendation if you want to play it safest, which is what I really have to do right now on this kind of call, is do you respond to the patient and say, you know, would you like me to respond to your question via an encrypted email via a secure patient portal, as an E visit? And if that patient then responds, yes, I would, you know, then I think that that's the request. And then you, I think you then save that email and then you go and address their question or questions that they had. In my opinion only is I think CMS is going to kind of be lenient on this right now.

Rick Gawenda (01:03:34):

I think other payers would be lenient on this right now, but again, you just in case something were to happen, you kind of need to cover your rear end and have that documentation there. I also think that since these codes don't really pay a whole heck of a lot of money you know, when you look at that G 20, 63, you're spending, you know, 21 or more minutes with them during a seven day period, you know, that payment's going to be somewhere between 32 to $36 depending on what state you're in, what locality you're in. So I don't see CMS really doing a bunch of audits on all of this stuff, but it's more just from a legal perspective and to protect yourself in case something happened where it happened with the patient.

Tannus Quatre (01:04:19):

Great. Thank you. So I've got one here. I'm gonna pose this to Hillary and then Sarah, you may want to chime in on this as well. Are you tracking COVID-19 related cancellations? How are you doing this in your EMR?

Hilary Foreman (01:04:36):

We are tracking missed visits in our EMR. We just haven't placed in the notes section. And we're just trying to look at it. We unfortunately are seeing quite a few many more and the home health side then on the senior living side. But I think as we go we are starting to see more and more people I want to say get more comfortable with infection control both on their side and on our side. So we expect to see that pick back up. Our customers are able to, for some of our products create custom questions or custom cancellation reasons so that they can just click that that was the reason and then they can run some cancellation reports on cancellations due to COVID-19.

Tannus Quatre (01:05:30):

Great. Related, do you know or have an estimate of how many PT clinics are still open versus temporarily closing doors due to COVID-19. Anybody want to take a stab at that?

Hilary Foreman (01:05:47):

I can speak for healthpro heritage that's very state specific. We have some States where it was ordered that they all closed, voluntarily closed due to whether or not they were treating a very immunocompromised caseload. They voluntarily chose to close for safety reasons. But I would say maybe half and half at this point for us.

Rick Gawenda (01:06:19):

And this is Rick, I think, is this an educated guess? I agree. I think it is state specific. I would also say it's probably also region specific within a state and the number of cases going on. And as I said already, the types of patients you're seeing in terms of diagnosis and also the age of the patient, their comorbidities, their risk for COVID-19. You know, obviously, did you have a patient that was now diagnosed with COVID-19 and they were already in your clinic yesterday or two days ago, three days ago. Is that going to force you then shut down and quarantine your staff? I think it's going to be a tough number to really figure out until months down the road.

Tannus Quatre (01:07:02):

Yeah. And some of the tracking that I've had some visibility into from a new claim flow perspective, I'm seeing we're seeing about 40 to 60% kind of in that range, regional specific decrease in the flow of new claims. And so you can kind of extrapolate from there in terms of what utilization is looking like in some private outpatient practices. So thank you. Okay, so this one's for Rick. When billing the G codes on a CMS 1500 form, would we bill just the CR modifier or would we bill GP CR or a PT E visit?

Rick Gawenda (01:07:45):

That is a great, great question. And you're going to love my answer. I think everybody knows my answer by now. We're seeking clarification of CMS on this and now if you are familiar with what CMS calls always therapy or sometimes therapies, CPT codes, those are the ones that always have to have the GP, the G O or the G. And modifier attach them when submitted to Medicare if done under a PT OT SLP plan of care, we're in the 2020 version of always in. Sometimes there'd be codes G 2061 G 2062 G 2063 are not listed in that file, which means right now as we talk today, they're not considered always or sometimes therapy codes, which technically means then GP, G O G N would not be required. However, we are hearing rumors from CMS that for some strange reason they're going to actually add G 2061 G 2062 G 2063 as sometimes therapy CPT codes. Then that would require GP, G N G O modifier, which then means they would actually apply to the annual therapy dollars threshold. Now that's what we're hearing rumors that they're going to do again, so we don't know right now, you know, because we're waiting for clarification. You know, obviously people like me, we've submitted all these questions to CMS trying to get clarification, but as you can imagine, they're swamped. They're trying to figure things out and we're just waiting for those answers to come out.

Tannus Quatre (01:09:28):

Thank you. Rick. got one here for Rick or perhaps Sheila. Do some of these probable changes in Medicare also apply to Medicaid?

Rick Gawenda (01:09:39):

Well it's number one. No. so you think Medicare changes is for Medicare and again, as I always say as I use the word Medicare, that is traditional Medicare doesn't include Medicare advantage. Now would that be in said by law, Medicare advantage plans at minimum have to offer and cover the same services that traditional Medicare does while since traditional Medicare is now covering. So they say those threeG codes, 2061 2062 2063. That means the Medicare advantage plan is also supposed to cover those codes as well. But this is not applied to Medicaid because Medicaid is state specific.

Tannus Quatre (01:10:27):

Great. Thank you. Okay. Hillary how many patients per day can a typical therapist see in part B in home care versus traditional settings?

Hilary Foreman (01:10:42):

Oh, it'll be significantly less. It depends on if you are doing the party in the home. On a senior living campus where the residents are much closer together or if it is in the larger community. So it is very different than a traditional clinic. It would be much more aligned to a home health type where you're counting more visits per day. So when doing modeling for that if you have access to what traditional, depending on your geography productivity expectations on the home health side, where they would be much closer to that. So it could be again, depending on your geography could be 50 to 60% of what a traditional outpatient would be. Thank you. Rick. Regarding initiation and consent by patient, does this have to be written or can it be verbal?

Rick Gawenda (01:11:41):

Well, it's going to be verbal. You almost find a recorded. So I would get it written just to cover yourself. So that again, I, you know, any time you're on this, these kinds of calls and as a consultant, you always gotta, you know, give I guess the most stringent advice or whatever. So I would say to have it written. And it could be something too that, you know, do you send them a document out and once they request a visit, do you create a document that you can send to them? Again, I'm not endorsing this product, you know, via DocuSign or some other format where this is all typed out and you had the patient, you know, electronically sign and date, you sign and date and then you say, that document is what I would do because you also gonna need to figure it out if you're going to be doing tele-health because how you get an EMU consent forms and all of that, that they're going to be consented to telehealth if they can be consented to being videoed and it'd be recorded and all of that.

Rick Gawenda (01:12:41):

So I will always say to try to have as much written down that a patient signs or they sent you an email, something like that that you can save to show just in case you got called out on it.

Tannus Quatre (01:12:55):

Great advice. Okay. What is synchronous versus asynchronous?

Rick Gawenda (01:13:03):

You know, asynchronous would be like that online patient portal. So again, I'm not endorsing the product called charm, so it's kind of a one way communication. It's kind of delayed. We're not live together. My doctor sends me an email, she maybe sends it at 11 o'clock in the morning. I comes into my email box. I may not sign into my account to eight o'clock tonight. I go lead, but she says I may or may not respond to her today. I may wait till tomorrow. Send her a question back or say thank you for sending. When should I come see you were synchronous talk communication, which is really what I think I hope you're going to be doing. If you're doing tele-health. It's live simultaneous two way audio, visual communication. So you know, think of face time. Okay. But you know, there's, and again, as I say some of these platforms and not endorsing them, like doxy, zoom. I know Google has something out there. There's a lot of platforms out there, think of FaceTime. So I can see Ben, Ben can see me. I can demonstrate exercise to Ben, I can watch, do the exercises, correct him. So it's live, simultaneous audio, visual communication.

Tannus Quatre (01:14:20):

Great. Thank you.

Rick Gawenda (01:14:21):

And again, I love Google. Just go to Google and type in asynchronous versus synchronous communication and all that will come up and you can also find different platforms you can use as well.

Tannus Quatre (01:14:35):

Okay. Awesome. okay. Hillary. I'm a physical therapist in private practice. Am I allowed to do in-home part B or is it only for a group practice and or rehab agency?

Hilary Foreman (01:14:48):

It would be for a rehab agency or a group practice. So there are ways to convert into those to be able to, there's some filings, again, depending on the state you're in that can easily allow for that. But you do have to go through some of those hoops to get there.

Tannus Quatre (01:15:07):

Okay. Thank you. Rick. Okay. So this one says just clarifying that we cannot do an evisit to qualify as a fifth or 10th visit.

Rick Gawenda (01:15:20):

Correct. So as we understand it an e-visit is not going to count as a visit towards the Medicare 10th visit progress report. So, for example, you know, you had a patient you know, come in and they had already had eight visits and then you shut the clinic down. A patient is apprehensive about coming in for an actual visit and now you do two eVisits, that's the next, you know, on March 26 and March 31st that's not visit nine and visit 10 towards a 10th visit progress report. So as we understand it today, e-visits do not count towards the 10th visit progress report. They don't count as an actual visit where a patient came in to see you.

Tannus Quatre (01:16:12):

Okay. Thank you. Okay. And I'm doing a time check here. We're going to continue for a few more minutes. We got a lot of questions coming in so we will do some followup from here. But, but I am going to kind of roll through a few final questions here. So this one can be, this may be Hillary, Sheila, Sarah. What PPE do you recommend or are you seeing in use for an asymptomatic home therapy patient?

Sheila Cougras (01:16:41):

This is Sheila. Hi. I would definitely recommend that you check with your local carrier or not your local carrier, but your local facility protocols and what supplies are available and what they have set up. It's been strongly recommended that protocols are set up at the local levels and what your state, local health departments are recommending. That would be your first place to check because I'm not sure which state you're in, but there is a website for all the States and you can check your local Health department.

Tannus Quatre (01:17:19):

Yes. absolutely. So we can work that into our followup communications. Here's another one. Can you elaborate? This is for Hillary. Can you elaborate a little more on the differences between home health provided via home health agency versus rehab company or provide a good resource, which explains the difference.

Hilary Foreman (01:17:39):

I'm sure I could actually provide we have a side by side that I could provide that you could share as part of the followups from this. A lot of it has to do with the billing process. Some of it has to do with credentialing of the therapists. For example, in a group practice, there's eight 55 B forms where therapists have their own PTN numbers. Only therapists can provide services under a rehab agency. Different States, different filings. Assistants might be able to provide those services to do the part B in the home. So there are the state specifics and then there's the therapist specifics. And then there's the billing specifics. So those are probably the three big buckets. But like I said, we have a side by side that I'll make sure that you have to send out.

Tannus Quatre (01:18:32):

Thank you. Hillary. Rick, are eVisits covered at the same 80, 20 percentage as a typical outpatient visit where the patient is responsible for a 20% co-insurance or that 20% gets sent along to their supplemental or secondary insurance.

Rick Gawenda (01:18:49):

Yes. CMS did say that the, you know, the G 2061 2062 2063 that they would count towards, you know, any deductibles, any co-insurance would apply. So again, the Medicare program and on my last slide where I gave you the pricing for Detroit, Michigan, the Medicare program with the 80% of that allowed amount and if they have a supplemental plan your that their Medigap plan, hopefully they would pick up the other 20%. They don't have a supplemental plan and then the patient would be responsible for the other 20%.

Tannus Quatre (01:19:26):

Thank you Rick. Are work comp carriers, paying for telemedicine for PT.

Rick Gawenda (01:19:34):

And my favorite answer, yes. No maybe so it depends and again, I noticed the answer people hate. Unfortunately back when I graduated PT school way back in 1991, it was pretty easy for us back then because every state just had one worker’s comp. We've had Michigan worker’s comp, Nebraska work comp California work comp, but now we have all these middlemen like align network, one call, med risk, etc. You have unfortunately have to do due diligence and check with every insurance company. And I'll be honest, you could call an insurance company and we're just going to make it Ben and you talk to Ben Monday, Tuesday, Wednesday, Thursday, Friday. And you asked them the exact same questions. I have days in a row and Ben gives you five different answers on five different days. Now that's not because he has five different personalities, more, no offense to the people on the insurance lines right now.

Rick Gawenda (01:20:27):

They have an impossible job right now there that they're not knowledgeable on COVID-19 and all of these changes that are going on and things like that. Because I'm hearing people all the time say, why called United health care? And they tell me they pay for telehealth with therapy. Where did you get the link? Did you get the citation somewhere on their website? No identity. Because if you go to the UHC website, UHC, that paid for telehealth. So again, what you're being told on the phone may or may not be correct. So again, very important to know how you're asking the question. And maybe kind of go for the answer you want to get, you know, kind of phrase the question. So the answer may be your way, but you have to answer your way. Ask them for the citation, you know, ask them on your website. Where is it, you know, can you walk me to a site? I can see it in writing cause it was not in writing. It may or may not be true what they're telling you on the telephone.

Tannus Quatre (01:21:27):

Thank you. Okay. So we're going to do three more questions and then we'll go ahead and wrap up at that point in time. So I just want to do a time check here. We're mindful of everyone's time. Hilary, how are you documenting new patient screening calls prior to initiating care?

Hilary Foreman (01:21:47):

In a variety of our systems we were able to add an additional note. In some systems we actually added the screening questions. So either we would do the screening questions and then the patient note would be together. So then once we did the visit, they would be together. And in some cases we've done the screening questions followed by a withheld or a refusal. If something in that screening then indicated that we should not be seeing the patient that day or they refuse that day or whatever those challenges might be. But we actually had added those to the system for that exact reason.

Tannus Quatre (01:22:28):

Thank you. Sarah, do you have anything to add on that? I'm not sure if there's anything that you're seeing with customers documenting screening calls.

Sarah Irey (01:22:36):

I would agree definitely with Hillary. The only thing is, you know, check with your organization.

Sheila Cougras (01:22:42):

Depending on, you know, your organization might want you to put it in your registration software if you have a hospital interface versus the actual act up documentation application. But definitely important to document those screens.

Tannus Quatre (01:22:58):

Okay. Thank you. Okay. Rick, are there any differences for critical access hospitals with telehealth? Evisits billing or reimbursement?

Rick Gawenda (01:23:10):

You know, again, with the e-visits we are waiting for clarification and CMS on, you know, can non-private practices, you know, go for the G codes, be paid for the G codes. So once we get that answer, of course that would apply, you know, whether you're a hospital or a regular hospital a while. So, you know, put a class that's health was, you are not paid under the Medicare physician fee schedule. You are paid any cost ratio basis. That's the other code unknown. And again with Keller house, do you want to check your conditions or participation with the Medicare program as a telehealth provider? Again, Medicare does not pay for telehealth, then they have to meet the two contracts with the other insurance companies that you've signed. So again, I think whether you're a critical access hospital, a regular hospital, your home health agency, do you impart, be in the home, you're a private practice. It's kind of doing your due diligence and check in with all those other insurance companies.

Tannus Quatre (01:24:09):

Okay. Thank you. So, Sheila, I'm going to direct this one to you. And this is in, and then more broadly, we're getting a lot of questions have come in about specific guidelines with regard to protecting employees and patients and use of masks and PPE. So, the one question that I think encapsulates it here, do employees have the right to refuse to treat positive COVID-19 patients if PPE is not available? We know that PPE is in short supply and not available in some areas. And so the way that I think that we should frame this up is do you have a recommendation for resources that our audience can use locally that can help guide them in the right direction for some of these broad questions about safety of caregivers and how they're treating patients in this COVID-19 period.

Sheila Cougras (01:25:04):

Yes, that's a really tough question. There are some resources like you said, that they could check with our state practice acts as well as looking at their local professional chapters and seeing if they can provide guidance there as well as their local health departments. And what are their rights? Is employees and receiving that PPE, I am hearing that quite a bit. And it's all over the news. That PPE, is it a high demand and there's shortage everywhere across the country. So that's a really hard one for me to give guidance or advice on, but there definitely are resources where you could check where are your rights in protecting yourself when you're employed. So I would start with your state practice act as well as your professional organizations and your local health departments.

Tannus Quatre (01:26:01):

Great. Thank you. Okay. So we're about to wrap it. There have been some questions coming in about access to these materials including the slide deck. Yes, we will make this all available to you. The recording. I think it's going to come out to you automatically and we will find a way to get you the slide deck as well, whether that's an included in a link in that email or some other means. So yes, we'll make sure that you've got all of the information here. I want to thank our presenters. This is just you know, we spun this up very quickly you know, over the past few days, I really appreciate you taking the time and investing in our ability to help our rehab professionals get this valuable information.

Tannus Quatre (01:26:47):

So special thank you to Rick Gawenda and Hilary Foreman. Also Sarah and Sheila for helping us put this together and to all of you that are out there on the front lines adapting your business models to continue the rehab care that is needed in your communities. We just really appreciate you. Thank you and are thinking about you constantly. We will have additional webinars that are coming out of the net health organization by you registering for this webinar. We will be able to make contact with you and let you know about those if you would like to attend more sessions and once again thank you so much for attending be safe and be well.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Mar 28, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, Jenna Kantor guests hosts and interviews Clay Watson, Tyler Vander Zanden and Kelly Reed on the Private Practice Section’s Key Contacts. PPS is more effective with the support of members who are dedicated to advocating on behalf of the industry. You can get involved in the section's advocacy efforts by becoming a Key Contact, joining the key contact subcommittee, or by taking action online via the APTA Legislative Action Portal.

In this episode, we discuss:

-What are the responsibilities of the PPS’s Key Contacts?

-How a Key Contact bridges the gap between legislators and constituents

-The personal and professional benefits of being a Key Contact

-And so much more!



Tyler Vander Zanden Twitter

Private Practice Section Key Contacts


A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Clay:

Clay Watson a Physical Therapist and owner/operator of Western Summit Rehabilitation, a consulting and therapy services staffing agency for home health. He is a  Past President of the Homecare and Hospice Association of Utah, a member of the Utah Falls Prevention Alliance and a recipient for an NIH falls prevention grant. This year I received the Excellence in Home Health Therapy Leadership Award from the Home Health Section of the APTA.

For more information on Kelly:

Kelly received her COMT (Certified Orthopedic Manual Therapist) from the North American Institute of Orthopedic Manual Therapy in 1994 and is an Orthopedic Certified Specialist (OCS). She received her Physical Therapy degree from Pacific University in 1983.

Kelly prides herself as being an excellent general orthopedic physical therapist. She specializes in lower-extremity dysfunctions, biomechanical assessments related to running/sports injuries, and assessments from minimalist training to custom-molded orthotics. She focuses on injury prevention through balancing the full body, not just the area of pain.  Additionally, she has specialized in the area of Temporomandibular dysfunction (TMD) for over 30 years.

Most recently she has been active in starting a BreathWorks program focusing on evaluation and education related to breathing physiology and its effect on overall wellness and healing. Her clinical skills continue to move in a direction that empowers clients to achieve their highest level of function in a balanced fashion.

Kelly was a 3-sport collegiate athlete and continues her love of athletics through her own personal training, running, yoga  and being a supportive presence  at her kids’ sporting events. An outdoor enthusiast, she loves trail running, hiking, gardening, camping, and keeping up with her husband Greg and their 3 active kids.

For more information on Tyler:

Dr. Tyler Vander Zanden is the former Founder and CEO of Movement Health Partners, a private practice company partnering with federal, corporate, and educational agencies to provide physical therapy services.  Tyler currently serves as a member of the Key Contact Subcommittee for the Private Practice Physical Therapy Section (PPS), where he meets with legislators to increase awareness of the key issues facing physical therapist-owned businesses and their patients.

Tyler earned his Doctorate of Physical Therapy from Marquette University along with a BS in Exercise Science.  Upon graduation, he completed a post-doctoral residency in Orthopedics from the University of Wisconsin-Madison.  Tyler is a board-certified by the American Board of Physical Therapy Specialties (ABPTS), as a clinical specialist in Geriatric Physical Therapy.

Tyler has an avid passion for high performance, technology and entrepreneurship and speaks regularly about finance and technology as it relates to the future of physical therapy.  He currently resides in Austin, TX where he serves his church and community and is launching his next start-up venture.

For more information on Jenna:

Jenna Kantor (co-founder) is a bubbly and energetic girl who was born and raised in Petaluma, California. Growing up, she trained and performed ballet throughout the United States. After earning a BA in Dance and Drama at the University of California, Irvine, she worked professionally in musical theatre for 15+ years with tours, regional theatres, & overseas ( until she found herself ready to move onto a new chapter in her life – a career in Physical Therapy. Jenna is currently in her 3rd year at Columbia University’s Physical Therapy Program. She is also a co-founder of the podcast, “Physiotherapy Performance Perspectives,” has an evidence-based monthly youtube series titled “Injury Prevention for Dancers,” is a NY SSIG Co-Founder, NYPTA Student Conclave 2017 Development Team, works with the NYPTA Greater New York Legislative Task Force and is the NYPTA Public Policy Committee Student Liaison. Jenna aspires to be a physical therapist for amateur and professional performers to help ensure long, healthy careers. To learn more, please check out her website:


Read the full transcript below:

Jenna Kantor (00:00):

Hello, this is Jenna Kanter with healthy, wealthy, and smart. I am here with three newer friends this year. We all our key contacts with the private practice section and we're coming on. Well, they're going to do more of the talking here. I'm just going to be doing the questions and if we're coming on to just say, Hey, this is a great opportunity to get involved. If you do not like the CMS cuts, this is what we do. We go and speak with the legislators to talk about that. We're getting more people to come and join us in this huge movement to fight for our profession, especially the private practices for all you people are working for private practices. This is the committee to be a part of, so please, please join the APTA, come join us and be a part of this great movement. I am here with Kelly Reed, Tyler Vander Zanden and Clay Watson. Yes, you guys. First of all, thank you so much for coming on. So I'm going to hand it to you first. Kelly, how did you first learn of being a key contact?

Kelly Reed (01:06):

Yeah, so I've been a member of PPS since I got out of PT school and I've always been involved. I've been on the board of PPS and wanting to get back into it. And so I just put my name out there, who needs help, how can I be helpful, wanted to kind of get on the government affairs committee. And instead I got asked to be on the key contact task force and it's been amazing.

Clay Watson (01:33):

I'm friends with some other physical therapists who've participated in this project and we had some interesting legislative successes in our state that helped reform some payment policy issues. And it kind of led to them asking me to help out with the congressional level.

Tyler Vander Zanden (01:53):

I actually got invited last year at the 2019 Graham sessions in Austin and I live in Austin. And that really kind of propelled me to do something, a call to action and how can I get involved personally. And so I looked at PPS to see where I could be of service and one of the openings was this key contact position.

Jenna Kantor (02:15):

I love it. And just to make sure for any students who might be listening, PPS stands for private practice section. So it is a section of the APTA. Clay, I'm going to move to you just because my eyes just happened to look up at you. So what does a key contact do?

Clay Watson (02:33):

We have been asked to develop relationships with specific legislators and every member of the private practice section and the APTA lives in a congressional district or they have a Senator and it makes sense to pair up people who have vested stake in policy to have a relationship with a representative or a Senator from their state. And this program designed to help us have longterm relationships so that when policy needs are coming up, we'll have a listening ear and there'll be able to hopefully hear the sides of our argument that are most beneficial to our profession.

Jenna Kantor:

Kelly, what is the time commitment with this?

Kelly Reed (03:14):

Yeah, minimal. We are asked, well a couple things, we have a monthly meeting and we are given contacts of which you just email the people and try and hook them up with their legislator and that might take, depending on how long your list is, you know anywhere between 15 to 45 minutes. Then we have an hour meeting and then the bigger thing is that we are provided all the information we need and when an action item comes out they send it to us and then all we have to do is basically cut and paste a letter and send it off to our legislature.


Jenna Kantor:

Yes. Would you Tyler mind differentiating between being a key contact with private practice section and also being a key contact on the committee?

Tyler Vander Zanden (04:09):

Yes. So being a key contact in general, what we're asking of those individuals that they be a private practice member and that they live in the district to what we're trying to assign them to. So we want them to have a relationship with that Congressman or Congresswoman in their specific district. So like as Kelly said and clay said, when there's an issue at hand in the profession or just to private practice in general, that congressional leader has a name and face of a person or a clinic that they can say, Oh, wow, you know, Kelly or Jenna or clay, like, you know, you're dealing with this right now and you're one of my constituents. And so we can have that relationship. And so that's what it looks like more at the key contact level. For us, like Kelly said we're on the committee side.

Tyler Vander Zanden (04:55):

We're the ones who are providing education to that specific key contact in the form of emails. We'll kind of give them block templates. So when they have to make that communication, it's not so hard. We send them and the practice or a chapter here sends us emails that they can be kind of up to speed on these legislation things. And then we recently had shot some videos in DC explaining the roles of the key contact. And so there'll be some videos that we'll have on the PPS website that they'll be able to always link back to if they need more education.

Kelly Reed (05:33):

Yeah. And I just wanted to build on those videos. They're short snippets, they won't take a lot of your time, but it gives you a lot of key information, just the nuts and bolts of what you need and you can look at them at your leisure and really helpful information.


Jenna Kantor:

Yeah. Clay, does it work? Does making a phone call if instructed to do that to sending an email or meeting with the legislator? Does that or is that a waste of people's time?

Clay Watson (05:59):

Well, it wouldn't be a waste of time or we wouldn't do it. Right. I mean one of the most interesting things when we had a legislative fly in this fall, I was with another therapist who had actually written the letter to get the wife of one of our congressmen into physical therapy school and it was her first employer. Now she's a home health physical therapist and that's what I do. I'm private practice owner, but I work in home health and when we are asking him questions specific to our industry, he understands private practice and he understands home health better than almost any Congressman out there. And so that's just a huge listening ear that we wouldn't have if we didn't have those longterm relationships.

Jenna Kantor (06:41):

I really just want to add in person is more effective than on the phone. On the phone is more effective than email. It is like any other relationship. So really the best way to make no change is to not do anything. What we're doing is the best way to make a change. It's where we have this insane power as constituents. Now for you, Kelly, what has been the biggest thing that has moved you and how the private practice section runs and works with the key contacts? Like what do you think is just so incredible that they do to make us so efficient with what we do to put our message out there to the right people?

Kelly Reed (07:27):

Yeah, I've been really impressed with the amount of information that PPS already has put together and the task force and members before us that are currently on the task force. Basically they hand you everything you need to be able to do your job to make and develop a relationship with your Congressman. It's really easy and I want to say for those who may be put off a little bit about not getting politically involved, we have to, this is our profession and when we know what we know, we know what we love and all we have to do is communicate that message. We build relationships every single day and that's exactly what this is just talking about what we love.

Jenna Kantor (08:11):

I think that's excellent. And any last words that any of you would like to say in regards to becoming a key contact for anyone who might be hesitant on jumping in?

Clay Watson (08:23):

One of the most important things I've learned is the value of the mentorship I've received from participating in this. Every time I have a question about how to approach an issue with one of our legislators, I have three or four other therapists who are also doing it that I can ask. They may know context about the legislature themselves and how to approach them on specific issues and they know the nuance of the issues in a way that helps me understand them with a lot more depth. So it's sort of like a pretty high value team to help the whole situation move forward and that's invaluable.

Jenna Kantor (08:56):

I love that. Thank you so much. And if you're wondering, I don't know what this is for me, why am I listening to this? They're just selling me, telling me to get involved. This is where the change you want to happen. I get the most interactions on my personal Facebook page when I write the word happiness because people are happy in the physical therapy world. This is what we are doing to make that huge change. I am saying this statement very strongly. I know everybody can have their own opinion. This is mine, but this is the majority of the profession in which I interact with which are non-members. This is the big culture of unhappiness and this is where we make that change. The private practice section are movers and shakers and are listening and taking such great action. These people who are here, who I'm interviewing are passionate, kind humans. We are all volunteering our time. We are all not getting paid and we're all doing it for you and we would love for you to join us because your voice is valuable.

Clay Watson (09:58):

Well, I think most of the time the people who are unsatisfied with the profession are the least engaged and sometimes they are very engaged in are not happy. But generally speaking, the more you're involved with the APTA, the more voice you have and the more ability you have to affect change. As physical therapists, our whole life is based on helping people affect change. And if you feel disempowered or however you want to describe it, the way to get that power back is to follow your own practice and dig in and take responsibility for it as much as you can. And there are many times when you're going to do it for not, that's just how life works. But the truth is trying to get better is amazingly empowering. And once in a while you get lucky and you actually do make a big change.

Tyler Vander Zanden (10:46):

Yeah. And I just wanted to say one more thing to dovetail is you're not alone. So if you're right now, if you're stuck and you're trying to figure out what to do, you have to start somewhere. And one of the beautiful things about getting on this subcommittee now less than a year is the networking and everything that the PPS and all the people that I've been able to meet not only in private practice, but then as a result of this legislative work that we've done. So something really to consider and if your slot is taken if you want to get on here and we don't have a specific slot open in your district, you can always start these efforts on your own and we would always be able to help you with that education that's still on the website there for your use.

Jenna Kantor (11:28):

I love it. Thank you. Thank you to each of you for coming on, this has meant so much to me. I know it means a lot to you as well. If any of you want to learn more, you can go to the private practice section website. It's under the advocacy tab where you'll find committees and you'll find key contacts. That's how you can get involved. Thank you for tuning in. Take care.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

Mar 26, 2020

This episode of the Healthy, Wealthy and Smart Podcast features a Private Practice Section Webinar, “Telehealth NOW” to address ongoing concerns for physical therapy practices during the COVID-19 pandemic.

In this webinar, we cover:

-How to navigate telehealth terminology and different vendors

-State and federal telehealth regulations to frequently check

-How to effectively bill for telehealth services

-An example of a telehealth physical therapy visit

-And so much more!



Lynn Steffes Twitter

Mark Milligan Twitter

Ali Schoos Twitter

PPS Covid19 Resources

ZOOM Recording of Telehealth Now Presentation 

Telehealth NOW Presentation slides

PPS Promoting Telehealth to Patients

PPS Tips and Tricks to Starting Telehealth


PPS Telehealth Coverage Policies during COVID19  


For more information on Lynn:

Lynn Steffes, PT, DPT is President/Coach/Consultant of Steffes & Associates, a rehabilitation consulting service based in Wisconsin. Providing consulting services to rehab providers nation-wide working.

She has enabled providers to achieve optimum success in the delivery of high quality, cost-effective care to their patients/clients.


Coaching/consulting in:

  • Marketing, program development
  • Selection, training & support of Practice Marketing Specialists
  • Customer Service initiatives, patient alumni programs
  • Lifestyle Medicine Programs
  • Negotiating managed care contracts, payer relations


Dr. Steffes is a 1981 graduate of Northwestern University and Transitional DPT in December of 2010 Evidence in Motion's Executive Management Program.


For more information on Mark:

Dr. Mark Milligan, PT, DPT, OCS, FAAOMPT earned his DPT at the University of the Colorado. He is a full-time clinician and owner of Revolution Human Physical Therapy and Education, a concierge PT practice and micro-education company. He is adjunct faculty for 3 Doctor of Physical Therapy Programs. Mark has presented at numerous state and national conferences about telehealth, pain science, dry needling and has been published in peer reviewed journals. He is the founder and CEO of Anywhere Healthcare, a telehealth platform for all healthcare disciplines. He is an active member of the TPTA, APTA, and AAOMPT.


For more information on Ali:

Ali Schoos received her degree in physical therapy in 1982 from the University of Puget Sound. She is a co-founder of Peak Sports and Spine Physical Therapy, practicing in Bellevue, WA. 


Ali has been active in numerous roles in the Physical Therapy Association of Washington (PTWA) and APTA.  She  has chaired her state private practice Special Interest Group (SIG) and Orthopedic SIG, and  currently serves on the APTA Private Practice Board of Directors. She is also currently serving on the PPS COVID19 advisory task force. She is a past board member of the Bellevue YMCA and on the King County Regional Advisory Group for the Alzheimer's Association


Read the full transcript below:

Carrie Stankiewicz (00:00:05):

Hello everyone. Welcome and thank you for joining us for this special webinar tele-health NOW. I'm Carrie Stankiewicz with education and program manager for the private practice section. Before we get started, I'd like to review a few procedural items to submit your questions. Please enter them into the Q and a box which you can access from the zoom menu. We'll collect your questions there and the speakers will respond to them. As we go through the presentation, we expect to have a large number of questions so we need to manage them carefully in a moment. Ali Schoos will give you some parameters around entering your questions. If you have a technical question, you can type that into the Q and a box and I will respond to you in text. Please note that with the extremely high volume of companies and individuals that are now using online platforms for conferencing, there is a strain placed upon the technology and the infrastructure. Our vendors have done their best to provide a high quality experience, but neither we nor they can control internet slow downs resulting from unusually high volume. In the chat box, we posted a number of resources for you to refer to. Please feel free to copy these links and save them for future reference. This webinar is being recorded and will be posted on the PPS website for everyone to view. And with that I'll turn this over to PPS board member Ali Schoos to get us started.

Ali Schoos (00:01:26):

Thanks Carrie. Hi everybody. I’m Ali. I am a private practice physical therapist from Bellevue, Washington. And thank you for that musical introduction. I am the cofounder of Peak Sport and spine physical therapy in the Pacific Northwest. And I do have the honor to serve you on the board of PPS. I'm also on the advisory task force around all things COVID-19 and this webinar is a result of that task force. Our goal is to bring you business owners relevant information right now to help you manage your practice through this crisis and come out whole on the other end. But the end a couple things about our question process. There are 500 of you on this webinar. So we do expect to have probably more questions that we can answer. So we would ask that when you post a question look and see if anyone else has posted a similar question so that we don't get bombarded with the same saying.

Ali Schoos (00:02:28):

Don't ask state specific questions that's relevant to the laws in your state and mandates in your state. So we're not going to be able to answer a state specific questions, although we will keep a copy of all the questions that come in and try to deal with them later. We will stop intermittently to answer as many questions as we can and I'm going to apologize in advance. I don't think we're going to be able to answer every single thing that you asked, but we'll do our best. I would like to introduce our main presenters. Dr. Lynn Steffes is a graduate of Northwestern university and earned her transitional DPT in 2010 from evidence in motion's executive management program. Lynn is the president, coach and consultant with Steffes and associates. It's a rehabilitation consulting service based in Wisconsin. Lynn provides consulting services to rehab providers among a wide range of services including marketing and program development selection and training and support of practice management specialists lifestyle medicine programs, negotiating contracts.

Ali Schoos (00:03:34):

And Lynn's also been a frequent provider of content, the educational webinars that KPS puts out. Our second presenter is Dr Mark Milligan who earned his DPT from the university of Colorado. Mark is a full time clinician and owner of revolution human physical therapy and education, a concierge, PT practice and micro education company. That was a new term for me, Mark as an adjunct faculty for three PT programs. He has presented at numerous state and national conferences on tele-health, pain science and dry needling. And he's also been published by peer review journals. Mark is the founder and CEO of anywhere healthcare, a TeleForm platform for all health care disciplines. And with that, I would like to let Lynn take it away.

Lynn Steffes (00:04:32):

Okay. So welcome to this webinar. And before I get started, the first thing I wanted to say to all of you is really we're here honoring you for the good work that you're trying to do in serving consumers in your marketplaces. So we know that all of you are incredibly dedicated, compassionate, amazing clinicians and business owners that are looking at this COVID crisis today. And then also looking forward and seeing how can we best serve our patients. And, many of you may be continuing to serve some people in your clinics or you may not be, but we certainly wanted to talk about this really important option. And to give you a little bit of background on some details with it. So with that, I'll jump into more of the content information. So the objectives that I'm in a primarily deal with are just looking at the position, talking a little bit about the statutes and rules that will govern your ability to deliver and access these services. And also some information about payment policy, whether it's federal, state, commercial, work comp. And then I'm going to turn it over to the real expert who is Mark Milligan. And so I kind of get stuck with the fun stuff, the payment and policy things. So next slide.

Lynn Steffes (00:05:58):

So APTA has long had a position that tele-health is an appropriate model of service delivery and as long as it's delivered with the same essence really that we deliver care. And so this isn't new to APTA to be looking at telehealth as a way of delivering care. At a state level. Different States have different rules or excuse me, statutes and rules that govern your ability to deliver telehealth care. So rather than us focusing on any one state today, what I'm recommending to you is that you reach out to your state level associations. APTA has a site that looks at state statutes and rules and determine what your current level of coverage is regarding tele-health. So there are two different aspects of telehealth that you would need to look at that are legal at a state level, which is obviously governs what you can do within your scope of practice. And the one is your statutes and rules that govern your scope. And the second one really is, are there specific tele-health laws in your state that would in any way limit you from delivering those services?

Lynn Steffes (00:07:17):

Keep in mind that if you've looked before or downloaded those policies before they may have been updated or there may be some emergency provisions in place. So I encourage you to begin there. So that’s an important first step. Certainly anytime you deliver outside your scope of services, your malpractice insurance is no longer required to cover you. So it's important to do. So one of the things that we want you to think about is as your considering telehealth we want you to first check your state practice act to verify just as I had mentioned, and then also find out if there are emergency provisions. It's possible that your state practice act is silent on tele-health and as long as there isn't a prohibition that I would turn to your chapter for guidance and they're examining boards need look further, you certainly are going to document legal and ethical reasons.

Lynn Steffes (00:08:14):

You're converting patients to telehealth visit, so if you've never done tele-health before or eVisits and you're going to start doing so, I think it would be important for your practice setting to document that transition and the decisions that were involved. You're going to also have to make sure that you are securing consent for each of your patients along with the right to refuse. I've been most of you know that your individual States have consent laws that govern what type of consent you have to get and it'll be important for you to get consent for telehealth or evisits and the format from your patients. Most of the time it will be fine to secure that consent verbally and to document when you received it carefully in the medical record. It's also a good idea to look at what types of emergency policy procedures you might need to put in place.

Lynn Steffes (00:09:10):

For example, if you were to be teaching a patient exercises and they're working on them in their home through a telehealth visit and they fell, what would you do to address the emergency? Are there other folks that their family members, caregivers there and then how that might be handled. And that's something you may even want to look at with your legal team. Keep in mind also if you're going to start using telehealth, that a secured portal is ideal and if you have a secure portal or something that is designed to share information over the internet or phone, you're going to need a business associate agreement in place that ensures HIPAA compliance. I think Mark's gonna deal a little bit later with some of the other HIPAA things that give us a little bit of wiggle room right now and then finally make sure and review your malpractice insurance policy to make sure you're covered.

Lynn Steffes (00:10:03):

I know HPSO provided guidance that we have a link on. And I also know PT1 PGM provided guidance on that saying you're covered. So, real quickly, I want to just start off by saying there are different types of visits. I think when this was first announced that Hey, Medicare is gonna cover a PT as a tele-health service. Everyone got very excited and what they didn't realize is that Medicare actually is not covering telehealth. Instead, we're going to talk about the distinction between the eVisits and then telehealth. We also have third party payers, commercial payers that are covering assessment and management visits and not tele-health, and then the actual telehealth visits. So we're going to kind of explore those three areas, but we want you to really listen for which area might fit your practice in your regulatory environment.

Lynn Steffes (00:11:03):

So true tele-health. Let's start with the good news. If we could do true telehealth and we can often, we're going to bill our 9700 codes. We're going to continue to apply the GPP PT modifier, but we're going to also use the OTU place of service code, which is going to communicate that we're doing tele-health. Now, some payers may actually be looking for either a different modifier or an additional modifier. So we're going to talk a little bit later about how you get that information from your payers, but it certainly is important.

Lynn Steffes (00:11:47):

I wanted to start off by saying that a lot of codes are out which are often used in telemedicine, which is physician covered telehealth 99421, 22 and 23. These are actually evaluation and management or ENM codes and those codes are really reserved for physicians or other qualified non physician providers such as PAs or NPs in general. These codes exclude therapist's ability to bill. However, we have been hearing occasionally that there are third party payers that want us to use that code. So I'm just going to say if someone suggests that you use those codes to bill those services, make sure that they provide a URL or a link for you so that you can see the policy that ensures that you will be covered for those codes. Because those are traditionally not therapy codes. Payment from Medicare. So we were super excited and we heard tele-health is covered. And really that was a misconception at the beginning. Medicare doesn't consider physical therapists as an approved telehealth provider. The list is in the bullet below. But Medicare advantage plans can actually make their own decisions and may choose to cover tele-health itself. A lot of times policies are carrier specific.

Lynn Steffes (00:13:20):

This slide is really pretty important and it's just to give you the sense that take a look at the date of this press release, CMS finalizes policies to bring innovative tele-health benefit to Medicare advantage. That was April of 2019, which seems like a hundred years ago right now. A very different time. And so Medicare advantage plans definitely had plans to expand telehealth services, but those plans also did not include PT, OT and speech. So this is not a new idea or a new fight that we're trying to leverage. However we may be in a unique position and I'm kind of a silver lining person and I'm hoping that this opportunity might actually give us a window to get in next. Your Medicaid programs. As you know, Medicare is more federal and Medicaid is state driven. So some Medicaid programs have tele-health policies.

Lynn Steffes (00:14:24):

The telehealth reimbursement policies vary state to state. Those are very fluid. We just have had multiple updates being published in the last three days in Wisconsin. So I know for a fact that you're going to have to kind of stay on top of that to determine if you're trying to serve the Medicaid beneficiaries in your state. How that policy might change in response to the COVID crisis. So keep looking and you're going to have to, this is a moving target. So keep in touch, keep going. So what type of virtual visit again and we talked about there's an evisit, there's assessment and management or tele-health. Let's look at what the actual definition for an evisit is in the 2020 physician fee schedule. Final rule, CMS described eVisits as non face to face, patient initiated. So I want you to really pay attention.

Lynn Steffes (00:15:21):

This has to be initiated. So the contact has to be initiated by the patient. Digital communications that require a clinical decision. So again, clinical decision, that's really important. So you are going to have to document that clinical decision making was made during the contact of a visit that might otherwise typically been provided in your office. So this is the definition of an e-visit and the code descriptors that Medicare is using. Our hick picks codes are related to the eVisits and they're really designed as a short term, kind of like a, I always think of it as like a bridge loan when you're building. They're designed to cover short term up to seven days of assessments and management activities that are conducted online or through a digital platform. And then again include clinical decision making. So what's an online patient portal? HHS has described a patient portal as a secure online website that gives patients convenient 24 hour access to personal health information.

Lynn Steffes (00:16:29):

Patient portal requires a secure username and a password in the absence of broadband access online accounts or smart phones or other means. CMS has indicated they want the service to the furnace, so they're giving us more flexibility. Mark's going to talk more about the technology a little later, but I just wanted you to know the Evisit has, you know, variety of opportunities including something like doing FaceTime with your patients. Go ahead. The billing and coding is what I think you're all waiting for. So physical therapists are eligible to use the Hicks picks codes and these codes require a CR modifier and the CR modifier really indicates that they're related to the COVID crisis. So we have G two Oh six one six two and six, three again, the definitions qualified, non physician healthcare, professional online assessment management. It has to be for an established patient.

Lynn Steffes (00:17:27):

And lots of questions come up. What is an established patient? It is a patient who you're currently seeing under a plan of care. And so what would happen is if you were seeing the patient, you'd have the next seven days to provide some type of E interaction with that patient that provided clinical decision making in input with them. That would be much like what you do in the office. And so the different code levels are really time-related. So imagine that you saw someone today's Wednesday. So imagine that you saw them in person on Monday. There would be a seven day consecutive day window at which time you could have one contact with them or you could have a couple contacts. Each time you had a contact you would have to document the contact information. But really when you actually go to bill the code, it would be a summary of the seven days and the documentation at that point in time would summarize what type of clinical decision making assessment and management occurred over those contacts. As you can see nobody's retiring with this funding. We've got the five to 10 minutes at 1227, 11 to 20 2165 and 21 or more minutes at 33 92 so pretty limited. The place of service is the location of the billing practitioner, which Medicare is suggesting that we would do places service 11 and you can deliver these services via the phone.

Lynn Steffes (00:19:10):

Assessment and management are comparable codes. Non hick picks but they're CPT. So nine, eight, nine, six, six, six, seven and six, eight and those are actually used for telephone assessment and management services, again by a non qualified physician health care professional to once again an established client. But this one further expands and says a parent or guardian. So these are again established patients and they have to be initiated by the patient. That doesn't mean that you can't contact the patient and offer them this service. It doesn't mean that you can't help them set up et cetera. It just means that the call itself that you're doing, the assessment and management code has to be initiated by the patient. The assessment and management codes have a little bit more parameters put around them. And one is that the call can't or it can't originate from the provider and it can't be within the previous seven days.

Lynn Steffes (00:20:13):

So the case I gave earlier for the visits, it would have to be seven days prior. And then it would be the assessment and management calls and then you couldn't see them again within the next 24 hours. So there are these windows of time, seven days prior you couldn't have had a physical one-on-one visit with them and 24 hours after. So as of right now, if you're going to be doing these assessment and management codes they would have those limitations. These are codes by the way that I'm starting to see emerging from some of the commercial pairs as covered in lieu of the hick picks codes.

Lynn Steffes (00:20:59):

These again are telephone discussion times thereby to 10 minutes, 11 to 20 and 21 to 30. And of course, because these are other payer codes, you'd have to look to the payer for coverage of the codes and payment. So true tele-health, we're back to that. There really isn't a specific CPT code for true tele-health. You would be using the therapy codes, the 9700 series paired with the OTU place of service code, which would indicate that it was provided remotely. Because if you're going to be providing these CPT codes, face these what are called face to face codes, which I would argue if you're doing telemedicine or telehealth, excuse me, they're face to face, you're going to have to verify that the payer allows you to use these codes when they're tele-health. So you can't just build these codes leading the pair to believe that they were provided in our office X. I wanted to say payer policy is fluid and that is followed by multiple exclamation points.

Lynn Steffes (00:22:07):

This is changing so fast. I literally just got off the phone before I stepped on this call saying we've got legislation coming in our state that's going to do some mandates. So you may have to check regularly. For example, in the state of Wisconsin, our governor just issued a stay at home order. So peers are going to have to reevaluate their policies if they want to continue to have their enrollees get services. So when you are, whether you hear from one another provider or whoever that someone covers telehealth or someone covers assessment and management or EAD visits, I would suggest that each time you call, you verify benefits and you're going to ask several questions, are you or the physical therapist eligible for telehealth payment? If so, which CPT codes would be completed via telehealth, so which CPT codes will be approved and then what modifiers are required.

Lynn Steffes (00:23:07):

So the modifier GT or 95 is often used in facility billing and the place of service OTU in independent practice billing. And then you're going to want to also find out what their payment rate is. So if they allow you to build nine seven one one zero will there be parity in what they pay you or equivalency and what they pay you based on telehealth versus in office. Are there any restrictions on the location of the PT or the patient? Because of course, right now if your PTs are practicing from home, that would have to be okay or your patient may actually live in a CBRF or other facility. Then what devices or applications do they have any restrictions on that and what if any consents are required and then any special documentation requirements. So those are some of the good questions to ask.

Lynn Steffes (00:24:00):

The other thing I will say is regardless of what they tell you, if you can get a link to their peer policy or anything in writing from them, I would highly recommend that you do that. And then don't assume that what is not covered today will not be covered tomorrow. And what someone tells you is covered may not be covered. I've already had providers that said, they called and asked about telehealth. They said it was covered and when they called back in a second patient, they said, well that's not what we meant. So be careful. And finally both Mark and I have been using this a lot. The center for connected health policy has a ton of great resources, but one of the best that I think you're going to want to download that will give you far more details than I'm able to give you in this brief discussion is their billing fact sheet. So the link to the billing fact sheet is here and I wish you the best. I think we can provide amazing services in person and also via these wonderful technologies. So thank you.

Ali Schoos (00:25:10):

Thanks Lynn. So a number of questions, they've come in and I answered a few of them. So if those of you who received the answer, if that wasn't enough clarity, ask it again. But then I'm just going to let you know what some of the questions are more clever. We can answer them. One, yes, you'll have access to the presentation after it's over. This is being recorded and it will be posted on the website, the next question, will we have access? Why need an option to refuse consent? Wouldn't the person just declined to sign consent? It said in the consent form that we have to give them the option to refuse.

Lynn Steffes (00:25:49):

Well, part of the option to review is, and that's a really good question, is if someone gives consent once, they still have an opportunity to withdraw consent or refuse it in the future. So someone tells you, you know, I'm happy to do telehealth or I'm happy to do evisits and they give you consent and the next time that you're in contact with them, they call and they say, I don't want this anymore. They always have that opportunity to review. So that's typically what that's for. I will say that each state practice act and sometimes an overriding practice act over healthcare professionals tell you what's required for consent.

Ali Schoos (00:26:28):

And then another person asked about the secure patient portal being ideal, but it didn't CMS make a, the HIPAA compliance issue more lax and the pre-cancers yes.

Ali Schoos (00:26:43):

Mark, he's got that later in the presentation. Can you build the e-visit code every seven days or just once and done?

Lynn Steffes (00:27:01):

As far as we don't, I don't know. We've been asking that question if it can be billed repeatedly. We've heard yes. And we've heard no. So I'm not sure. I don't know Ali or Mark, if you know anything more.

Ali Schoos (00:27:14):

It's the same thing. And I apologize, we cannot get a straight answer on that. I think some people are saying, I'm just going to do it more than once and see what happens. Again, it's not a big charge. You're not going to get rich or go broke. So if you want to try it, the worst that'll happen is that a bit tonight.

Lynn Steffes (00:27:30):

Right. And we haven't had to seven day periods to try it yet. They've been released. So it hasn't even been an opportunity.

Ali Schoos (00:27:36):

Right, right. And then does the evisit have to occur within seven days of the last in-person visit or could it be 10 days or 14 days after the last in-person visit?

Lynn Steffes (00:27:53):

I don't think there's a restriction that says it has to be within seven days. I just think it can't be sooner than seven days.

Ali Schoos (00:28:00):

Yeah, I understand. Okay. and then someone wanted an example on it, an example regarding the verbage to justify the clinical decision making to use an evisit

Lynn Steffes (00:28:16):

For an individual patient or the practice.

Ali Schoos (00:28:18):

So when you're documenting, you know, political decision making. Yeah.

Lynn Steffes (00:28:23):

Okay. So you could document that either the facility or the patient or the clinician made a decision that it was safer to do an evisit versus the in person visit. And that there was a good, a good reason to do that in your clinical decision making would reflect that you advise the patient or gave the patient it's specific instruction. The patient asks you questions, you update an exercise program, you perhaps revisited how they're doing on something and gave them feedback. So again, it's kind of like you're documenting a regular visit but the clinical, so I would decide that you did the visit you know, virtually for a fairly simple, straightforward reason that that was what was appropriate at the time due to the crisis or for the patient. Now, Mark, you may address this later when you're talking about tele-health on an ongoing basis because there's lots of good reasons to do it. But right now I think we're talking COVID.

Ali Schoos (00:29:29):

Right? And then Mark you want to address now or later what you might be documenting when COVID is over.

Lynn Steffes (00:29:38):


Mark Milligan (00:29:42):

So this is a new space to navigate. And so when this crisis is over, I think that this will be a normal part of a plan of care. Right? So it will be an expected plan of care that you will put forth in a patient that they will have a combination of both digital and in person visits. If you line it out from the beginning and set it up that way, then there no deviation or there a deviation from your initial plan of care. That's how I would handle it.

Ali Schoos (00:30:10):

And then one person did ask if you have, if the patient, if you do a second seven day visit, yes. The patient would have to initiate that phone call the second time as well or that contact the second time as well. Yeah. Can you see a Medicare patient per tele-health per cache? Some many visits are covered and I did answer earlier. Yes. You can see Medicare patients for past, since telehealth is not actually covered.

Lynn Steffes (00:30:39):

Absolutely. Any patient where it's not a covered service unless you have, for example, say you had a contract with a certain commercial payer that had a prohibition to doing any services, which rarely do they for a non-covered service. You would inform the patient that this is not a covered service and you could go ahead and bill cash for it. For your Medicare patients. And ABN is not required, it's optional, but some folks will use the optional ABN kind of as a backup to ensure that they feel that their Medicare patients were well informed that this was not a covered service.

Ali Schoos (00:31:17):

That's a great question. Wanting to know if your PTA can provide the telehealth service if the supervising PT is not online with them because it's virtual

Lynn Steffes (00:31:30):

Currently for Medicare. The answer I believe is no, but I don't know with other payers. And that would be a question. If you were anticipating a PTA providing the services telehealth services that you would ask. I would think that the visits because they involve clinical decision making and the assessment and management would likely not be covered. But I can't, I think telehealth would be flexible. What do you think Mark?

Mark Milligan (00:31:59):

Right, so Texas just, I think we also have to default to the rules and regs of the state level as well. Texas just eliminated the verbiage that eliminate, that took PTs away from delivering tele-health. So state rags may have a prohibition written that physical therapist assistants can't provide that care. I need, I'll pull up the Texas specific language that I believe there's a caveat that says that it cannot be used for supervision, but no one has defined whether or not a PTA can perform it being unsupervised. Does that make sense? PTs are not physically being supervised in all scopes practice, right? Like in home health settings. PTs are not digitally covered or supervised by or physically supervised by PT immediately. It's by phone contact. Right.

Ali Schoos (00:32:48):

Well I get in state law. Yeah. And obviously in a private practice for Medicare there has to be onsite supervision.

Mark Milligan (00:32:58):

Right. So state law and then I'll, yes, I can check with the Texas regs too, but it's a state regulated issue.

Ali Schoos (00:33:06):

Yeah. Very good question. And there they are pouring in now guys. So lots and lots of questions here. I'm trying to go through them. Should we keep going and let Mark deliver and then we'll go back and ask more answers. And some of these make an answer with Mark's presentations. We'll come back to these. Yup.

Mark Milligan (00:33:23):

All right. So thank you for allowing me to be here and being with you guys in this presentation. Lynn, I know that you said earlier that that's not the exciting stuff, but that's what everybody wants to hear. So regardless if it's exciting, it's definitely information that is necessary for all of us to continue to keep our doors open and see patients. Right? So again, I'm Mark Milligan, I'm out of Austin, Texas and we're going to cover, basically we're going to cover just what tele-health is. We're going to get some baseline terminology, technology who players in the game evidence and then kind of how to implement it in a practice. Then is going to actually talk to us how to implement it into practice, right. Ali is has implemented this into her clinic. She's delivered care.

Mark Milligan (00:34:09):

She's also as a clinic owner has implemented as a clinic owner. So she's going to give us the nitty gritty on how this actually looks for a private practice owner. So we're going to start with basic terminology because again, terms, words have meaning and terminology can be misleading. And there's been a lot of misleading terminology that's been spread around the physical therapy world since tele-health and eVisits have all been introduced. So tele-health really is just a very large, broad term that describes any type of health, education or delivery of care using telecommunications technologies. And as you'll see that it applies to almost every profession other than medicine. Telemedicine is specifically owned and basically utilized only and exclusively with physician deliver care and their extended providers. Right. So I think one of the bigger issues that came across our country earlier or late last week was when tell them when I think the president said that telemedicine is going to be available for everybody and that you know, that there's these broad sweeping terms where it doesn't really change if you hear the term telemedicine, it doesn't shift anything for physical therapists necessarily.

Mark Milligan (00:35:21):

So you have to do your due diligence when it comes to looking at the information about telemedicine and who that applies to. Right? And so also when you look at your insurance policies and, and other types of documents, make sure that you're referring to telehealth or telerehab for physical therapy services. If you ask about telemedicine benefits, you will not be considered a provider for telemedicine. So make sure that you make those two distinctions. So tele-health again is we help manage our patients through their own their own illnesses to improve self care and access to education support systems and treatment. Telerehab is more of our specific a tele term, if you will. So really it's about delivery of rehabilitation service over a communication that works and the internet. So you can do assessment and functional abilities in their environment and clinical therapy.

Mark Milligan (00:36:12):

So when you're looking at benefits, you can also check to see if they have tele rehab benefits. Telerehab benefits also shows up more in clinical research, right? If you do research and look into the efficacy and effectiveness of digitally delivered care, tele rehab will be a much more used, utilized term than tele-health for physical therapy specific. Tele-Health again really accomplishes and encompasses all types of providers, dentists, counseling disaster management, consumer and professional education. So really tele-health is one of those terms that is not a very good descriptor of exactly what we do. But during these times, it's the most accepted term of what we do. So out of the all those things, just make sure that telemedicine, you understand that does not apply to us as physical therapists. And to make sure that if you hear something about telemedicine that you clarify that or that you clarify that those rules apply or may or may not apply to us.

Mark Milligan (00:37:13):

Some other terms that are coming up across the country are models of telehealth, right? So some terms of delivery so right now currently, what you're watching and how we're interacting would be a live video or synchronous technology. So this is a live two way interaction between the person and the patient and the caregiver or the patient, a caregiver or provider using the auto visual [inaudible] communications technology. So this can be used for both diagnostic and treatment services. And it's just like anything you've done on a video call with your family. So as long as you're live face to face talking to the patient, you're good. Second term is asynchronous. You'll hear this term floated around a circle. The asynchronous modes of communication are basically or otherwise known as store and forward. This is non live communication, right? So this could be emails of HEPs.

Mark Milligan (00:38:05):

This could be a recorded video of exercises that you send the patient. This could be a recorded exercise where the patient demonstrates their exercises and sends it to you. It could be lab results, it could be any type of electronic communication that happens on non-life, a synchronous video. So that's the important differentiator in those two modes of delivering telehealth. So those in some States, these get specific, I in Texas, I'll just give Texas, I'm here in Austin and Texas, you can't initiate tele-health via asynchronous mode of delivery. You have to have a live synchronous session before you can actually utilize asynchronous care. So depending on the state that you're in, that may impact the mode and model of how you deliver telehealth. So please be mindful of these types of definitions.

Mark Milligan (00:38:59):

Also there's remote patient monitoring is another term that's used. This is really about data health data that's collected from an individual at one location and delivered electronically to another. So when this comes to a lot of patients that have chronic diseases that they need to be monitored or something needs to be checked on them regularly, like wait for patients that have CHF they have a digital scale, they can weigh themselves daily and then that data is uploaded into the physicians portal or cloud and then they're monitored on a daily basis remotely for any progression of weight gain. That could be a contraindication or a need to necessitate a medicine change due to CHF. Typically right now, not a lot of physical therapists are in this space. They may be monitoring some of those patients, but they're not too many PTs are actually delivering this model of care.

Mark Milligan (00:39:50):

Typically this is a physician or hospital base. And then mobile health really depends on or is determined by apps and different mobile devices and things that appear that can be very portable, including tele-health. So I would, I would umbrella tele rehab and M health together because you can deliver it via a PDA, cell phone or tablet. Right. So this is more just to the, the more mobile you are as a provider, you can do telehealth with someone on the beach. And depending on your place of service code, you could deliver telehealth while you're on the beach. So just think about that as, as we talk about more app based functions of some platforms that could be applicable to that. So some of the technology that's really out there that we'll pretend I'll briefly brushed these just so you're aware of them, but know that right now in this time of the COVID 19 crisis, some of these may not be the best thing to implement into your practice right now, but know that the virtual reality and tele rehab is an extremely that's a very quickly developing technology where patients put on goggles and they can meet and go into augmented reality and meet their therapist in different spaces to perform exercises or to see exercises demonstrated.

Mark Milligan (00:41:03):

So it's a really cool technology. There's motion technology where patients can see themselves on the computer. And so they were they were able to look through and see themselves moving or get the movement collected from their body and pushed into a system. So sensors and body body monitoring have been they're an interesting technology where you can actually wear a piece of clothing or have a different sensor that will sense your body positioning and space and alert you and change your posture. Haptic technology as really interesting to me. It's cloth and clothing that you can actually generate sensations through distantly. So I could, a patient could have on a haptic cloth and then I can manipulate something a hundred miles away and they could feel the sensation on their skin. So I know if anybody has a new car and they're, and they've, you know, kind of diverted out of their lane and their seat has vibrated on there.

Mark Milligan (00:42:00):

But think about that as haptic technology and how that can be utilized in physical therapy for tactile queuing and for input AI, artificial intelligence that will come into play when we look at a larger type of systems and startup companies that are leveraging AI in order to deliver a digital physical therapy PDAs, electronical medical records, wireless technology, mobile apps are all just different ways that people can connect and also get data and information that can be a really important for medical monitoring. Right? So I think we all notice the explosion with the Apple watch that started to take a heart rate and other sensors and other vitals. And so that would be an idea of wireless technology and then that would also tap into the Apple medical records. So it all kind of is encompassed and in those, in that realm as well.

Mark Milligan (00:42:55):

So just terms that you should be aware of, not necessarily in the immediacy for the deployment of telehealth into your practice, but just to be aware of. So for your business really to get down and dirty and tele-health, typically it takes some time to implement telehealth into a practice. So do due diligence. You need to come up with your business plan, your patient demographics, right? Some people will not want to tele-health or they wouldn't choose telehealth at a given rate. But now with the current situation, many people are seeing this as a really viable option to dilute, to get care delivered to them. But you also have to make sure and take into consideration general cultural and generational issues. And also there's a tremendous bias amongst the long low income patients because they don't have access to high broadband wifi or they may not have a tablet to get care or they may not have access to a safe space to exercise.

Mark Milligan (00:43:46):

So please take into consideration patient demographics and the ability to deliver care because that may be impacted greatly depending on the patient population that you serve. So you also need to have relevant current healthcare delivery systems to how you deliver care. If you you need to make sure it blends with your current type of care and the delivery method that you deliver to your patients, you need to have skills and responsibilities as a PT providing tele-health. I'll touch on this briefly. Ali's going to cover some of this is that you've got to have good video, adequate etiquette. You have to make sure that you have, you know, appropriate lighting room to move and you need to be able to communicate nicely over video. And so that's a different wait, I know some of you have always had been on a tele on some type of teleconference when there's 48 people talking.

Mark Milligan (00:44:35):

Understanding the rules and kind of engagement by a telehealth is important to know as well. You also need HIPAA compliance scripts for patient communication and the protection of PI, right? If you're delivering care in a busy area where other people can hear you, you're transmitting their PI. So making sure that you take precautions and steps in order to and to protect your patients who you're treating digitally and on the other end, patient needs to be protected as well. And you also need to make sure you have appropriate policies and procedures in place for consent for medical emergencies. What Lynn covered earlier to protect PI, I know there's talk about people recording visits, right? Some payers I know in Texas are requiring recording visits to get paid for a telehealth. And so that video becomes a part of the patient's PI.

Mark Milligan (00:45:21):

So how are you going to store that? Who, where are you going to store it? How long? I mean, you store it from the normal five years. Right? So making sure that you have all of your business practices and policies in place for procedures is really important. And then your IT development and installation. Every system is different. Right now across the board you could have a list of a hundred different ways to deploy tele-health in your business. Just depends on how that model fits into your business and your patient flow. And to your workflow. So right now because of this rapid adoption, there's a lot of trying to navigate in plug and play systems, which is pretty normal. But it's even become more apparent that the need for some centralized systems for delivering this digital care.

Mark Milligan (00:46:08):

So you need it. That's my second question. You need a strong IT department to make sure you have secure system set up in place with your policies and procedures and protocol, right? So your equipment, I really want to make sure you're HIPAA compliant because as lens that earlier there has been a lowering of the shield of HIPAA during this COVID crisis. I'm going to sit here and tell you that you should always choose a HIPAA compliant, secure platform to deliver care if it's available. If it is not, then you may in that circumstance use a non HIPPA compliant platform, which we'll talk about later. But you need to do your due diligence in documenting why you chose that. And you need to document the time, the approximate length of time that that patient's PI was could have been compromised and the patient needs to be able to consent to this non HIPPA delivered care.

Mark Milligan (00:47:00):

Right? So I think that's an important part that a patient, like Lynn said about denial of their consent. You need to inform the patient, Hey, you know what? This isn't a secure platform. This is not a HIPAA compliant encrypted platform. Are you okay with continuing to go through with this? And they may or may not say yes, right? So you need to make sure that your connectivity reliable, you need to have bandwidth, audio and video interface quality. You need to make sure that the staff can use and learn the equipment both easily and onsite and remotely when needed. So can this function when you can't get to the clinic? Right. That's a great question. And is the system compatible with your current hardware software? Most tele-health systems right now can integrate. It just takes time. There's a process, typically integration of a telehealth system, depending on how you deploy, it can take a couple of weeks and maybe two to three weeks depending on branding and depending on how you want it to look.

Mark Milligan (00:47:55):

And so the scope of how you can deploy it into your clinical practice, the timeframes can vary anywhere from 12 hours, six hours to two, two to four weeks to six weeks, depending on the level of integration and the level of branding and the level of system that you want to deploy in your practice. All right, so some simple, the beautiful thing about this is most systems operate with very simple hardware, right? So you have some wifi up and download speeds that need to be a minimum. The minimum requirements, they need a laptop microphone or a headset. I prefer a good old wired headphones, right? I know this seems antiquated, but most people are switching to battery power to rechargeable headphones and they're lasting for an hour or two and then they're dying. So if you're in the middle of a healthcare day, if you're treating and training and triaging patients, I highly recommend either having a couple of sets of rechargeable earbuds or headphones or just go old school with cables and you don't have to worry about that at all, right?

Mark Milligan (00:48:56):

The mobility may be a little bit limited, but it depends on how you function in that telehealth visit that this may be restraining or not. It just depends on how you're set up. But again, it's hard. It's very challenging. Once your headphones die to do a visit through just the speakers on your computer, the qualities, it goes down pretty quickly. And then you need to think about what you're surrounding yourself with. You need to create a neutral background. We need to have a quiet room. You need a room to move as Ali will show you soon. That movement and room for both the therapist and the patient are super important because this isn't a normal, this isn't a normal treatment in a clinic where you have a table and you have a confined space and you do everything within that space, right?

Mark Milligan (00:49:44):

This is an opportunity where you have to help the patient move and show them. So Ali was going to be an amazing demonstrator of how you need to have the space both for the provider and the patient and similar on the other side, the patient needs that wifi service or cell service in order to get those uploads and download speeds. And there's simple tools that you can send to your patient but they can check it's just you can, there's probably 20 free links that they could just click a speed test and it can check the speed of their wifi. So that's an easy way to make sure patients have the capability. So there are other technology out there like VR and all these fancy systems. But look, when the rubber meets the road right now we're trying to get everybody on and adopting telehealth as quickly as possible.

Ali Schoos (00:50:28):

And these are the bare requirements, the essentials that you need. So practice models of telehealth. Actually, I was just a good time to stop or is it for questions? Yeah. All right. Well let's pause. Well, you're muted though. There we go. That's smart. Thank you. I've been madly typing away, so I'm really trying to answer the questions that I can just to simplify things and if there are questions that I think the whole group has to hear, I'm trying to save them. So we've been doing a little bit of both Mark. You've got some really good questions and land these yeah. Either one of you. If a patient has authorized visits, do the telehealth visits count towards those authorized visits? So if they'd been given six authorized visits, would Pella and I have a telehealth visit? Would that be one of them?

Lynn Steffes (00:51:21):

I guess if you're authorizing the visits and you're authorizing tele-health and that is one of the visits. Telehealth itself. Yes. if you're doing E visits or the assessment and management calls, those are not counted. And so I think it depends. It's pay are going to be peer specific. Mark, I don't know if you have any, anything else, but to me a telehealth visit is a visit. It's truly therapy. It just doesn't have to be, it doesn't happen to be physically present. So I would say it would count. But in the case of the eVisits, we've been told they do not count either toward the therapy threshold or toward the visit count.

Ali Schoos (00:52:04):

Yeah. And if insurance isn't paying for the visit at all. So let's say you had two in clinic visits in one telehealth visit, if the patient, it's cash for the telehealth visit and that would not count towards their authorized business because insurance company isn't counting it. Oh, that's a good point. Yeah, absolutely. Yeah. And if you needed authorization for an in an in clinic visit, you would need authorization for a telehealth visit. If it's going to be paid for, unless your insurance company waives that. So you really have to ask every single one of your payers what their policies are around this. All right. Amazing. Just the language that you said just there is confusing enough for a million people to navigate that. I want to say that better Mark to explain it was part, no, I'm just saying it was perfectly explained yet. It's still so confusing. No. Yeah. somebody want clarification. The seven, they felt like the seven days after the last in clinic visit it helped the 70s started after the patient reaches out requesting the phone call. No, it's actually the plane. Right?

Lynn Steffes (00:53:13):

There's be a separation of seven days from the last at least seven days than the last time you saw the patient to build the assessment and management code and then you can't physically see the patient for another 24 hours. And so I think what they're trying to do is say, Hey, you know, this clinical decision making probably isn't need right away. I don't know if I agree with that, but if you're going to see them any way, they probably didn't need this call. I'm not saying I agree, but I'm just saying that's my interpretation. Mark. Do you know anything else?

Ali Schoos (00:53:46):

And, and I think just to clarify one more time when I think it's a misunderstanding when it's an assessment management versus,

Lynn Steffes (00:53:53):

Okay. So the Eve visit did not have that same restriction. It's assessment and management that has that restriction.

Mark Milligan (00:53:59):

Okay. So could you clarify when the visits can be seen?

Ali Schoos (00:54:07):

It has to be more than seven days after the patient was last seen and it has to be an on Epic open.

Lynn Steffes (00:54:14):

Yeah. To be an established patient on the product.

Ali Schoos (00:54:17):

Right, right. But it can be 10 days later, 14 newsletters throughout the COVID process actually.

Lynn Steffes (00:54:23):

And I've not seen anything that says you can't see them within 24 hours after that. I've not seen that. So do you guys have speak up? Yeah.

Ali Schoos (00:54:36):

Does the patient have to be in the same state of the time of the event as if there's a super important Mark?

Mark Milligan (00:54:41):

Yeah. So licenser compact rules and state licensure co licensures rule here, you must have a license in the state that the patient resides in to deliver care for that patient or have practice reciprocity through the licensure compact to provide care to that patient. There has been floating rumors around this country that are licensed. We now have national scope of practice and that w our limits of state have been dissolved by some magical powers, but that I can tell you that that has not occurred. And that we still have to maintain state boundaries for our licensure on a state level. So the location of where the patient is, you have to have a license in that or practice reciprocity in that state.

Ali Schoos (00:55:29):

Thanks. And then Mark, we are only, this person wants to know if they can only see current patients for telehealth purchase. Can they see new ones? And again, the answer is different if it's Medicare or commercial payers can explain that.

Mark Milligan (00:55:43):

Yeah, of course. So for Medicare, they've established that it has to be an established patient for an evisit. So for initiation of an evaluation, it's going to be state level. If you have any regs and rules for your state that that doesn't allow you to do that. I've not heard of that yet. In fact, some policies in this country are just paying for the evaluation only by a telehealth, which makes no sense. But you can, for cash based patients, you can do it at a treatment and about and evaluations and treatment based on your state rules and regs. And so same thing for commercial based on your state rules and regs, you can perform an evaluation and treatments. So we have to default to your practice act in order to make sure you can do those. But are you guys aware of any States that don't allow? Well, there are a couple of States that have been questionable, right? Arizona just came through this morning saying that they have tele-health abilities to practice that. But I'm trying to think off the top of my head. If any state doesn't allow telehealth for physical therapists, my brain is a little mush. Right.

Ali Schoos (00:56:50):

Wow. That Arizona. But they just changed it. That's when you said that just changed today. That's allowed it. But I couldn't tell you which ones still maybe don't.

Mark Milligan (00:56:59):

So defer to your state rules and regs. If you can participate as a provider and provide telehealth services, then that shouldn't limit you as to whether or not you can eval or treat. But it may, it may.

Ali Schoos (00:57:13):

Okay. I'm typing one more answer here. Someone asked if they could take care of patient, just skip over the whole evisit process and do a telehealth visit. And the easy answer is yes. You don't have to do EVAs. That's just because they have Medicare in favor of a telehealth visit.

Mark Milligan (00:57:29):

They have to pay cash for that telehealth visit though. Right?

Ali Schoos (00:57:40):

Sorry. I'll chance to seven days at the end, I think. Why don't you go ahead and keep going back.

Mark Milligan (00:57:45):

Yeah. Awesome. Sure. Thank you. Those are all great questions. And those questions, again, the beautiful thing about the ambiguity of this presentation is that all answers will not be valid within the time that they've left my mouth. So you can't, or Ali’s mouth or Lynn’s mouth. So things are changing on an extremely rapid pace. And so please be mindful and please be considerate or consider that these answers may not be applicable tomorrow depending on the circumstance. So current practices in telehealth, really I like to break these down in just three kind of buckets, right? Companies that provide a service for you as a business owner to connect with their patients and provide care. There's companies that have licensed providers that actually deliver care. And then there's companies that use technology and sometimes a human combination to deliver care, right? So this bar, so the bar, the top one is what I want to focus on with all the PPS owners, because that is who you want to connect with in order to provide your patients with care.

Mark Milligan (00:58:47):

Okay. The other two, I would consider these to be in competition, right? So video platforms are platforms out there that allow you to sign up either a monthly or subscription. Some are free, and you can use their services in order to deliver care through your staff to your patients. That's the important key here. Again, I'm the founder of anywhere.Healthcare. We are HIPPA compliant platform that allows schedule and messaging with the connection of video. We're a relatively inexpensive for now we have it as $10 a month for three months to get everybody on board. And as fast as possible, our normal prices, $25 per provider per month zoom, there's a free version, there's a free version that's not HIPAA compliant. But HIPAA compliant for zoom for providers is $200. Five providers is $200 a month, so $40 per provider per month.

Mark Milligan (00:59:36):

Coveo has a free system. Doximity has a free system. But these are just basic. You're, you typically pay for bells and whistles in these systems, right? So we'll offer you a room based system where you just send a link to the patient, the patient meets in the room and that's what you do. There's no messaging and there's no other type of communication or ability to for the patient to sign on. I think that, you know, it's unique that I said platforms in here, but not all of these are actual platforms by definition of the secure platform from Medicare. So back to Lynn's point earlier, I think there's needs to be distinction that some of these like zoom and doxy and Skype they do not have portals, secure portals that patients have to sign into to qualify as a visit communication anywhere healthcare does.

Mark Milligan (01:00:25):

And I believe clock tree has a patient sign in as well. And so you need to be, when you look at these platforms, take into consideration the patient population that you're treating. So when it comes to, we'll get to the HIPAA compliance and just a little bit we know right now due to the lax of HIPAA rules and regs that you can use things like FaceTime or Google chat or Skype or Apple. What else? Facetime. There's Google. There's WhatsApp, there's lots of different communication platforms on your phone right now. They're advising that at this time that you can use those as long as you document well. But choose a platform that's secure if possible. All right, so tele-health platforms and systems and EHR is also anywhere healthcare Cario Bluejay in handheld med bridge now has a telehealth option practice.

Mark Milligan (01:01:17):

Perfect. EMR has a tele-health option. PT everywhere is an EMR with a telehealth option. So these are going to be a little bit more in depth and how they engage you and your system and your clients. So some of these, I know Indian health in handheld has a complete patient management or CRM, a customer relationship management system. You know, PT everywhere is an entire EHR. So some of these systems may not be right for your practice right now because of the integration needed at this point, not very many people want to go through an EHR integration or transfer during the middle of a healthcare crisis. So these are all opportunities as you look into the future. First kind of systems wide platform setups that you can take into consideration for your company. Companies like you, health, wellness, health, physio, physio, reflection, health there.

Mark Milligan (01:02:08):

Now these companies are companies where a patient can click on this website and be connected with a therapist by their company. So this would be in my consideration, the competition to private practitioners across the country, right? So these are companies that are providing tele-health for, for PT specifically and others in the game such as hinge health, simple therapy, Chi health and Kyo are all app based that solicit direct to patients. So you can search simple therapy or Chi health and they are an app base where a patient will pay a small monthly fee in order to get web delivered. An avatar directed exercises or exercise videos. And I bring this to mind because these four companies, this is a huge exploding space and musculoskeletal care because these are contracting with major employers to be their provider of musculoskeletal care or their first line in musculoskeletal prevention.

Mark Milligan (01:03:02):

So as private practice owners, we need to be really aware of this, of these companies in the space. Because just last year alone, those four companies had $165 million in capital investment, right? They had massive amounts of funding that were pushing at these because they're scalable and because they have infinite amount of users because they're AI driven and you can deploy them rapidly to, to huge audiences. So really be mindful in how you communicate about the services that we offer and the importance of what we do. Because there's people out there and there's companies out there, there are trying to eliminate the physical presence of physical therapy across this country. So knowing the rules is really important, right? The biggest important thing that you can know as a PT providing telehealth is that you can treat, you have to treat the patient person the same way as if in the clinic.

Mark Milligan (01:03:54):

This is paramount. So you have to have consent form signed. You have to have consent to treat, you have to have all your your dots. Dot eyes I's dotted and T's crossed. When you're treating patients to make sure that you treat them just like they're in person. This, just because you do a digital cash based visit doesn't mean you don't have to document. And I say that only because people have asked me that, right? This is a real patient. You have to treat it as a real patient, as a real visit. So please be constantly professional and how you manage patient care. Knowing the licensure compact is also super important. The patient, what I defer to earlier, the patient, you must have a license or practice reciprocity in the state that the patient resides in. There have been talk about, well, what if somebody goes on vacation?

Mark Milligan (01:04:38):

What if somebody goes on or their summer home? That that is a very gray area that hasn't been well defined to my knowledge. Have either of you heard of anyone defining them being out of their compact state for a defined period of time? I have not. So you're talking about the patient or the therapists, right. Let's say my patient in, I have compact reciprocity in Missouri. Let's say my patient in Missouri goes to Indiana for four weeks. Can I now treat them while they're in Indiana because they're not in a state that I have a license or compact or reciprocity?

Lynn Steffes (01:05:17):

Well, it really is, it's my understanding that it's the location of the patient at the time of the encounter. We've had lots of questions on this behind the scenes as well. Like what if my patient is, their residence is in one state and I'm doing tele-health and another if they were to come to me, I'd be covered, but then they would be in your state. So in the case of telehealth, it's my understanding that if you are licensed in the state, whether through your primary license or compact license that the patient is in at the time of the encounter, then it's covered. If not, it's not covered any different.

Mark Milligan (01:06:01):

I've just, there's been people argue like, what if my patient goes skiing in a state that doesn't cover in Nevada and they hurt their knee, right? And they're gone for a week and I still consult them while they're gone for a week. Technically, since they're not, you know, they're not a resident, they're not living there. So those questions are extremely gray right now. So I would default back to the current rules and regs that say that the patient has to be in the state that you have license to practice them.

Ali Schoos (01:06:24):

Yeah. I think people want them to be great because it sounds like they're only gone for a week, but that doesn't only gone for me as a Trump law. So unless we're specifically pulled, that is true. I would not do that.

Mark Milligan (01:06:37):

Right. And why should you care? One, you could, it could be damaging to your license too. You can pro, you can really do a lot of targeted marketing across those areas, right? So you can now reach people across the country. HIPAA, a fun topic. That's the old definition of HIPAA that we need to maintain or the telehealth provision we need to maintain it. But really current language means that we, they're going to, they're not going to impose penalties for noncompliance. And so under this notice, Apple FaceTime, messenger, video chat, Google Hangouts, Skype, Mmm. Can it be used to provide without risk that they will be imposed penalty on. However you need to notify those patients that these third party applications or predict potentially introduce risk and that you need to get an okay to use them. Again, this is temporary.

Mark Milligan (01:07:26):

Most of the information that we're talking about with insurances and compliance and everything are all temporary orders. So make sure that you're understanding that it's out of the essence that you maintain as much as you can. Cause separate costs a lot of money. All right, so why should we care? It works. Customers want it. I'll go through these pretty rapidly because right now customer driven decision making is not as, I don't think is as relevant, but after the fact that we need to come back to this when this is over, this is relevant. Customers want this. Customers by age group want to try a telehealth across all demographics. And so just make sure that you understand that before we had this crisis, many people would love for their care to be delivered digitally. And so across. There's different reasons that they have time savings, faster service, cost savings, better access to professionals.

Mark Milligan (01:08:21):

However, there were some perceived barriers as a person in person care was a preference. There's privacy concerns, uncertainly about reimbursement tech and then how to use it. All of these things can be alleviated during these current times with communication and helping your patient understand the technology that you're using. Right? But why should we really care as a profession because it works, right? There's been a lot of studies that look at the efficacy of our effectiveness of telehealth in tele rehab specifically. There's been over 50 studies that and more coming out that tele rehab is a benefit or as is no less than effective as in-person care. All right. There's one major study with Veritas from Duke that they looked at a 300 ortho patients that had total knee replacements. Half of them went to inpatient or half of them went to outpatient orthopedic and clinics.

Mark Milligan (01:09:12):

The other half went to home with an app to get exercises and there was no difference in longterm outcome or total cost in three months after discharge and they saved almost $2,800 per patient. So there are studies that are coming out and post-stroke MSK, pulmonary rehab, cardiac rehab, joint replacements, low back pain that have all demonstrated that digital delivered care, whether that be in person or some apps can be just as effective as in person care. So knowing that those are the cases that we actually can make an impact digitally. It's an incredible opportunity for us as a profession, right? But I think we also need to step into the space and own our profession because others recognize the viability and the validity of how we use technology to treat musculoskeletal conditions. And they're stepping into the space too in a hurry. So it's just the beginning and now I'm gonna turn it over to Ali who's going to you know, my back hurts. Ali, can you help me?

Ali Schoos (01:10:08):

So, yes, I can, I'm going to screen you via telehealth before I let you come into my office. So Carrie, I think you're gonna try to give me the full screen Mark when those are off. MarK Fullscreen.

Ali Schoos (01:10:28):

There we go. All right, so you guys, I asked him to put me on full screen. I don't have slides because I really want to talk to you in a way that you are going to be talking to your patient when you do a telehealth visit. So I had been thinking about doing telehealth for a couple of years and that's a whole nother story why I didn't get off the dime and do it. But when the COVID pandemic struck and it hit really in the Seattle area first, in fact, the nursing home facility that was the epicenter of the outbreak is just up the road from my office. I knew that we needed to get going and get telehealth in place. And although it feels like that was a year ago, it was really about 10 days ago and we've done it, we've gone from zero to providing telehealth in 10 days or less.

Ali Schoos (01:11:13):

Actually, actually we did it in six days. So the thought process that I went through was shoot first aim later and looked at, gosh, let's just go with a free platform. Let's just get going and do this. And the very first platform that I signed up for, I looked at I realized that tele-health was something that we want to be offering as a long game, not just a short game. And I wanted it to be more robust and then I would be paying for a platform regardless. So I looked a little deeper and decided that I the two things were most important to me was HIPAA compliance because I didn't want to change platforms because I'm not compliant now and I'm going to be compliant. And the second issue was really having access to someone who could walk me through the process.

Ali Schoos (01:11:58):

I didn't want a platform where I had to figure all of it out. I wanted someone who could tell me, I'm not a techie person, so tell me what that meant. Do I need, how do I, how do I set it up? What does the patient need? And so this is not a PPS endorsement. I did use I am using anywhere healthcare with Mark and he has walked us through the process. So you know right away when you were able to get I got all my therapists signed up before I even knew what I was doing. Got all a therapist signed up and asked them to go in industry and start using the platform. Have visits with coworkers, have visits with friends and family and just practice and get comfortable and make sure that they were able to do it at the office.

Ali Schoos (01:12:42):

Where did we want to do it? We ended up choosing my office as the best place. This is my home, not my in-clinic office. And then I asked everyone to look into their homes and make sure that they have the appropriate technology and appropriate space to do it at home as well. While they were doing all of that, we were working on the other side to make sure that we had the patient invitation letter or patient welcome letter that we had a letter that describes the patients what they needed to do on their end and have available. And then the consent form, which was all within the platform, which is all online and portal. And then I had my, you know, diving in like I do, I had my front desk start calling the patients who had been canceling their appointments to see if they wanted to take a tele-health option.

Ali Schoos (01:13:27):

And lo and behold, not very many of them did. So realized I think we need a transcript for how we talk to patients about telehealth. And I don't need to let the patient understand the value of tele-health, but to make sure my staff understood that about your health. And it made it pretty clear that people don't really understand how can you do physical therapy through a computer. You have to be able to touch me. Right. I mean, you touched me all the time when I'm in the clinic and it's very true. We do touch our patients and that's a very important part of what we do. But I think the majority of what we do is education and exercise. And that can be done very effectively across this platform. You have to make sure that your therapist and your patients understand that.

Ali Schoos (01:14:11):

So the next thing we did after a script that everyone would use is I created a video and put it on our Facebook page that is too long, but go ahead and go to my Facebook page and look at it so you can get ideas on what you want to do and don't want to do. How we did it for two reasons. One was to explain what we're doing during the COVID crisis, how are altering how we see our patients, and then explaining the telehealth option to them. And then I walked through with them what an actual visit looks like. And so they're looking at their computer while I'm talking to them and said, you know, if we're going to ask you the same questions that we're gonna ask you when you come in for a visit, I want to know what your history is.

Ali Schoos (01:14:55):

I want to know any special tests you've had done. I want to know what makes you worse and better. And then really critically, I want to ask you about red flags, meaning things that are important for me to know to make sure that you are appropriate for me to treat, to safely treat across the health platform, so that if there is something amiss, I can handle that by referring you on to another healthcare provider asking more questions. And again, in this crisis maybe doing a phone consult with another provider to make sure that we get you the appropriate care if telehealth is not. So you do need to make sure that your providers are asking the same red flag questions that they should be asking when the patient is in the clinic. So it's not really different, it's just enhanced importance for me.

Ali Schoos (01:15:42):

So the next thing we did then is have the physical therapists, Oh, let me back up a little bit. I do want to explain to you the other important thing about when you're on this call and what I did on my video was demonstrated for patients. What that visit after those questions would physically look like. So if I'm seeing the shoulders always easy to explain here, if I'm seeing a patient has shoulder pathology, I want to make sure that I have enough room and they have enough room for me to move around and show them what I want them to do. I can't just say, well, you know, flex your arms to 90 degrees or do XYZ because I can't touch them or cue them as easily. I need to be able to show them. So I'm going to ask them to raise their arms above their head.

Ali Schoos (01:16:25):

I just said, I can't really see what you're doing. I want you to push your chair away. Okay, stand up for me now. Go ahead and do this for me. So move your arms. Great. Now can you reach behind your back? Show me what that looks like. Let's go sideways and Oh, that's sucking kind of funny right there. I think Ellie has a rotator cuff problem and you know, go through all their emotions and I might say, well, can you resist yourself? So push down against your arm while you're trying to raise it. Does that hurt? Can you do that? Don't use right or left because that's backwards in a screen now it's even worse than are in the clinic. So say raise your involved arm or injured arm or however you want to do that and your resist that. Make it bend your elbow and push down against your arm.

Ali Schoos (01:17:05):

When you tried to touch your shoulder, just the same kind of cues, but show them what it is that you want them to do. If it's on their back, their knee, you're going to, I can only see part of you. Guess what? My screen moves and you are allowed to move during your tele-health. It's going to tell your patient, I want you to move your screen now so I can see your feet. I'm going to be able to see you. You know, do a little squat for me. Go ahead and hang onto the wall if you need to use the desk. So you're going to use the things that are around you. Turn sideways and then forwards. I can see what your back looks like. You have the ability to have your patients do quite a few things. You don't even, you know, you're looking at their shoulder.

Ali Schoos (01:17:47):

Let's just screen your neck out a little bit. So backwards, any pain going into either are so you can do quite a bit. And your history should have cleared out a lot of your red flags and, but you know, if you're concerned about something more serious that you can't evaluate across the screen. So once you've done all that therapist and a patient, well, much better idea that, Oh, I guess you can do this with me. And then you might want to ask your patient to have some things handy for you to be able to show them what you think they're going to be able to doing, whether it's stretching bands or foam rollers or some lightweights, or even teach them how to make some lightweights at home so they have something to left when you get to that point. Mmm. And then the final thing, two final things.

Ali Schoos (01:18:33):

I had our patient, our therapists call all of our current patients or who were current prior to the COVID crisis. Call all of them. Check in on, I'm asking how they're doing, is there anything that you need from us? And then explain our telehealth and e-visit options to them. Let them know that they can go to the Facebook page to look at the video to understand it a little bit better. And then just that personal touch. And then we are next emailing all of our patients through our patient engagement platform to let them how again that we have altered our in office visits due to the COVID crisis so that are stay in place, mandate by the governor. We will still be seeing extremely essential critical patients in the office. But our largest mechanism for reaching out to them and monitoring them and help them rehab during this time is through telehealth.

Ali Schoos (01:19:24):

So, and I think that's really critical so that when they think they don't need you today, maybe in a week or two, they realize, wow, I really do need to talk to my physical therapist. What did she say about how I could get ahold of her? And they'll go back to that email and find that information and reach out to you, especially if your office is closed, make sure that they know how to contact you so they can do that telehealth visit. And on many of these platforms, there's a mechanism for the patient. They can use the platform to reach out to physical therapists. And that's how we did it. So like I said, six days, we did our first visit from when we said go. So there you go. Mark, back to you and Lynn and let's answer some more questions. Yeah, that's great.

Mark Milligan (01:20:08):

That was awesome. Yeah, it was, I think the important thing that all providers need to understand is there's a learning curve here, right? There's a steep learning curve and you really have to, you have to practice it. Like Ali said, yet everybody practiced before this. And also you need to be, I like to term it humble and open with your patients and understanding that, look, this is new for everybody. This isn't how we've done things for years and now it's time to do something differently. So if you are, if you are if you're with your patient when I started doing this, I'd be like, you know what, John, this is the first time I've seen somebody with knee pain on a virtual visit. Let's figure it out together. Right? And, and work through it. And, and it also gives you opportunity to see where your patients live and the equipment they have.

Mark Milligan (01:20:50):

I know Ali said that you can, they can have equipment, but you know what a can of beans, some cans weigh 16 ounces, that's a pound, right? And they, most people have a belt. And so a belt becomes a great nerve glide or a stretch strap to do nerve glides with. And you know, you just have to get really creative and be a Ninja when it comes to a telehealth visit. IFor me it's really exciting for problem solving because you, you really just a giant problem solver. So thank you Ali. That was amazing.

Lynn Steffes (01:21:19):

Ali, we had a lot of questions. I wonder if I could take a minute and ask some questions that were specific. So one of them was can you talk a little bit about your patient demographics?

Ali Schoos (01:21:33):

Yeah, I think my patient demographics are pretty typical outpatient or so. We have about 20% Medicare 22 maybe it's going to range a little bit, but we see everything from junior high age athletes, kids through that Medicare population. I would say we have a fairly, our geriatric population is fairly active, but about 5% of them are pretty geriatric.

Lynn Steffes (01:22:01):

What about socioeconomic wise?

Ali Schoos (01:22:04):

Socioeconomic imagine value values on you guys? I'm like tech plans. So socioeconomically, I live in a high wealth area, but we also have one of the biggest immigrant populations in the United States. So there's a mix. You have a mix of lower socioeconomic status, but I'd say probably obviously higher than in much.

Lynn Steffes (01:22:27):

Yeah. There are also some questions just about the name of your practice and your Facebook and websites and maybe after you can take a minute to type it in.

Ali Schoos (01:22:36):

Yeah, I mean, I think Carrie, that's on the reason I was like, if not, I'll make sure it's on the resource link.

Lynn Steffes (01:22:42):

Okay. And then there was a question, a specific question. I don't know if you or Mark could take it about the vestibular patients. Give an example of how you might treat a vestibular patient.

Ali Schoos (01:22:56):

So that's a great question, by the way. That is one of the people that I think is essential. And so we have seven treating therapists. We will probably have one therapist in the office or going to the office as needed. I would say a really acute vestibular patient probably needs an in office visits. You could make sure that they're not having a stroke or that, you know, what's the problem? However, let's say, say someone you've seen before that has a recurrent problem or those of you who are vestibular therapists. I'm not, but we do have him in my office, so I don't want to misspeak here, but let's say you can do it on telehealth. I know therapists can demo an epley maneuver. She can actually have a plant and have her computer screens set up. Just got it for me and demo how to do an epley maneuver for the patient. So it is possible if that was your only choice, you don't have to think about what's best for the patient. And if the patient can't access anybody and they're scared to go to the emergency room and your office isn't open, you showing them how to do an Epley maneuver is better than what they're getting otherwise. So there's my answer.

Lynn Steffes (01:24:04):

That sounds good. Mark. There is a question that came in that I think would be perfect or two questions for you and one is that they indicated one obstacle I've been running into is getting the medical history and the body chart filled out on line. Do you have any advice on resources for getting people were converted to digital or interactive version?

Mark Milligan (01:24:24):

Oh yeah, so that's a great question. Great question. So there's actually a couple of companies that do intake digital intakes once, I think it's called intake queue. Is it actually a company that you sign up for their services and they do digital forms? But there's also, I have, when I first started my practice, I just, I'm not that, even though I'm in tech, I don't do a lot of tech, so I don't know how to convert PDF. So I just had, I went to and had somebody do fillable forms for all of my forms. So a fillable PDF form. You just email that to the patient and they can fill it out on their computer and sign it and then just save it and email it back to you. So that's been the easiest way that I've found to do a digital intake is just have your forms be PDF and fillable.

Mark Milligan (01:25:13):

You know, and, and in these times, like I've also emailed patients and had them fill it out at home and then hold it up to their camera and then I've taken pictures of that and then reviewed it. That's another way to do it. And then knowing that I'm going to see a patient in person, I'll often, or you could have them fill out some of the forms and have them take pictures and send it to you over a secure method or email it through you for their phones so pictures can work. So you have to get creative in that space for sure. But fillable PDF forms have been by far the easiest. I have my entire intake paperwork as a fillable PDF form.

Lynn Steffes (01:25:51):

Okay. That sounds good. There's a question about documentation of the sessions and I guess the biggest thing I would say is document. Like you're doing an in person, just go ahead and document that they gave consent, your location, location in the platform. I guess the other thing is the other question I thought would be good to answer live is how long are the sessions? Usually it's tele-health.

Mark Milligan (01:26:16):

Yeah, so that's a great question. Ali can also respond to this with our clinicians. So an initial eval can be anywhere from 30 to 70 minutes. It really depends on the patient. It depends on their condition. It depends on their comfort, the technology they're set up. But followups are typically in the 20 minute range, 20 to 25 minutes. They're not very long. Because you just get it done. You're not entertaining and asking about cats and seeing how their life is, you're really just getting in there and getting it done. For those cash based practitioners out there who want to charge patients cash, I would take your hourly rate and divide it by four and I would just bill in 15 minute increments. Right. Just give the patients manageable, manageable chunks of time that they can pay for and not have to think they have to see you for an hour for a PT visit. And so it makes it, I think, affordable and approachable for some patients. And you can still charge the same hourly rate. It's just broken down in chunks because some people don't need a lot of time. They may just need to review the hip hike and clamshell and, and S sideline abduction exercises that you gave them. That'll take 10 to 15 minutes. But so do it that way. From my experience. Evals anywhere from 30 to 70 and then followups are pretty much 15 to 25, some of them.

Ali Schoos (01:27:29):

Yeah, Mark. So that's what we're doing. We're doing initial evals for an hour because we want to make sure that if you get into this across again at via platform that you really haven't had time to ask all the important questions and all that. That's great. But that return visits have so far, 30 minutes have been adequate for us. Again, I think you can be a little bit more efficient. Some that chitchat doesn't happen. So I think you might even be a little bit more efficient. I'm a chit chatter myself. I'm with my patients and yeah, so I think that 30 and 60 is good. And there was a question about how we're getting reimbursed for these visits. We've been doing them for less than a week, well a week. So I have no idea in terms of if insurance is going to pay us, we have done our due diligence to the best of our ability as to who might pay us and we will bill those insurers. We're doing a cash rate when we know it's not covered and we reduced, we made the choice. Everyone has to do this for themselves. I think there's pros and cons. We reduced our rate mainly because so many people are going to be out of work right now and we don't tell her that's new to my clinic. So we reduced our rates, we didn't make them free, but we reduced our rates to encourage people to utilize the service.

Lynn Steffes (01:28:41):

Mark, there was one other question. I know we have to tie things up, but do you find that your telehealth clients over time, not just for this COVID crisis, but that they offer, may offer a brief first free visit or a sample visit as a way of helping people understand what to expect?

Mark Milligan (01:28:58):

Right. So I think the business owners on this call need to think about how they're going to integrate digital care into their practice when this is over. Right? And so one of the ways that I've seen to be very effective is to offer a button on your screen that just says contact for, would you like a free video consult, right? Just do a free consult just like you would in a free screen in your clinic. And that helps them both get comfortable with it, expect it. And also there's been some good, some good data that we've gathered that people that do that telehealth video visit and then show up into your clinic, have more, I have a higher rate of completed plans of care than if as if they do just a walk in free visit. So just because of the dynamics of the end of it where you, they have to sign up for care and it's awkward.

Mark Milligan (01:29:42):

So if a patient does a video visit and they show up, you know, they're invested, right? They get to meet you face to face before and so they're more likely to stay. So I think that when this is all said and done, finding ways to integrate telehealth into your clinical practice and how it makes the most sense will be necessary. But yes, there's, I mean, you can give away care to any body on this planet. It's legal to give care to Medicare beneficiaries. You can donate care. So you can you would a free screen or a free tele-health touch or free visit is perfectly appropriate way to help introduce people to digital care. I know we're at a time, how do you guys have it to tie this up?

Ali Schoos (01:30:26):

So if I can intervene and I guess I think, thank you Mark and Lynn, you guys just did a great job and everyone, they really have worked very hard. I had no idea how fast these guys are turning around this information for you. So thank you very much. I'm going to put a plug in for your keeping us an ABT boards. They are working their tails off to get people as current information as they can around rules and regulations and billing and tele-health and managing your practices. So when we're going to keep doing it, ups website is open to the public. We've taken a firewall down for all information about COVID, so please use it even if you're not a member. Lynn and Mark and I, and then we'll meet after this to decide if based on what happened today, we should do a follow up webinar. So if that's an interest to you, type something in real quick. And then just use the website. If you have more information or you know, reach out to one of us. Anything else that Mark you or Lynn would like to add? Dive in. Just dive in and do it.

Mark Milligan (01:31:28):

Yup. Just dive in. Just do it. Be kind to one another and understand that this is a working together. We can become a better profession because of it. So that's my final word. Bless you all for doing what you do. Thanks so much for serving as a sounding board.

Ali Schoos (01:31:45):

Thank you. All right, thanks everybody.

Carrie Stankiewicz (01:31:50):

All right, thank you all for attending today. As we've noted, this will be recorded and posted on our website along with a copy of the slide presentations and all of the links that we've referred to are in the slide presentation. And most of those links are to resources that are directly on the PPS website. On our COVID 19 page. So if you haven't already, please take the time to explore that page. Ali and Mark and Lynn, thank you so much for your time today and I'll wish everyone a great evening.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Mar 23, 2020

Live from my personal Facebook page, I welcome Dr. Mark Milligan, PT, DPT from Anytime.Healthcare as he discussing how we can implement telehealth services into our physical therapy practice. 

In this episode we discuss: 

* How to set up a telehealth platform
* How to perform an initial eval and follow sessions
* How to bill (at least what we know right now)
* The paperwork you need to start seeing patients today
* And so much more! 


Connected Health Policy/Telehealth Coverage Policies

State Survey of telehealth Commercial Payers

Telehealth Paperwork


For more information on Mark: 

Dr. Mark Milligan, PT, DPT, is a board certified, fellowship-trained orthopedic physical therapist. He specializes in the intelligent prevention and treatment of all human movement conditions.

He is a full-time clinician with multiple patient populations and is the Founder of Revolution Human Health, a non-profit physical therapy network. Helping others create the best patient experience and outcomes through his continuing education company specializing in micro-education is also a passion.

His latest venture is creating the easiest pathway to access healthcare for providers and patients with Anywhere Healthcare, a tele-health platform. He is an active member of the TPTA, APTA, and AAOMPT and has a great interest in the pain epidemic, public health, population health, and governmental affairs.

Read the full transcript below: 

Karen: (00:07):

Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information you need to live your best life, healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, dr Karen. Let's see. Hey everybody. Welcome back to the podcast. I am your host, Karen Litzy and in

Karen  (00:40):

Day's episode. I am sort of re airing a Facebook and Instagram live that I did last Wednesday with dr Mark Milligan all about telehealth. So a little bit more about Mark. He is a board certified fellowship trained orthopedic physical therapist. He specializes in the intelligent prevention and treatment of all human movement conditions. He's fulltime clinician with multiple patient populations and is the founder of revolution human health, a nonprofit physical therapy network, helping others create the best patient experience and outcomes through his continuing education company specializes specializing in micro education is also a passion. His latest venture is creating an easy pathway to access healthcare for providers and patients with anywhere. Dot. Healthcare. This is a telehealth platform. He is an active member of the Texas PTA, P T a and a amped and has great interest in pain epidemic, public health, population health and government, governmental affairs.

Karen  (01:41):

I should also mention that he is also on the PPS coven task force. So if you want to get the most up to date information on how the coven pandemic is affecting physical therapists in private practice, you can find that at the private practice sections website. It's all free even for non-members. All right, now onto today's podcast. Like I said, this is a recording from the Facebook live that we did last week. And in it we talk about what is telehealth. We talk about how to set up telehealth, how to implement telehealth, how to conduct a telehealth session for an initial eval or for a followup. We talk about how to get paid for telehealth and this is the information that we knew at the time. That was last Wednesday. Like I said, things are moving really, really quickly here. So the best thing to do in Mark says this is to check with your individual insurance providers, check with your state things are moving really, really fast.

Karen  (02:45):

And of course finally we talk about answer a lot of viewer questions. So a big thanks to Mark and I think this is really timely and I hope that all physical therapists that if you're listening to this, that you can set up an implement your telehealth practice ASAP. Thanks for listening. So today we're talking about how to implement telehealth into your physical therapy practice. As we all know, the COBIT 19 virus is causing a lot of disruption in healthcare and we're hoping that telehealth can help at least mitigate some of that interruption for the sake of our patients, for the sake of our own practices and for our businesses and for our profession. So Mark, what I would love for you to do is can you just talk a little bit more about yourself, where you're coming from and why we're doing this interview.

Mark  (03:34):

So Mark Milligan, Austin, Texas physical therapists board certified fellowship trained, but also for the last few years have stepped into a telehealth space and have anywhere healthcare, which is a digital platform for delivering healthcare. It's agnostic to provide her, so PTs, mental health providers, anybody that needs a HIPAA compliant platform to connect with patients. So the current situation is it's pretty mind blowing, right? We're seeing a, a world changing epidemic that will change the landscape of healthcare as we know it today. For several reasons. One is that people will be now exposed to a delivery of care method that they weren't otherwise are supposed to before. So telehealth and tele PT and tele medicine had been out there for a long time. Teladoc started in, in 1987, somewhere in there. So it's been around for a long time, but a rapid adoption of telehealth has really occurring right now for physical therapists.

Mark  (04:30):

What we need to know and what are the most important things right now are how it applies to us in this landscape. How can we be the best providers to meet our patients? Demand to help quell fear, doubt and an anxiety for our patients as well as, as providers and our businesses. And so stepping into this space is, it's been a little bit overwhelming. It's been a nonstop 70, 96 hours really. And so everything that I say today may or may not be true and four hours or smart [inaudible] because of how fast things are changing. So yeah, I think that tees it up. You want to kick it off? Yeah,

Karen  (05:10):

No, I think that's, that's great. That's perfect. So let's start out with, we got a number of questions from people from different therapists from around the country. And I think let's start with the number one question is how do you actually set it up? Totally basic one Oh one. So let's start with that,

Mark  (05:33):

Right? So the first thing you have to make sure is that you have patients that want this. And right now everybody wants that, right? So patient adoption of technology can be challenging, especially especially generational. So the issue with in, yeah. Pre COBIT has been adoption by, by therapists and by patients just because of ease of use. Now it's a, it's a forced adoption. So now we're in a set up where we, where are going to want this regardless of whether or not they want it. So first thing is patient population. Second thing is you need to look at your business, right? You need to look at your patient workflow and your business flow. So you need to have the appropriate from a business standpoint, you need to have a liability to make sure that you're covered in the telehealth space. So in my experience over the past few years, almost every liability insurance cover, it doesn't see telehealth as a, is a different delivery mode for physical therapy.

Mark  (06:26):

But with everything changing rapidly, it would be real. It would be highly advised that you contact your liability insurance provider and make sure that tele-health is approved as, as in your cupboard. All right? So that's logistics. Secondly, you need paperwork, you need onboarding paperwork for digital visits. You'll need a telehealth consent form and you'll need the digital release form. And if you're recording visits, you need to have a very specific form that that allows you to record patient visits. Some States don't allow recording some. And so you have to be very mindful of that. So onboarding paperwork, it's, it's good to have in fillable PDFs so that a patient can fill it out and then send it back to you digitally. Making sure that that transmission is is secure. You can also have E faxes, right? So they can electronically fax to you over a secure portal as well. So just basic things that we haven't really thought about as providers we need to adopt as mobile providers. Right. So, Oh, go ahead.

Karen  (07:24):

I know, I was going to say, so when we're talking about who is the best, what is the easiest way for us as a clinician to get that paperwork

Mark  (07:32):

Right? So they can email me. I've gotten a tele-health consent. I've got I've got that. So they can just email me at market anywhere. Dot. Healthcare. And I can send 'em I'm been sending that out over Facebook. I'm happy to share that with people. And of course you need to make sure and adapt it for your state in your practice. It's a word doc so you can switch out the logos and everything, but I'm happy to provide that for people. They can pass that that step.

Karen  (07:57):

And then one more question on paperwork and things like that. So when we are calling our insurance, our liability insurance carriers, aren't there specific questions we need to ask them or like what is the best way to have that conversation with our liability insurance providers?

Mark (08:16):

Right. Just say in this facing time that we're starting to provide care digitally. Am I covered for providing telehealth as a physical therapist? Simple. Straightforward.

Karen (08:25):

Okay. And so you may already be covered in your current policy, it might be part of your current policy, you just don't know it and then you're not, is that then added as a rider to your yes.

Mark (08:38):

Typically it's a very inexpensive writer. Okay.

 Karen (08:41):

All right. So before we set everything up, we get our liability coverage covered and we get consent forms, which can email to you or you can share them on under this post. It's whatever you feel more, most comfortable with or what might be easiest. And then we do what we got the paperwork covered. Now what?

Mark (09:06):

So you're sending that out to the patient. So they need to agree to be treated digitally. Right now it's really an interesting space. The CMS has waived temporarily a HIPAA privacy with when it comes to digital communication. I'm can't stress this enough that this is a temporary wave in, in the absence of mass abilities to communicate or HIPAA compliant platforms that patient that people are able to communicate via other means of non HIPPA compliant video software. So right now Skype and FaceTime are considered and what's the other one? Zoom and zoom and those well-known platforms are, are open, enable all those zooms just increased their prices yesterday. Yeah, so I would argue that you could use the, what's free and what's available right now in preparation as you prepare after this is over, you'll need to go back to HIPAA compliance. So in the immediacy video platforms are readily available across all. You cannot use public facing video platforms like tick talk or other things that mass put out your video. Okay.

Karen (10:22):

Instagram live or Facebook live. You can have your patient video, you can have your patient treatment sessions over live video,

Mark (10:30):

Right. That it means sounds, it sounds obvious, but you never know where people will do right by a group session. You can just do a giant group session. I'm going to train everybody on the East coast of America on a Facebook live.

Karen (10:42):

Yeah. Okay. All right, so good to know. So no one social media lives like we're doing right now, but for the time being during this outbreak, we can use face time, we can use zoom, we can use Facebook, zoom, Skype,

Mark (10:59):

Right. Totally. And you need to make sure that in your notes and documentation for your intake software or your intake paperwork, that you are waiting, that the patient is waiving their HIPAA rights during this time due to the COBIT outbreak and you are using this unsecured software and you will return to it as soon as possible. Right. Okay. This is a window. This isn't something that will last. And you need to note for your own CYA that you are, you acknowledged the existing coven scenario and that you will prepare for post that with, with my platform. Yeah. Yep. So technology on the technology side, it's really easy because you can plug and play as long as you get someone's if they have an iPhone or if they have Skype, easy set up, you can connect technology there. So once you get the form signed, you have the informed consent, the HIPAA, the HIPAA included waiver as well to sure that they understand that they are on an, they have to understand and agree to an unsecured network.

Mark (11:58):

Even though you can provide it, some people may not want it because FaceTime, that's all easily hackable. Right? So so they may not, or may, they may, they may not want to agree to that. So just have to be transparent with them in the, in your services. Right. So once you get that, I mean, it's really a matter of getting the patients, depending on your system, everybody's so different. So if you're, if you are a concierge PT and you're practicing out there for a fee for service cash base, you handle all your own scheduling when it comes for their time, you just flip them and you just call them on FaceTime, right? You collect their face, their number and you connect that way and you do your treatment, which we'll talk about in a bit, some other scheduling systems. You may have to, you know, type in a telehealth visit and your scheduling system or have some type of a demarkation for a telehealth visit versus an in person visit.

Mark (12:47):

And so work with your scheduling software, work with who you work with in order to make sure that that's appropriate so you can have the right amount of, or the right type of scheduling so you know where to go and what to do and how to bounce it. A billing, again, for the concierge practices out there, this is fee for service. Tele-Health doesn't take as long as normal to as normal PT. So I have my hourly rate broken down into 15 minute increments because it's roughly about 15 to 30 minutes. Is it an average tele-health followup evaluations in the last 40 to 50 minutes? But it just completely depends. So fee for service, it's really straight forward. You just charge per time, per minute, dollar, dollar, dollar, $52 a minute to 15 minute depending on your price point.

Karen (13:29):

Okay. All right. So now let's get into, so knowing how to actually set it up. So we've got a lot of these different things. What are some other platforms? I know anywhere. Dot. Health care. Doxy.Me.

Mark  (13:46):

Yup. Doxy.Me co view. So anywhere. Dot. Healthcare is the platform that I created. It's straight forward. Right now I'm offering you a $10 a month, unlimited use for anybody for three months while onboarding everybody. So to, to help people get to see patients doxy dot. Me actually has a free version where that's a, a room where people meet. So you can actually sign up. The patient is sent a link, they click on a link and it drops them right in a meeting room. Super convenient, super easy. There's no bells and whistles and it's free right now. So you can do that. I think a couple of other platforms I've seen throughout the Facebook live of Facebook groups that I'm in a few platforms are pushing out a free entry level software right now. So it's everywhere. So I think

Karen  (14:31):

We'll use G suite

Mark  (14:32):

D suite, right? So G suite, if you have a BA with, with Google, you can use Google meet. Right now actually with the, with the HIPAA waiver that's happening right now, you can actually use Google hangout. That would be another appropriate thing to use as long as the other person has the G suite or Google doc, a Google suite downloaded on their computer. So there are lots of, there's literally lots of options now there, there are other companies that offer other features, right? As you get into anywhere that healthcare, not only as a platform, but also as a billing feature and a scheduling feature. Doxy dot. Me if you upgrade to the higher levels, has a scheduling feature, a messaging feature, all types of stuff. So it really looking for different platforms. You need to be, do your due diligence and test them out to see what fits your practice best. I mean, some, some have exercises that are completely a part of the package that you can just have an HTP that sends right out from the program. Some have an actual, a range of motion measuring system so people can move their arm or their body in front of them. The then they can actually measure range of motion live on camera, which is pretty cool. So it just really depends on the need for your, your practice and also the practice size.

Karen  (15:44):

Got it. Yeah. Okay. So that's a lot of options for people going from free to low priced too.

Mark  (15:52):

$200 a month for co for HIPAA compliance zoom.

Karen  (15:55):

Right, right. Yeah. Yeah. Okay. So lots of options there for people. So we know we need some onboarding paperwork and we need to call our liability insurance carriers to see if they cover telehealth. Presently. And if they don't, then we need to ask them to put an addendum on and you can, they can do that immediately. It doesn't take like 30 days for that to happen. Right. Should be immediate. Okay. And so once we have all of the right paperwork and everything we decide what platform we're going to use and you just gave a whole bunch of different platforms that people can use. So all of those platforms are pretty easy to set up. And like you said, you send a link to the patient, they'd drop in and boom, there you go. And at this time we can use Facebook and Skype and, and not Facebook, sorry, Facebook. We can use Skype, regular zoom face time, all that. Okay. All right. Now

Mark  (16:58):

You may need other equipment though. You may, depending on the situation you may need. So some people, a desktop versus a computer are versus a tablet versus a phone all matter, right? So a desktop computer tends to be really well for you to have good communication and see the patient really well. But it's also very challenging for me to move my desktop to show somebody how to get on the floor and exercise, right? So the part of being a a digital physical therapist is that you have to be able to move and your equipment has to move with you. So some people use, I, you know, some people use a selfie stick to demonstrate exercises, right? Some people have one of those little iPhone holders that can be multiple or wrap around something so they can have different angles or show people at different places.

Mark  (17:41):

So understand that desktop can be good for this face to face interaction and the, and the immediate subjective interview. But maybe moving towards the objective exam or, or showing the exercise parts you may want to find or have a different device that's more mobile. So just thoughts for that. And you also need to think about your area or your headphones, your microphone and your lighting that can all add or take away from the experience of the digital experience. So making sure that you have those things. I use, I'm old school. I just use the old wired ear buds. They, when you're on the computer a long time, the wireless can die, right? And then all of a sudden you don't have new headphones. So I'm always a fan of just good old fashioned things that won't die on you after a long day of work.

Mark  (18:26):

So something to think about. You also may want to get a tripod to hold up your computer or you can get a standing desk. So there's lots of options in that space. But also you have to be considered for your backdrop. I love your backdrop that you have there in New York here and with the, with the cherry tree, that's all. It's very Boston's. That's awesome. I just have a plain white wall. Just be mindful of the environment that you're delivering this care in, right? You don't want you to be distracted. You don't want the patient to be distracted. You need to connect with the patient. Some of the key things that you need to think about are the connection that you're going to have with a patient. Something you can do easier face to face. It's challenging to get the connection and to have the emotional connection with the patient by a digital care. So setting up the environment for not only you to feel safe and, and that you feel comfortable that you're, no one's going to bust in, but also your patient needs to feel safe in that space too, so they can communicate to you in a free way that their patient information isn't being broadcasted to other people as well. So backdrops, microphones, computers, tablets, all have to be taken into consideration while you're doing this, while you're doing this intervention.

Karen  (19:32):

Okay, thank you. Those are great tips. How about cats that could, that could help or hurt you. Right? People love a cat. Great. If not, it can be a problem

Mark  (19:44):

Or at least they're not allergic to it. They're alerted to it. It doesn't matter. Right? So

Karen  (19:47):

Right. So pets can help or hinder, just kind of depends. Okay. So we've got, let's say now everyone has a better idea of how to set it up. And then the next question I got was how, Oh, they said this is great. Sound isn't great. I don't know why this sounds not great on, on Instagram, but, well, I mean it's going to be out on it as a podcast as well. So we'll, you'll be able to hear full sound tomorrow. At any rate, I dunno what to do. I could get my earbuds, but as we just said, what if they time out on me? Yeah. Okay. So let's talk about let's talk about how do you, what was it? How did, Oh, how do you actually execute a session?

Mark  (20:40):

Yeah. So once you've got somebody on the line, once you've got a patient in front of you, right? We know from our PT and our PT exam that about 80 to 90% of your differential diagnosis occurs in the subjective. So you go back to your old way of being, you shut up and you listen to the patient. Right? So, you know, so this is also assuming that you're doing an evaluation via telehealth, right? So most people at this space have patients that they'll flip from brick and mortar or in person into telehealth. So that's a different beast, right? So that's followup. That's exercise progression. Those are obvious things, right? That you're going to show them. You're going to talk them through their progression and talk to them about what they need to do next. Maybe show them a few new exercises when you're, we're, we're going to get, what we're talking about right now is the new patient that you'd never met before and what, how do you gain information to get them treated?

Mark  (21:33):

So subjective is key, right? You need to have your differential diagnosis hat on. You need to ask the next best questions, their intake form. You should have looked over, created your hypothesis list and make sure that you have a good idea of what you're trying to discover. It's your responsibility as a provider. I know it's written in the Texas legislation that if you, if the patient is not appropriate for digital care, you have to get them to an in-person provider, right? So doing your, you still have to do your red flag screens, you still have to do your due diligence and your differential diagnosis and make sure the patient's appropriate. Right? This is, you have to consider a digital visit to be no different than an in person visit. You have to take every precaution that you would take. I'm minus taking vitals unless the patient has their own, you know, portable, vital kit. You're gonna have them do that. But you have to take every precaution you would from an initial evaluation perspective as you would in a digital space. So going back to forms, you also have to have your intake form and consent to treat in there as well. That needs to be signed off as well.

Karen  (22:31):

So the, the same sort of forms that someone would have if they were coming to you or if you're like a mobile practice like me, you have them sign that initial paperwork regardless of whether you're seeing them in their home, in your clinic or, or via telehealth completely.

Mark  (22:48):

This is, you cannot be this any differently. Right? So take it, having all the consent to treat forms, signed all your intake paperwork done, differential diagnosis, red flags, you know, your three tiers. Are they appropriate for physical therapy or are they a treat and refer or they refer. You have to have that, you have to have that hat on. And so if they're presenting with sub with symptoms that aren't musculoskeletal and presentation, you need to be mindful of that and get them to the approved provider, right? So you have to be a triage at this point. So once you get through and determine their appropriate for intervention, you have to get your thinking hat on, right? This is where, this is where things change. And as a mobile PTM, I know that you have walked into somebody's house and been like, huh, how are we going to do PT in here today?

Mark  (23:32):

Or you have to completely be a problem solver. Think about being a problem solver on steroids when it comes to digital health. Right? Because you didn't have, at least in someone's physical environment, you can see what they have available. Right? If you treating me right now, all you would know is I'd have a white wall behind me. You don't know what chairs I have. You don't know what equipment I have. You don't know anything that I have. So asking them about what equipment's available is important. I take all my patients, depending on what they have, if they have, my most common thing I treat is, is back pain. So most commonly about 20 to 40% of patients, that's 20 to 30% of patients will fit into some type of directional preference when it comes to low back pain. So I take them through an active range of motion our digital active range of motion to see what exacerbates or relieves their symptoms. And if, and if repeated extensions and standing it relieves their symptoms, I go why? Clear out other things, but I go right into treatment. Right. So you can use progressive movements, repeated motions right in your treatment from the get go the same way you would do in the clinic.

Mark  (24:35):

Some of them prior,

Karen  (24:36):

It's New York. I don't even literally grown even here at anymore. It's just did with something there. Is there the engine going up, I don't even hear it. Anyway.

Mark  (24:46):

White noise. White noise. Yeah. So you have to go through your objective range of motion in your objective measurements just like you would in home or in the clinic at home. So knowing your physical exam and having a musculoskeletal screen is super important. So if I have somebody with radiating arm pain that I'm treating, where's my arm on my camera? If I have somebody with radiating right arm pain, I'm going to take them through cervical active range of motion. I've actually even had people do over pressure to themselves. Right. To see, I've had somebody to do their own spurlings to see if it's ridic. So you have to get really creative teaching someone how to do a UNL TT a on camera is because you have to back up. Right? That's another thing. You have to have visibility and you have to have the ability to see what the patient's doing and also correct them while they're doing their motion. So I take my patients, do as many physical exams that they can do on their own without, without me being present to do it.

Karen  (25:45):

Yeah. So I think it's important to note cause my good friend Amy Samala said, can you do this for brand new patients in your practice or is this just to be used for existing patients? So I think Amy, I think we're covering that right now, that yes, Mark is sort of taking us through how he might do an initial evaluation with someone via telehealth.

Mark  (26:05):

Totally. Totally. Now I think we should probably circle back to billing again and payment. I think we, we've,

Karen  (26:12):

Yeah, yeah, yeah, yeah. Let's definitely talk about that. And one other thing that I, I want to make people aware of, Mark, is how using you want to have space. So not only you want to make sure that not only your patient has space or depth, but that you do as well as a therapist because you may need to step back to show them something and then come closer.

Mark  (26:33):

Right. And I've I often, so I have a flat couch in the back, so I have this couch that's right behind me so I actually use that. I pushed my chair of the way and I show repeated extensions and prone. It's a six or seven foot long couch and I show double needs to test and I sh if I mirror exercises for patients. So you cannot do everything verbally, you can't. Could you imagine telling somebody, okay, I'm going to walk you through a double a single knee to chest with words only. It becomes extremely challenging. So you get up and you move. I just hop on the couch. I'm like, all right, so you're going to lay on your back. You'll grab both knees. You see my hands on the outside of my knees. Knees are slightly apart. We're going to pull that all the way up until you feel a big stretch in your back and I show them.

Mark  (27:13):

I walked through the exercises with them. Same thing with, same thing with nerve glides, right? If I'm doing a U L T T a I'm going to say, I'll bring your a shoulder all the way up. Like you're going to put those little, or you CC that you're going to put the little ion right and then you're gonna lift your elbow up and see if that changes it. Right. And so you have to walk them through. It's easier for them to mirror you than it is to say, okay, you need maximum shoulder flection with external rotation. NOLA deviate. Like you can't do that.

Karen  (27:39):

Yeah, we know jargon doesn't work. Yes. You can never say that in an NPR. If you are face to face them, you would never just sit there with your arms folded and be like, okay, flex your arm to hear externally. Like if you just want to do that, you wouldn't do it. I think it's important to know that we can still certainly in well versed in strong verbal communication in this space. Oh, that's nice. From work. Yes. Or there was a delay. Oh, okay. So I think we're good. So Amy said, yes, sorry, there's a delay. She's all the way in New Jersey, so forgive the Jersey part. Yeah, New Jersey. Okay. all right. So I think people get an idea that yes, this is how you can set this up. You just want to make sure that each of you have enough physical space to do everything that you want to do. That yes, you can do your initial evaluation. It's all about the subjective, in my opinion, in that initial evaluation anyway. Definitely. and then once you see them for the initial evaluation, as you start progressing them, like you said, it would be like any other exercise progression you're just not putting hands on, but it can be done.

Mark  (28:51):

Definitely. Definitely. If you think about the interventions that we do in the clinic that you can apply to home. So I work with people that you know, that don't, they may not have good balance. So safety is a, is a concern in that space. Right? So I talk people in a corner, I show them what it looks like to get into a corner with a chair in front of me or in front of my couch or the chair in front of me and teach them how to do single leg stance while having my fingertips on the chair. Right eye. You have to physically show people what to do so they understand that better. And so like you said, it's about being able to show and speak at the same time, right? Because a lot of the field like nerve tension testing, a lot of times it's, you can feel the tension before the symptoms ever get there.

Mark (29:34):

So you have to educate somebody that has a really angry nerve that's a, it's a hot nerve and say, look, we're just going to take this up until you barely feel it. Right. We're just going to touch it. And then if you feel it there, just bring it back down. Right. You, you can't rely on your hands to feel that tension anymore. Not that we can reliably feel it anyway, but we want to make sure that we prime the patient for success. Right? Communicate expectations. Like we're going to do some discovery today. We're going to walk through a lot of different movements to see what's happening with your body. See if we can figure out ways that we can help you feel better through movement. Cause that's what ideally what we're going to do, right? We need to make sure that we enable patients and make them feel safe and comfortable that we're going to help them. We're going to take them through this. We just need to, we need to communicate to that. This is going to be something that I should be completely comfortable with. Yeah.

Karen  (30:24):

Perfect. All right. Now let's get to the part that everybody really wants to know about billing. Someone. let's see. Oh, Mark Rubenstein also New Jersey. He had kinda some of the same questions. No, I have nothing against New Jersey, New Jersey. So he kind of had the same question I had before we went live. He said but Medicare will only pay now for existing patients as per info yesterday. So this is the info, I guess on that evisit versus tele-health. So can you kind of give us, cause I know just for background, Mark is a part of a PPS task force and he is really being updated a lot. And I'll let you kind of talk a little bit more about that and, and how you are helping to work the billing aspect of things and the difference between an evisit and tele-health.

Mark  (31:20):

Right. I'd like to first shout out to the PPS members, Allie shoes and the I and alpha are our lobbyist for the APA. We are meeting for hours daily and we are, so everyday we have scheduled calls on this task who have a task force. We're pushing out content on the APA plus the PPS site. So there are 18 to 20 people that are hard at work to get, to gather information, to interpret it and then to question it and then make sure that it's legal. Right. Because there's information that comes out that it's great information, but it may not be legal for us to do based on practice act. So there's, there's a federal level, then there's the, then there's the PTA level, then there's the state level, then there's your individual insurance levels. So there's a, there's so many different paradigms. It's not just a cut and dry situation.

Mark  (32:06):

So right now, some of the biggest things that we're working on behind the scenes with this PPS task force are really are defining out what it means from Medicare as it relates to the visit ruling. So E visits technically are not telehealth. Medicare is not calling these eVisits tele-health. They're calling them eVisits because they derive them from the medical, from the MD coding as, as a bra, a brief and abrupt follow up to a situation where the patient is in an engaged patient. So imagine somebody who may not be feeling well after seeing, having a doctor's appointment just to follow up to touch. So the visit codes right now can only be billed based on time, so their cumulative time and there are three levels. The max level is 21 minutes to be billed one time over a week. And so you add all the time for one week and over 21 minutes is the third code.

Mark  (32:59):

And that can only be a build a once every, well in seven one time in seven days. There is a question right now about whether or not that code can be repeated the next seven days. That information has not been gotten yet. We have not had a clear answer on that. So please be patient while we investigate whether or not that code can be repeated the next week. So right now, currently we are still working on whether or not now that these eVisits have come out, the question is now whether or not CMS sees us as telehealth providers, which upfront does it look like they do. But we still haven't gotten for Bay. We still haven't gotten the, the appropriate word from CMS whether or not we are. We are providing tele-health, which they said we're not. So we can assume we can assume anything.

Mark  (33:49):

But so they said we're not providing tele-health, but we think they will. They won't include us in the, as a telehealth provider, which is extremely important because if they don't consider us Medicare providers, then we can, well, I'll wait about Medicare billing Medicare patients, we'll, we'll wait to hear what happens. I'll have to have an update on that. And so right now we are not approved providers for telehealth, for Medicare. And we can build he visits with an established patient that has to make contact through a patient portal to the provider to request their evisit. Now it's been clarified that you can notify a patient that they have the option of that type of care. You can tell the patient, Hey, you know, we're not treating people in person, but you do have the option for an evisit. Here's how you do it. If you choose, if you were to choose to have an E visit, you would go to this part of our website to our port, your patient portal and request a visit so you can prime patients to go utilize that service. Whether or not you can only do that for one week or multiple weeks, that's in question.

Karen  (34:52):

Okay. And a patient portal is not Skype zoom face time or any of the telehealth platforms that is not a patient yet.

Mark  (35:04):

Well, some platforms have a portal, some, so it has to be a patient portal. So it has to be a place where a patient can log in and request a visit. And so we're still also waiting for a clear definition of a patient portal. But for our understanding the patient, it's a place where the patient goes to get their information or connect or message their provider. Right. So right now that's still being clarified through CMS on the other private payer front and medicate well, so Medicaid is being rapidly adopted by payers all across the country. Right. So we've seen, I know Louisiana is about to release a wording today at some point. I know that I think Minnesota, I think that a few others have already, Medicaid has already blasted that inflammation and that are, that are, that there are approving and paying for telehealth or physical therapists, payers on a national level are all over the place.

Mark  (36:00):

So if you are a, in the work provider, you need to call your payers and ask very specific questions and we have people working on this across the country. You have to ask them if your patient has tele-health benefits, you need to ask them if those benefits are payable to a physical therapist. So if a therapist is a PT, a paid as a payable provider of telehealth services, if they need any modification codes, right? So like an Oh two location code modifier, right? That needs to be asked and then what CPT codes they reimburse for. Okay. Right. So manual therapy is not going to be one, but neuro, our neuro they're ex their acts home care, self care, all of those codes should be available. And it just depends on the, on the payer and the carrier. Okay. I have a Google doc that we can link that I'm trying to collect that data from across the country.

Mark  (36:58):

So people can have open access to it that I can send you that link here and it's on a couple of Facebook pages. But we're trying to collect that data so people can see because, and you don't put any reimbursable fees, don't breach your contracts, don't talk about a fee per schedule, but where you're scheduling fees or your fee schedule. But I'm just put whether or not they pay if it's parody, right? Some States out parody. So here's the kicker. Parody States doesn't miss it necessarily mean payment, right? And this is a, this is a very confusing, a very confusing thing. So somebody says, Oh, we have parody in the state so that, and then we are going to get paid equal in person as we do digitally. Just because you have parody doesn't mean to pay your pace for telehealth, right? They may pay for physical therapy, but they may not pay for tele rehab, right? Yes. Check.

Karen  (37:47):

Why can they just not make this easy?

Mark  (37:50):

Right? So you can have parody in a state and you could have a parody law and then the payer not even pay for telehealth. Right? So there's nuances upon nuance, on nuance. And in some States, some carriers have contracts with larger telemedicine providers and their members can only have telehealth through that tele provider and they may not have tele, they might not have tele PT. So then they had no tele-health, physical therapy option for that payer. Does that make sense?

Karen  (38:28):

Okay, so I'm going to just do this. So for example, I'm just going to take a for example, and tell me if I heard you correctly. Oh one more thing. So Rina said, we're talking about the visits, that's all specifically for Medicare patients only the egoist. Yes, yes.

Mark  (38:46):

As of now we have, we are unaware. I am unaware. I'll say that of any payer that's adopted the evisit policy and that's as of our Medicare Copa. Our coven call ended at noon today. So I don't know. That may change.

Karen  (39:02):

Okay. So let's talk about your individual. Let's talk. Oh, somebody said, Oh Mark, can you bring your microphone closer to your mouth? But you've got the ear buds in,

Mark  (39:13):

Right? So I have my phone a lot. Loose ear buds are going to the computer, but now you see if you can bring the microphone closer to your mouth, then they see my giant fivehead here and I'm like, I mean, how about if I go, that's fine. We'll do that.

Karen  (39:32):

We'll do that. It's fine. It's fine. Okay. Oh, so here, let me just ask some, get some of the questions. So Kim wants to know, she's in New Jersey also. He lives in New Jersey, but her practice is in Brooklyn. How do we find out if our state has parody?

Mark  (39:51):

So again, I, the, I will link you guys to the center for connected health policy and I also have a link to the parody in the different States. So I have links to both of those that I can give you, that we can add to this.

Karen  (40:07):

Yeah, we can put that in the comments under this Facebook under the live here.

Mark  (40:12):

So where, and so the, the commercial parody book is only 150 pages of nice, easy light reading. Where should I go for Facebook live?

Karen  (40:23):

Just go, if you go to my page, just go to me and then you can put it in. You'll see, you'll see us. You can put it in the comment section or we could put it in the comments section. When we're done with the live, we can add it in as well.

Mark  (40:35):

Oh, there we are. All right. So I'm dropping it in the, yeah,

Karen  (40:37):

You can drop it in right now too.

Mark  (40:38):

There's the parody laws. Here is the fact sheet on the UpToDate. This is a live document on what's happening in the world right now. As far as tele-health policies and procedures across the country. So those two documents should have a lot of information. But here's the kicker. Just because the state has a parody law doesn't mean that, that, that the payers have a policy that reimburses tele PT,

Karen  (41:08):

Right? So parody and, and just to be very clear parody means because you, you can do tele-health because you see them in person. So it's like

Mark  (41:20):

No. So parody only means parody only means payment. So parody means if they have a parody law and they both reimburse for inpatient physical therapy and for telehealth benefits, they paid equal.

Karen  (41:32):

Say again

Mark (41:33):

If the, if the, if a payer say let's let's say blue cross blue shield, if that, if that patient has a blue cross blue shield policy and they have a physical therapy benefits and they have tele-health benefits that a physical therapist can provide, they pay equal. Right. Okay. So it's the same face to face as the say. So because a lot of insurances will the 75% or 50% of impersonal versus digital. So it's literally a payment equality clause.

Karen (42:02):

I see. Okay. Okay. But you have to call blue cross blue shield because they may not actually, that patient's policy might not include tele-health.

Mark (42:13):

Right. And then even if they have a parity law, you're not getting paid for it.

Karen (42:17):

Got it. Right. I got it right. It's okay. Kim. I hope that my inability to understand help you. Dah, dah, dah, dah, dah. Can hear Mark fine. I'm physic. Oh, Deborah joy Sheldon. She said, is there a particular language that needs to be included in the documentation? So when we document the visit, how, so? Let's say we know how to set it up. We have the visit, how do we document it?

Mark (42:47):

Right? So you typically documented as a telehealth visit. So there's no you, your billing will coat it with an OTU location modifier, but you need to denote specifically that it was a digital visit. Okay. Yeah, that's the,

Karen  (43:02):

Because we just got a question on what's the location coding for telehealth and you just answered it. So Abby, I hope that that helps you. And [inaudible] can we skip insurance and just bill cash or has this new E health stuff messed that up?

Mark  (43:26):

So that's unsure right now. So the visit has, it's not considered telehealth by early information. That's not considered to be telehealth. We are still not telehealth providers by Medicare. So that should not impact that. That's my, that's my personal uninformed or relatively informed opinion. Please don't take that to anybody else. We're still discovering that. And private payers still do not, are not adopting that yet. That we've heard of. And so you should,

Mark  (44:01):

If you are currently billing or having people pay cash in there and they do not have coverage, then you should be able to continue doing that. Does that make sense? Okay. Right. I mean, you need to check your contract language. Where we get sticky is, is this considered a non-covered service by a policy? Right. So this is where the sticky sticky comes in. Okay. Is tele-health considered physical therapy just delivered in a different manner, not a non-covered service, right? Yeah. Yeah. Well that V that opinion varies. And so if it's a non-covered service for Medicare, you can, they can, you can charge cash for that service. Right? And so, and that also applies to other payers. Correct. So if, if your payer has a policy that considers telehealth to be reimbursable by PTs, you wouldn't be able to pay, have them pay cash. But if

Karen  (45:03):

Your individual patient's insurance does not cover telehealth right, then can you charge the patient cash?

Mark (45:12):

I'm not a healthcare attorney. But we're doing that.

Karen  (45:16):

Where the heck, I know she's on here somewhere here in Jackson. I know she's watching, I saw her log on,

Karen  (45:23):

Come on or Jackson answer that question for me

Karen  (45:25):

Or an answer that question please in the comment section if you're still watching if not, maybe we can ask her or care Gaynor through the APA might be able to answer that question. So again, that question is if Aaron's still watching is if your patient's specific policy does not cover telehealth, again we'll use blue cross blue shield. So they have blue cross blue shield, they do not cover telehealth. Can you charge cash to that patient if they don't have it covered on their policy?

Mark (46:02):

That is a good question. Yeah, that's a great question. And I think, I mean I, I think I know what my answer would be but I cannot speak as

Karen (46:12):

Brought any information to anyone or misleading information. So maybe that's something we can ask Cara Gaynor on Twitter. Maybe she can answer that or if Aaron is still listening, maybe she can pop that into the comment section at some point. So

Mark (46:28):

And having amazing people that are listening that can help. Yeah, exactly. Taking, cause this is a, this is a mad house right now when it comes to legislation and information. So it's all over the place and apparently so yeah, it's just all over the place. We can't information that was [inaudible] I did hear that. Some of the bigger things for Rhode Island and for Pennsylvania this morning, that the governor, the governor assigned legislation that would massively require all payers to pay all providers for telehealth. All right. Yeah. Yeah, yeah. Okay. One other big question that comes up is location for these for, for billing. Right. And so the word from CMS is the, the, the POS code is the location of the billing practitioner. So in the case where remote services are rendered it does not matter where the corporate address of the billing provider is either, nor does it matter what the beneficiary's address, it matters where the services was rendered. That is where the biller is located. Okay. All right. So when that happened,

Karen (47:43):

Put that into like example.

Mark  (47:45):

So when that happens, let's say yes. So if you are, New York has parody, right? Or you got to know you guys have compact revolution, right? Correct. I thought you did. So let's say you're a large provider and you have multiple States that you are in charge over that or multiple States. You treat patients and you're billing Medicare that the, the, the service in the, in the billing, in the service location code is the place where the provider is located.

Karen  (48:18):

I see. So like for example, if we use something like Athletico like a big gigantic company or maybe someone like, I think Michelle Kali has some places in Rhode Island. I think she just went to Massachusetts, but the headquarters is in Rhode Island. So if you're a therapist in their Massachusetts office, you're using Massachusetts.

Mark  (48:40):

No, you're using wherever you are and delivering the code. Deliver.

Karen (48:43):

Where do you get where you are? Okay.

Mark  (48:45):

Okay. Yup.

Karen  (48:46):

Okay. and then Michelle Townshend said, how does this work with EHR? Ours?

Mark (48:55):

Yeah. So eeh

Karen  (48:57):

So she is looking at a separate telehealth provider from our EHR who also does our billing.

Mark  (49:04):

Right. So EHR is, there's only a handful of the HRS in the physical therapy space that offer tele-health as a part of the platform. I think PT everywhere is a platform that has that has it built in. And self doc is another ER EHR that'll be live and in the next couple of weeks they'll have a platform within six weeks. But most of them are stand alone freestanding. So you just have to find the best system that are set up that can work simultaneously with your other systems. There's really no way to unless the company has an integration with your EHR, which the HRS don't like to integrate with people because that's patient data and it's a, it's a whole hot mess. So most of these are just freestanding side by side. So you'll have your EHR on one side and you're in your camera on the other. So you just do, and that's what I did with anywhere healthcare, it's just basic connection so you can document everything ever somewhere else. Okay.

Karen  (50:03):

All right. And then Debra says, Mark, my state has parody related to my hospital being F, Q, H C I do not know what that means. Any insight on that? So what does FQHC mean? Any thoughts if not, maybe

Mark  (50:25):

It's a federally qualified health center federally. Okay. So they have parody. I don't think I understand the question.

Karen  (50:33):

Yeah. In my S my state has parody related to my hospital being FQHC. Any insight on that?

Mark  (50:40):

Oh good. So she Oh, she said they have parody.

Karen  (50:43):

Yeah, they have PR has parody. Yeah.

Mark  (50:46):

I'm unsure on that. That has to parody is I've, I linked that doc into the live on Facebook. I can look up parody by state and by organization. Okay. Yeah.

Karen  (50:59):

Okay. Let's see. Let me we already touched, so I'm just kind of, what paperwork do we need? We talked about that. Oh, what if you're not a Medicare provider? Gosh, all right. Dah, dah, dah. Oh, we are usingG suite and This is from,uKelly Dougan, I think. Yeah. But haven't started officially yet. We have an ABN and I wanted to have liability form as well. So those liability forms, that's something that we can, that you can maybe share also on this link here and people can make it their own. Is that by liability? Like the patient has to sign off on saying yes, I'm okay with having telehealth.

Mark  (51:51):

Is that of course for me. Yeah, I would assume that what she's saying. Yeah. So I'll, I'll create a, I'll create a Google drive folder and drop a link in to the chat

Karen  (52:05):

And then one other, we've got two other questions. So to clarify for service location code, so that you said that, is that like the OTU code? Right. Okay. If I or any of my PTs are in their own home while tele-health with patient, is she using her home address?

Mark  (52:28):

Oh, that I can't answer that I haven't gotten, yeah, that would be a billing question. That hasn't been brought up, but I, we have a meeting tomorrow morning and I'll ask that question.

Karen  (52:39):

All right, Kimmy, we will get to that.

Mark  (52:43):

We're saying the PTs can just stay home and bill from there. But Medicare has specific guidelines on origination sites. And I know if origination sites apply to eVisits versus telehealth. That very question. Do origination, do originations, I'm writing it down so we can ask this to origination sites. Apply to eVisits. Yeah, cause that's, that's a game changer too.

Karen  (53:11):

Yeah, yeah. Oh, sorry. She said, sorry, I meant to say service location. Did you clarify for service location address? If I or any of my PTs are in their home while doing telehealth, do they use their home address or does she use her address? So Kim, like lives in New Jersey, her practice in Brooklyn. So that's a really good question. So, Kim, maybe we can get back to you with that answer.

Mark  (53:33):

And is she a Medicare provider?

Karen  (53:35):

Kim, are you a Medicare provider? I think so. We'll see. We're on like a 22nd delay.

Mark  (53:43):

Yeah. So I'll ask, I'll ask service location for employees versus brick and mortar versus mobile provider.

Karen  (53:52):

Perfect. And then Sarah Catman says, if you are licensed in more than one state, but only practice, may single state, can you only do telehealth in the state you practice in or can you do, hello, hello, hello. Telehealth and States you are licensed in.

Mark  (54:12):

Yeah. So that's where it comes to state rules and regs and yeah. So everywhere that you have a practice reciprocity or you have a licensed in other States, as long as they, you are allowed legally to practice tele-health in that state. Yes, you can practice telehealth in that state. I mean it's, but you have to sit, you have to make sure to abide by the rules and regs when it comes to our the licensure compact of the rules and regs of the state that the patient abides in or they live in. Right. Cause that's just compact language. So like I can do tele-health and Missouri, but they don't have direct access. So I would still have to have direct access or I'd have to have a referral for that patient if I want to open Missouri. Right. So like example. Yeah. so I think, yeah, so we have to make sure that you abide by the laws of the state that the patient resides in. But yes, you can do tele-health across the country. That's the beautiful thing about the compact, right. Compact allows for us to practice across this country with with little, with, without a lot of that a lot of restraint or not restraint, but a lot of challenge.

Karen  (55:20):

Okay, perfect. All right, so we're at about an hour, which is as long as I think people's attention spans are, and I think we have an apparently as long as Instagram will go live. So if anyone has any other questions, please you can keep adding them into this feed here and we'll try and get to them as, as best we can. Thank you Mark for dropping that stuff into dropping those links in here. And again, we'll get some of the, the onboarding paperwork from you and maybe can drop it in here as well, or you can point us to maybe where it's been put in other Facebook Facebook links. But yeah, everybody, you're welcome. You're welcome. And Mark, thank you so much. This was above and beyond. I think what you had to do but I think we all appreciate you so much because we're in a time where there's a lot of uncertainty and tele-health is at least a way to one, keep our patients healthy and moving and to kind of keep our practices going as best we can in these times because we don't know.

Mark (56:38):

Yeah. We don't know.

Karen  (56:41):


Mark  (56:43):

Yeah, I think, I think, I think as a profession we need to remain calm and PT on, right? Like there's a lot of things happening right now. There's to be the, the future is unknown for us as a healthcare profession. All I do know is that it's going to be changed on the other end. This will no longer be an exception to the rule. This will be an expected method of care. People will, will now grow to understand that digital health is a real opportunity in every aspect, not just in, in telemedicine. So I think if I can say one final thing is just be prepared to adopt this and, and, and set up your systems for the long game. Not for this short, immediate, even though the immediate needs to happen. We have things in place like the waiver for using different platforms just to make it happen while it is, but set your practice up, set your systems up for a long game to provide digital care to your patients. Because that's where we're going to go. Part of it is so yeah, but be patient with each other, love each other be kind and wash your hands,

Karen  (57:49):

Wash your hands and don't touch your face. Yeah. And be mindful of the people if you are still, if your offices are still open, be mindful of the people coming into your office. If you are a home health therapist, be mindful of the people that you're that you're going to be treating because they may be in that vulnerable population. And because we, there's so much that we don't know, just be very mindful of how you're doing that and utilizing telehealth is a great way to have that extension of care for our patients, so.

Mark  (58:27):

Right. And feel free to reach out to me market anywhere. Dot. Health care. I'm here as a resource. I'm trying to be as available as I can. I have to go to the bathroom occasionally or drink some water, eat some food, but I'm trying to be as available as I can in order to help help us transition and get through this, navigate this time.

Karen  (58:45):

All right, well Mark, thank you so much. Got it. You've got everything there. Check out. Also, check out Mark's platform anywhere. Dot healthcare. I'll be happy to give a plug for that of course. And thank you so much. I really appreciate it. This is everyone else on this, on this call, so thank you.

Mark  (59:01):

Beautiful. Thank you.

Karen  (59:04):

Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitterinstagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Mar 16, 2020

LIVE from the APTA Combined Sections Meeting in Denver, Colorado, I welcome Tannus Quatre on the show to discuss marketing. Tannus Quatre is Vice President of Sales for Net Health, a leading software company serving therapists across the care spectrum. Tannus speaks nationally on the topics of entrepreneurship, marketing, and finance, and has been published in numerous publications including PT in Motion, Impact Magazine, and Advance for Directors in Rehabilitation.

In this episode, we discuss:

-What do new clients look for when they choose their physical therapy provider

-How to ask your practice ambassadors for a five-star review

-What branding strategies hold the best investment for your practice

-How to convert marketing touchpoints to new client leads

-And so much more!



Tannus Quatre Twitter

Tannus Quatre Facebook

Tannus Quatre Instagram

Tannus Quatre LinkedIn   



A big thank you to Net Health for sponsoring this episode!  Learn more about Four Ways That Outpatient Therapy Providers Can Increase Patient Engagement in 2020!


For more information on Tannus:

Tannus Quatre is Vice President of Sales for Net Health, a leading software company serving therapists across the care spectrum.  Tannus studied physical therapy at the University of California at San Francisco, and has practiced as a PT in outpatient, inpatient and home health settings.  In 2007, he founded Vantage Clinical Solutions, a business services firm specializing in marketing and revenue cycle management for rehab therapists in private practice.  Tannus speaks nationally on the topics of entrepreneurship, marketing, and finance, and has been published in numerous publications including PT in Motion, Impact Magazine, and Advance for Directors in Rehabilitation.


Read the full transcript below:

Karen Litzy (00:01):

Hey everybody, welcome back to the podcast. I'm your host, Karen Litzy. Today, as you can probably hear in the background, it's a little bit louder than it normally is and that's because I am recording this live at the American physical therapy associations combined sections meeting in Denver, Colorado, which has about 15,000 plus people and I am currently in the exhibit hall getting ready for a great interview about why patients come to see us. What is the why behind when the patient coming to see us, what can we do as physical therapists to reach those patients? As we know, there's a lot of people that need physical therapy and a lot of them do not come to see us. To help me through all this, I'm really happy to have Tannus Quatre here to talk about what we as physical therapists can do to help get patients in to see us and to be happy with their courses of care. So Tannus, welcome. All right, so let's just jump right in. Why don't you give the listeners just a little bit more about you and how you went from a practicing physical therapist into more kind of the marketing side of physical therapy.

Tannus Quatre (01:12):

Perfect. Yeah. I started as a physical therapist about 20 years ago. And in my clinical career, I had found that I was much more driven towards being curious about how patients find physical therapists, how physical therapists can run efficient practices so that at the end of the day they can grow their practices and be in business for a long time and care for lots of folks in their community. So I was just really programmed to be interested in those types of things. And so I went off and started my own company that focused in areas like that specifically in the areas of marketing, which a lot of what we're going to be talking about today.

Karen Litzy (01:56):

So then tell us now, why are first time patient s coming to your practice? So in your experience and what you've seen with people you've helped, why are they coming?

Tannus Quatre (02:08):

Yeah. So I mean there's a couple layers to this. So the obvious one is they're coming because they've got something that they need to be fixed or something they need to have addressed, right? They're in pain or, or some sort of, some level of function that they're not currently able to achieve. At a deeper level. And I think this really ties into where we need to be thinking with regard to our marketing strategy is a customer or a patient comes to us because they're looking for hope. They're looking for some better path towards a better life that they are not currently experiencing due to some type of functional limitation or pain or other illness or injury that they're undergoing.

Karen Litzy (02:46):

So oftentimes when people are seeking out a physical therapist, do you think the average person is saying, well, I'm going to look up this physical therapist. I'm going to look up their education. I'm going to see if they did a residency. I'm going to see if they're board certified. Did they do a fellowship or are they saying, how far is this from my home? Do they have parking? Can I get there easily? Do they have appointment times at work for me. So there's a lot of variables there. So what do you think weights as more?

Tannus Quatre (03:21):

Yeah, so really, really great question. I will answer that with kind of a story that pertains to me. I don't know the first thing about cars, but I know that I have to have a car that functions in order to have a productive life, get from a to B, take the kids where they need to go and so forth. So when I need to get care for my vehicle, I go to see a mechanic and I choose that mechanic based on interestingly what, what I think is, is a really good parallel to how customers choose us as physical therapists. I assume going in as I choose a mechanic that most auto mechanics are going to hit a certain threshold for quality. I assume that I go in, I pay my money, my car is going to come out and it's going to work.

Tannus Quatre (04:05):

Sometimes that's not the case, but the most times, and I've used different mechanics over the years, most of the time they hit that threshold. So then the question becomes what are all of the other things that, that not only brings me to find a mechanic in the first place, the one that I choose, but why do I keep going back time and time again? For me, that answer comes down to mostly trust. I in that trust had, there's a lot of tentacles to that rapport, likability, timeliness reliability and so on. But really I keep going back to someone or to a mechanic for reasons other than the fact that they've got the best pedigree and the latest state of the art equipment when it comes to fixing my car because my assumption is my car is going to be fixed when I leave.

Tannus Quatre (04:57):

And I think that that's a mindset that helps me calibrate around what are really truly the drivers of a consumer that comes in and chooses Karen Litzy as their provider and then stays with you over time. I think that assumption that we should be thinking from is that frame of mind shouldn't be that the assumption is the customer's going to get good care and they expect that, but that's the basic bar. It's all of the other things. How much do they like you? How quickly do you respond? How deep is that bond and that relationship you've created that makes them say, I'm going to come back and see you time and time again and not even bother Googling for somebody else that may be out there in their market.

Karen Litzy (05:37):

And I think, I love kind of taking an example outside of physical therapy and as you are saying that in my head I'm thinking like I get my hair colored and I love my colorist. She moved out of New York city. I tried someone else, like the color was good, but I didn't have that bond or that relationship. Like the color is just wasn't, we didn't click, we didn't vibe. So now I'm willing to take an hour and a half train ride to New Jersey to get my hair colored because of the relationship that I have with this stylist, with this colorist. And so I think if we can think about it in those terms, choosing a physical therapist should kind of be the same. So I think you are going for the culture, for the person, for the relationship. And like you said, the baseline should be you get better, right?

Tannus Quatre (06:33):

Absolutely. your hair looks beautiful by the way. But yeah, I think that's a great example. So, you know, another way to maybe say it is how I think about it is we're looking for peace of mind. We're going to have different challenges throughout our life, whether it's our car or our body and we need a doctor as a physical therapist or a medical doctor. We need folks that help us complete our life and our ability to have peace of mind that we have put together that network that is going to help us feel comfortable with the choices that we've made and be able to efficiently realize that the outcomes that we're looking for, even though technically speaking, maybe you could find somebody who is a better colorist for your hair that might even be closer to you, but you've got peace and you've got everything you need and you've got that relationship you need and your meeting that bar for quality. So you go back to time and time again. And I think that's really the threshold we should be thinking about with our customers.

Karen Litzy (07:35):

That kind of segways beautifully into what I wanted to ask next and what is success? So when we think about a successful plan of care or a successful business, is it good outcomes or great outcomes or is it good relationships or maybe it's a combination of both. I don't know.

Tannus Quatre (07:56):

Yeah, great question. So obviously outcomes are extremely important. So I look at that as a baseline. That's the proof that we've set out to achieve with our customers. So outcomes undoubtedly. But when you do look deeper beyond that and you're looking for metrics that help you understand, am I doing a good job of yes adhering to or you know, treating through a plan of care and making sure that I'm doing good in the moment with this one customer. Outcomes is definitely something you should be looking at. But looking deeper than that are we creating a lifestyle that is going to be sustainable beyond us? I start to think about things like, okay, how compliant is a customer or is a patient with the plan of care that I'm putting into place?

Tannus Quatre (08:50):

How good of a job am I doing at influencing that customer to believe they need to be compliant with what I'm asking or prescribing them to do? And then loyalty. Are they coming back? Are they completing their entire episode of care or not if they, you know, do I see them through one episode and then I never hear from them again for the rest of their life when I know for a fact that they're going to need myself or a substitute for myself at some point in time. To me those are really, really important indicators of success when it comes to how good of a job are we doing, not just being technicians as rehab therapists but as educators and ambassadors for the profession. That really the better job that we do there to set our clientele up to be able to know when to use us effectively and how to adhere to what we prescribed to them. To me, that's really where success comes in because by us planting those seeds correctly and motivating an influence in our customers to participate, that's ultimately how they're going to keep themselves healthy for a lifetime.

Karen Litzy (09:57):

I love that you use the word ambassador. I use that all the time cause someone asked me a couple of weeks ago, well I don't want to say, I don't want to say you're a referral source, I don't want to say Oh my patients are referral sources and there's something else I can use cause it just feels icky to this person. It feels icky to me too. And I said, well I, instead of saying referral sources, I say that my former patients or clients are all ambassadors for my practice. And that's what I say to them. Like, thank you for being such a great ambassador. So I don't have a referral fee or anything like that. I just have like a lot of thank you cards. They say thank you for being such a great ambassador. So I'm really glad that you use that because I think that's a mindset that brass people have to get out.

Tannus Quatre (10:48):

Yeah, absolutely. And I appreciate that point. I would say also that I love the word ambassador and I think that by that ambassador, being an ambassador is very empowering and empowering somebody is a gift. And we have the ability to provide that gift to our clientele by helping them feel like they're now part of the profession by going out and encouraging others to experience the same benefits that they have. And if we get that mindset right and we're really have a culture of ambassadorship both within our profession as our professionals and with those that we serve, sky's the limit for what we can create.

Karen Litzy (11:28):

And I think it goes beyond your individual practice, but it helps to elevate the profession of physical therapy.

Tannus Quatre (11:35):

Absolutely. Yeah. And it makes things like when we're talking about marketing, marketing is kind of like a logistical, tactical, strategic thing, right? It's like how do we attract people to us? It makes it very authentic and simplifies it quite a bit when we really think about it from the standpoint of building ambassadors through quality, passionate care that people want to go out and rave about.

Karen Litzy (11:58):

Absolutely. And now I know we've been kind of interchanging these words throughout the interview, but we've got patients, customers, clients. In your experience, what kind of clicks for that potential person coming to see you? What do they want to be called or what should we be calling them or does it matter?

Tannus Quatre (12:21):

Yeah, I think they probably want to be called by their first name. I think that what we want to I think that the mindset that we want to be in though is that, and this is my personal preference, but I'm an ambassador of this idea, so I'm going to be passionate about this is customers have a choice and choice is the key. If we look at that variable there, a customer can choose to come see us for the first time and they can come, they can choose to come see us time and time again. They can choose to be compliant with their prescribed therapies which sometimes are painful or not very enjoyable at all. Right? The choice is really that key term. And for me, choice equates to being a customer. Customers have a choice. So if when we use the word patient, although it's you know, in our vernacular and along the health paradigm in healthcare patient to me is being instructed or being prescribed as to what to do. It's the opposite of having a choice. And so for me, when I'm having this conversation with my customers who are private practice owners like yourself, I really I really advocate for the use of customer because I think it really represents what we're trying to do, which is have customers choose us. Time and time again.

Karen Litzy (13:46):

Be sort of more active, play a more active role. Patient can sometimes have more of a passive connotation that I'm just here waiting to hear what the PT needs to tell me what to do instead of having a shared decision making about their plan of care.

Tannus Quatre (14:00):

Yes, yes. And, as we know and more proof of the phrase customer. Our customers are researching us out before coming in. They're looking us up on Google. They're doing all the things that we do if we're buying a product on Amazon, right? So that those are customer behaviors. And I think by us really embracing that, it allows us to be more agile and strategic about our marketing efforts.

Karen Litzy (14:24):

So now let's talk about, you just mentioned Google. So people are going to Google us, they're going to look at Google reviews, Yelp reviews. So, what drives these positive reviews that people are reading hopefully reading about us.


And on that note, we're going to take a quick break to hear from our sponsor net health and we'll be right back. This episode is brought to you by net health, net health outpatient EMR and billing software. Redox powered by X fit provides an all in one software solution with guided documentation workflows to make it easy for therapists to use and streamline billing processes to help speed billing and improve reimbursement. You could check out net health’s new tip sheet to learn four ways that outpatient therapy providers can increase patient engagement in 2020 at

Tannus Quatre (15:25):

So interestingly what's not driving the positive reviews is strictly about outcomes and the quality of care, which is really what we're all about at the end of the day. Right? We kind of started with that. What's driving positive reviews? I would just put it into one word, which is relationship. If you have a strong relationship and within that relationship you identify as part of it, like you're really, really an ambassador raving fan. It's not even if you were to request a happy customer, Hey would you, would you mind saying some positive about me? Absolutely. They're going to want to do that. But, if you think about what really drives someone to take it upon themselves to say, you know what, you are so damn good that I'm going to go out and do a solid for you because I want to help build your business for you.

Tannus Quatre (16:14):

That's based on a relationship. And I think part of it is the identity too, of feeling proud about the fact that like if you get the latest iPhone all right and you're stoked about it, don't you feel kinda good about the fact that you're the one going out bragging about the fact that you're one of the first on the block that's gotten the latest and the greatest in that same sentiment or that same idea is what drives us to go online and be public about positive experiences we have with our rehab therapists.

Karen Litzy (16:44):

And now let's say we're going to get to marketing in a second, but let's say you're a physical therapist, a private practice owner or you're working for a private practice. How do you bring up to your client or your customer like, Hey, I would really love for you to leave a review on Yelp or on Google, when is the right time to do that? And is there any verbiage that we want to avoid?

Tannus Quatre (17:10):

Yeah. Okay. I love the question. The answer is yes, there's a right time. What I coach therapists to be looking for is I just call it the opportunity and it's happening like right now as we speak. By the time we're done with this, it'll have that opportunity will have happened in hundreds of clinics throughout the U S as we speak. That opportunity can come by way of a customer saying, Hey, I feel great today. That's a lead for us, right? That's somebody who's happy and they're expressing that to us. It can be somebody who has achieved an outcome that they had not yet achieved or they met a goal that you had established together and you both acknowledge that in the moment. There's really deep moments too and we've all had them where a customer or a patient gives us a big warm hug and tells us that they love us and they've never ever been in this position before having met us and they're that emotionally bonded to us in that moment.

Tannus Quatre (18:11):

They might even have a tear in their eye. Those are all opportunities and there's infinite flavors of what those can look like. But the first thing we need to do is identify or be trained, really to like see that as truly an opportunity to now build an ambassador. Because now the next step is to empower that patient or that customer to go out and do something that's gonna make them feel even better and it's going to give back to the profession and it's gonna support your business. So once you identify that opportunity, it's a very, in a very authentic and sincere way to say, Hey, listen what you just expressed to me as, as my patient or as my customer means the world to me. And that's why I exist and I want is to help people just like you. Would you be willing to help me help others experience what you're going through in this moment?

Tannus Quatre (18:58):

Right now the answer is going to be a resounding yes. Now it's logistics. Okay? Would you like to know how this is what you can do? Are you on Google? Do you have a Facebook account? Are you on Yelp? You figure out what, what flavor suits your business needs best. We find that most, it's easiest on Google or Facebook because most people are there. But it's simply, Hey, if I provide you with a link and all you had to do is click that link and leave a positive review, would you be willing to do that? Would you make that commitment? To me, the answer is going to be a resounding yes. And we find that to be highly successful at tying the opportunity to the ask and to the results.

Karen Litzy (19:37):

Perfect. Thank you. I'm sure a lot of people will find that super helpful. So now we spoke about why people are coming to you for the first time. What does success look like? What drives those reviews? How we should be thinking about our customers or clients, patients, customers or clients. So let's now tie that altogether and talk about marketing. So how does all of that tie into the way we should or could be marketing our practice?

Tannus Quatre (20:09):

Yeah, I mean in infinite ways.

Karen Litzy (20:14):

It's an easy question, right?

Tannus Quatre (20:16):

Yeah. Well I mean to me that's all the fodder that the best marketing plans out there for large organizations or small should be using, which is do we have our fundamentals right? Do we have customers that we can benefit? Do they say positive things about us? Are there signs of success that they're coming back for more and more? Are they compliant? Are they loyal to us? If you have those two things you can now take that and deliver that out into your community as evidence or social proof that you are the provider of choice. And how do you do that? You know, how can that be constituted within the context of a marketing plan? We believe a lot in content marketing because really everything we do, including this podcast right here, it's all content, right?

Tannus Quatre (21:06):

And content is the best tool that you can be using for marketing. Cause you can use it to draw people near to you. So whether it's taking that a script that we just discussed to generate a five star review online, that by itself is one prong of a marketing plan. That is a content marketing plan that's driven by content that's coming from a happy patient that they're then posting online, taking testimonials or if you use outcomes tools and you're able to demonstrate that you're better in your market than your peers and taking that content and then dripping it out via social channels via the press, via email, name, the channel, it doesn't matter. But by dripping that out there into the community and using that to pique curiosity, curiosity and interest, that's basically leveraging your fundamentals into a very, very strong marketing plan.

Karen Litzy (22:00):

And let's talk about consistency. So we know that it takes a lot of touch points before someone will purchase. Like, I think I was doing some research a couple of months ago and came across this study where I think it took 20 touch points for someone to buy a chocolate bar and it was like 300 before they would buy an expensive set of headphones. And so a touch point can be just like you said, it could be something on social media, could be something they read in, in a publication or a blog or, so we know a lot of touch points are necessary for something that might cost a little bit more money or a little bit more time. Right. So let's talk about consistency of marketing and what, what can we do?

Tannus Quatre (22:41):

Yeah, it's a consistency of those touch points is, is really everything. So, we tabulate that basically in terms of impressions. So how many times do eyeballs or ears meet with the brand that we're promoting. And then in addition to that, you want to have a variety of how those touch points are experienced. So it would be one thing to have you just to use your examples. Let's say it's 20 touchpoints or  300 touch points through email. You think about that, that's going to have one type of impact on you, right? And that impact might be, I'm getting too much email. Okay, well but if you, if you get to that 20 or that 300 points and it's through a combination of certain percentage of email, social media, I'm getting some through the podcast, a little bit on the new station.

Tannus Quatre (23:34):

I'm getting, you know, something in my snail mail mailbox at home. All of those different touch points aggregated together. It's really how all the big brands do it. If you think about that when we buy an iPhone or we buy a Nike or something like that, we don't just see him in sports illustrated or the Apple store, we see it in multi channels every single day. We'll see. We have about 6,000 brand impressions that a customer is exposed to every single day. Right? And in order to permeate that as physical therapists, we have to have true consistency and volume when it comes to touch points, what that exact number is, if it's 20 or 300, it's going to depend on a lot of variables that are going to be unique to your market or your practice. But the key is you have to be consistent and you have to be, you have to be multichannel.

Karen Litzy (24:27):

Different spokes in that wheel, right. In that marketing wheel. It's not just snail mail or it's not just a Facebook ad here and there. It's a lot, especially in a world where people are bombarded on a daily basis by stuff. Right?

Tannus Quatre (24:45):

Yeah, no, absolutely. Yeah. So, so then I will sometimes get the same question, like, how many times do I have to, you know, touch a customer with a piece of collateral? Or how many times do I have to market to an influencer or a physician before I can expect them to do X, Y, and Z ? And that's the wrong question to be asking because there's no straight answer. It's iterative. If you track your data, you're going to know for you exactly how much budget and how many impressions you need to see in Facebook in order to generate a lead, right? It's going to look different maybe for email, but the key is to really understand your own business and don't be afraid to try something new. If you're not doing email campaigns, which I would suggest to you're doing right, try email campaign, track your conversion rates and see if it's something that's working for you.

Karen Litzy (25:38):

And you know, we'll start wrapping things up here a little bit, but if you could give a physical therapy, let's say a private practice owner, we'll use that. What would be, and again, knowing there's a million tips, but what are your top few tips on how to market efficiently and with integrity and to not feel like a used car salesman?

Tannus Quatre (26:06):

Yeah. okay. A couple of things. So the first thing is believing in yourself and your value proposition. That's the biggest threat that we have to our profession is that sometimes we feel like we're too expensive or we feel like there's too much cash that's owed up front from a patient. And we start to second guess ourselves so that in any marketing channel we were not as effective. Okay. So, so that would be the first thing I would say is really understand and believe in your value in everything you craft around that's going to have a lot of authenticity, sincerity, and passion and that will be felt and heard. Okay. And I think the second thing that I would probably offer is know your lane. There are if you take some of the big brands out there, they have resources to be able to succeed at a certain scale that doesn't work at a smaller scale.

Tannus Quatre (27:05):

Okay. So just because it can be effective to have the name of your company splashed on the, you know, the outfield fence, you know, for a major league ballclub doesn't mean it's right for you. Right. so knowing what your lane is and a lot of times if I kind of now bring it down to kind of the micro level and talk about a small private practice, a small private practice trying to do a whole bunch of different marketing things, man, it's going to be hard to do. And probably what's going to end up happening is you're not going to really hit the bar on any one of those things. So I would much rather counsel a private practice to say, Hey, we're going to dominate these three areas. We are going to lead our community with workshops.

Tannus Quatre (27:54):

We're going to do better than anybody else with holding workshops in our facility. We're going to do it consistently. We're going to pour the resources on and make sure that every single month we're doing workshops and we're also going to dominate Instagram. You know, if you said those are the two things, because that's, you know, it, it comes naturally to you. It's channels that you're familiar with and it was just those two things and you didn't do anything else. I think you're going to have more of ability, more of an ability to have success. And if you don't have success or you do to be able to understand and tweak your success if you choose those lanes because they can work for you. And I see far too many people trying to do a little bit of everything, throwing spaghetti at the wall to see what sticks and the reality is you don't meet the threshold anywhere and you really don't know what's working anywhere. So you don't know how to, how to tweak things and make them better over time. So I think that the authenticity and believing in yourself and really knowing your lane and choosing to stay in that lane are the two things.

Karen Litzy (28:55):

Some advice and it's, you know, if we put it into our client language, we would never give a patient 10 exercises on the first time we see them. We would give them maybe one or two so they can master those. Because if you are trying to do 10 you end up doing none. So I can understand that. If you're a small business owner, I'm a small business owner. If I tried to do a million different marketing ideas, I'd be like, forget it. This isn't, I'm not doing anything. I'm done. No more marketing. Yep.

Tannus Quatre (29:24):

And, and, and, and that's kinda what happens. It's a lot of back to you mentioned consistency. It's a lot of starting and stopping. When you try to do too much, it's you say, okay, I'm doing a lot of everything. I don't know what's working or what's not. So pivot, try something else. It may or may not be more successful. Right.

Karen Litzy (29:38):

Great. Great advice. All right, now it's a question I ask everyone. Knowing where you are now in your life and in your career, what advice would you give to yourself as a new grad right out of PT school?

Tannus Quatre (29:52):

Okay. love the question. Leave fear at the door. I spent too much of the early part of my career, probably the first five to seven years or so. Asking for a lot of permission. Thinking that there was a lot of things that weren't quite right for me and that there was some excuse or some magic wand that other people had to achieve things that I thought were really compelling or intriguing. Instead of just getting out there and saying, screw it, let's just fail fast, fail often and like get on the path to success. So I think that's the one thing that I would have told myself to do out of PT school.

Karen Litzy (30:33):

Excellent advice. And that could be at any stage of life. Great advice. So now where can people find you? Tell us a little bit more about your company and where they can find it.

Tannus Quatre (30:42):

Yeah, absolutely. So I am proud to be part of the net health company, so I can be emailed at You can also find me on all of the social channels at Tannus Quatre.

Karen Litzy (31:02):

Awesome. Well, thank you so much for taking the time out and in the middle of CSM, and hopefully this isn't too loud for all of you listening. I don't think it is, but thank you so much, Tannus. This was great. And again, if anyone wants to reach out to Tannus, we will have all of those links in the show notes at so thank you.

Tannus Quatre (31:22):

I love it. Thanks for having me, Karen.


Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts

Mar 9, 2020

On this episode of the Healthy, Wealthy and Smart Podcast, Jenna Kantor guests hosts and interviews Domenic Fraboni on content creation for social media.  Domenic Fraboni is a physical therapist in Los Angeles, California and lifestyle consultant focusing on mindset, movement and meals through online coaching.

In this episode, we discuss:

-How to choose the right social media platform for your target audience

-The importance of developing engagement with your content

-How to stay authentic and avoid the negativities of social media use

-And so much more!


Domenic Fraboni Instagram

Domenic Fraboni Twitter

A big thank you to Net Health for sponsoring this episode! 

Check out Optima’s Top Trends For Outpatient Therapy In 2020!


For more information on Domenic:

Domenic Fraboni is a Doctor of Physical Therapy and Certified Strength and Conditioning Coach. He earned this after graduating from Mayo Clinic School of Health Sciences in Rochester, MN IN 2018. He is a member of the American Physical Therapy Association (APTA), attending many events nationwide to advocate for the advance of the physical therapy profession as well as accessibility to higher quality of care. As a recent member of the APTA Student Assembly Board of Directors and active advocate for healthcare reform, Domenic likes to focus his efforts on systemic healthcare change. He was an avid coach, unified partner, and volunteer coordinator for Special Olympics. He now has relocated to Los Angeles where he coaches people into their bodies using a unique approach of Health and Lifestyle consulting in the areas of mindset, movement, and meals through his company, The Wellness Destination. Domenic focuses his services on the true and authentic connection he hopes to create with patients, clients, or those who looking for help on their health journey. Then he may be able to help empower individuals overcome some barriers and create true progress and independence in their lifelong healing journey! 


For more information on Jenna:

Jenna Kantor (co-founder) is a bubbly and energetic girl who was born and raised in Petaluma, California. Growing up, she trained and performed ballet throughout the United States. After earning a BA in Dance and Drama at the University of California, Irvine, she worked professionally in musical theatre for 15+ years with tours, regional theatres, & overseas ( until she found herself ready to move onto a new chapter in her life – a career in Physical Therapy. Jenna is currently in her 3rd year at Columbia University’s Physical Therapy Program. She is also a co-founder of the podcast, “Physiotherapy Performance Perspectives,” has an evidence-based monthly youtube series titled “Injury Prevention for Dancers,” is a NY SSIG Co-Founder, NYPTA Student Conclave 2017 Development Team, works with the NYPTA Greater New York Legislative Task Force and is the NYPTA Public Policy Committee Student Liaison. Jenna aspires to be a physical therapist for amateur and professional performers to help ensure long, healthy careers. To learn more, please check out her website:


Read the full transcript below:

Jenna Kantor (00:01):

Hello, this is Jenna Kantor with healthy, wealthy and smart, super excited to be here at Graham sessions 2020 with Domenic Fraboni, who I know from student assembly running for that, the board of directors and then also now on social media, which is our big focus because he has been putting a lot of work specifically on Instagram. So I wanted to have a discussion on this journey, I'm going to call you Dom now. Let's make it casual with Dom, so, first of all, thank you so much for coming on.

Domenic Fraboni (00:37):

Thanks for having me and being interested in what I might have to say. It's been kind of a journey this past six months with a lot of changes for me, especially career-wise, location-wise, and the social media thing. You just want me to dive in a little bit.

Jenna Kantor (00:50):

Actually first, let's start with why you chose Instagram, because when choosing a social media platform that you're thinking of a specific audience, so would you mind diving into that so people can start picking their brain and thinking, even if Instagram is where their audience is?

Domenic Fraboni (01:06):

I think my choice in platform had a little less to do with what I was wanting and just have more by chance. You know, I started dating somebody who has a big following and notice some of them started taking a liking in me or an interest in me. And it was at that point that I realized, Hey, Instagram, I've wanted to find a place I can start creating some content, whether it's recording exercises, whether it's just putting out thoughts, thought provoking things for potential clients or potential humans. I'm all about getting access to good information out to the humans so that they can make the decisions for themselves. And we know in this online era and the age of information, I would love to be contributing to what I think can be, you know, more trustworthy information that's online. So I started getting this Instagram following and I'm like, okay, let's do this. Let's put out some content. And I think it worked great for that because a lot of times people go to Instagram for content of that sort. So I'm like, Hey, great marriage. So that's kind of how choosing Instagram as a platform came about more by chance than by my direct choice.

Jenna Kantor (02:12):

How did you figure out what your content would be on?

Domenic Fraboni (02:19):

Yeah, that's another great question. I'm kind of in my purpose moving into this career as a professional. I always said I want to empower people to independence in their journey, right? And then kind of my themes that came out of that were movement. I'm a doctor of physical therapy. So clearly movement is huge to me and how I deal with clients and patients. Mindset. Cause I do also understand that in the psychosocial realm of how we treat humans and how we deal with humans, our mindset, our emotions, our mental state has a lot to do with how we feel physically and how we move and meals. So I'm like, Hey, maybe if my content surrounded those three themes, that can be my stick mindset, the movement and the meals. And it had a little, a little bit of a ring with the three M's there.

Domenic Fraboni (03:03):

So that's where I just started with those three things in mind and trying not to question myself was the biggest thing going in where you asked, Hey, how'd you know what kind of content to put out? I knew I had these people following me and that they might be interested in what I have to say. So my first step was just doing, it was starting to put out content and asking questions. If you ever have a time online where you have people following you and you don't know what they want, ask them. And so I started asking questions. I was very lucky to have people around me who had kind of gone through a transition like this into putting themselves out there. And a lot of what they said is just do it. You know what you're good at, you know what you're passionate about. These people have started following you for a reason, the ones that need to hear it will resonate and the ones that want certain things, we'll let you know when you ask. So I started asking questions to the people that were following me and they also just started putting out content and realizing what it was that people resonated well with.

Jenna Kantor: (04:04):

And for you, what were your measures that you are using to go, Oh, this is what they want to see from you?


Domenic Fraboni:

So I like to say that and a lot of people in social media want to try to separate the success of their posts and their media from the likes and the comments and that stuff. And it can get really kind of cloudy in our head as, Oh, why did this not have as many likes as this? And so really early on when I started doing this, I tried separating myself from likes. Everyone wants a lot of likes on their stuff and it really is not likes on your posts that mean people are engaging with it or connecting with it. The things that I really started to realize is the more direct messages, the more DMs or the more comments that people are connecting with are saying like, Hey, I love this.

Domenic Fraboni (04:56):

I tried it. It feels this way or I'm glad you shared that. Thanks so much for sharing more about yourself, whatever that means that I'm connecting with them personally in some manner. And so I liked to kind of dive into those ones that got a lot of personal direct messages or comments. And I'm big when it comes to feel and the energy between an interaction with people. So when I got interactions back from people that fueled that same purpose or energy, that was the reason I put that post out. There we go. Like those are my metrics. And I live in more of a subjective world myself because research makes me cringe a little bit sometimes. But it's the field that you can't get away from. So when I had people responding to me that made me feel something, I understood that maybe they took something away from that that made them feel something inside.

Domenic Fraboni (05:43):

So try to steer away from becoming obsessed with likes or comments and really steer towards and into the things that, you know, people feel something when they read it and will connect with it and reach out because of that. And I feel like I've helped to engage my audience a little more.


Jenna Kantor:

I love that. And with all the content that you're doing, how did you figure out how often you're going to be posting?


Domenic Fraboni:

Yeah, so like the frequency is huge too because consistency breeds trust, you know, people, although we are putting out this free content and it does take time to put together, you know, people like following, you know, people are content providers that they know are going to be there for them or that they know are going to be there and continue to put that out. So I'd say the first thing was like, okay, I need to be consistent.

Domenic Fraboni (06:35):

And initially when I was starting this, I had a little more time on my hands and I was, I decided, okay, I can take Sundays off and I'll post six times a week. And then I realized as I started getting more coming onto my schedule that that was a bit tough and so I landed on doing something about three times a week, three to four times a week and making sure I'm very consistent in that, but then also engaging when possible and making sure that those connections that are made aren't just done because I need to make my three posts a week again is all has to come from this intention inside me, so whether it ends up being two times a week or six times a week, I know that it's all still coming from this great energy that I trust and in behind what I'm putting out.

Domenic Fraboni (07:18):

Again to create those relationships, whether online or whether in person or whether just through DMs or comments. We are creating relationships and connections with these people in some way and so if the post I can put out has a slight influence on that energy that might drive them to be open to different options, then that's what I'm going to put out. I've landed somewhere in that realm of three or four days just based on how much other work I have in my collective sphere right now. But I think that's plenty for me to continue that frequency of engagement to make sure people know that I'm going to show up.

Domenic Fraboni (07:54):

Do you have to know everything to start something on Instagram? Yes. If you're not an absolute expert, then you no, absolutely not. And I think if you look through Instagram pretty quickly, you'll realize that not everybody is an absolute expert or knows everything in what they're posting. And I hear a lot of PTs or specifically younger PTs who will see other pages and be like, what the heck is this? Like, this isn't how it is or this isn't how you should do that exercise. Or like, wow, they aren't even paying attention to this. And my thing to them is like, we'll record an exercise and put it out or record a video of yourself doing it and say like, this is how I do it. Not to bash or be against that person. I'm very, very much so against calling people out. I put my air quotes over that even though we're on audio, but calling people out or having turf Wars with other people because you don't agree with them. We don't have to agree. We do also just have to understand that there are a lot of people that are open to those other routes. And this isn't for PTs.

Jenna Kantor (08:56):

This is for people.

Domenic Fraboni (08:57):

Yeah. So leave your ego at the door, leave your ego away from your phone and put out great content that you know you can stand behind and you won't have to worry about that as much.

Jenna Kantor (09:10):

I love that so much. What has been the biggest lesson you've learned since really diving into your consistency and all your content on Instagram?

Domenic Fraboni (09:19):

Yeah. Be authentic and trust yourself. It's really empowering. Well one, when you find that empowerment within you just to say like, I know what I know and I know where that comes from. And when you sit in that space, no matter what you put out or what someone says about it can impact that. And so yeah, I spend time on posts that I put out and they don't go anywhere. Maybe I have a slight bid or a question in my head like what happened there? Why did that not get that following? But I don't emotionally attach myself to any expectation on that. So the biggest challenge is the expectation of yourself or the comparison bug that might come out. Instagram's doing this thing where they're taking away the ability to see likes on a lot of posts now, which I think in a lot of aspects is great cause there are a lot of people in these younger generations that are going through anxieties and depressions because of this technology addiction, which is a whole nother topic.

Domenic Fraboni (10:17):

And that's the initial reason I never wanted to get into this cause I knew technology draws on these very addictive processes to get people to continue to use and to continue to abuse those processes until literally we are physiologically addicted. And that's why I stayed away from it. And instead knowing that that can happen and the intent from where I'm coming, I know that we can use these processes that may be addictive to get great information out to people and to help them understand and have access to that kind of stuff. So yeah, my biggest challenge, a challenge is going back to your initial question was you know, comparison and seeing what other people are doing, which is why I brought up the likes and like, Oh they got that many likes and they have this many followers and this and that. You know, like you start wanting to do that in your head again, shut those things down right away because you don't know what their purposes are, where the people that follow them are coming from or what they're looking for. And so be authentic and try not to get that comparison bug on your shoulder.

Jenna Kantor (11:18):

Boom, Shaka Laka I love that. So where can people find you on the Instagram?

Domenic Fraboni (11:24):

So if you type in doctor, just drDomDPT, it's drDomDPT, you can find me. I put out stuff on movement, mindset and meals. And my goal is to empower you to independence in your journey. Cause everybody could use a little bit of good information to maybe open up what other possibilities could be on your path.

Jenna Kantor (11:45):

I love that. So thank you for everyone who tuned in to listen to this podcast. You can also get that information on where to find Dom in the bio as well. Dom, thank you so much for coming on.

Domenic Fraboni (11:56):

Thanks. This has been amazing. Jenna. I love getting to see you here at Graham sessions and thanks for interviewing me.


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