New Legislation Passed in NYS on Telehealth and OTAs!!!

(1) NYS has become the latest and last state to require licensure for OTAs!

(2) The OT/PT telehealth parity bill was also signed into law. The law states that deductibles, co-insurance or other conditions for coverage of telemedicine cannot differ from those for in-person visits. It also differentiates between telemedicine and telehealth. Telemedicine, it says, refers to real time, two-way electronic audiovisual communications, while telehealth can include telephones calls, remote patient monitoring devices or other electronic means of diagnosis, consultation, education and treatment.

Table of Contents for Policy and Procedure Manual


1.  Initial Intake Form – Generic for Adults and Specific to Pediatrics
2.  Generic Evaluation Forms  (Pediatric and Adult Practices)
3.  Generic Progress Re-evaluation Note
4.  Generic Discharge Form
5.  Assignment of Benefits Form/Patient Notification of Billing/Cancellation/Discontinuance of Services Policy/Financial Policy Form
6.  Medicare Beneficiary Form
7.  Authorization for Release of Confidential Information
8.  Notice of Patient Privacy Practice/ Patient Information Consent Form
9.  Patient Satisfaction Survey
10.  Referral Source Satisfaction Survey
11.  Photo/Video Release Form / Waiver Form for Onsite Classes/Permission Slip for Caregivers
1.  Incident Reporting and Form
2.  Child Abuse
3.  Confidentiality, Release and Handling of Information including HIV Information
4.  Confidentiality for Emails/Faxes
5.  Emergency Preparedness Plan
6.  Health and Safety Issues Including Universal Precautions, Infection Control/   Handwashing Procedures
7.  HIPAA Policy and Procedures –
8.  Rehabilitation Update/Documentation for Medicare Patients
9.  Clinical Chart Review Form

1.  Application Form, Orientation and Minimum Requirements of Therapists
2.  Reference Forms
3.  Clinical Competency Review Form
4.  Employee Health Assessment
5.  Hepatitis B Consent/Decline Form
6.  Freedom from Impairment Form
7.  On Site Clinical Competency Form
8.  Sample Employee Handbook
9.   Code of Ethics  – OT, PT ST
1o. Job Descriptions – clinical and non clinical –

1. Sample Temporary Personnel Services Agreement
2. Sample Home Care Personnel Services Agreement
3.  Sample Contract for School District Service Provision
4.  Sample Independent Contractor Agreement
5.  Sample Employee Contract

PLUS – New for 2018 – forms for pre payment and prompt payment discounts, medical hardshipconsent for treatment

Purchase now:  $160 for downloadable, editable word document you can edit and customize with your practice name etc.

The Art of Communication – Easier Said Than Done ( no pun intended)

Good communication is at the heart of patient safety, cultural sensitivity, and the pillar of quality care.  Most of the time we focus on the message we are communicating, and how best to choose  words that adequately communicate the message we are trying to convey, while using language that the patient and family fully understand.  Yet, as pointed out in a great NY Times Op Ed Piece this week  (Doctor Shut up and Listen by Nitmal Joshi ), we need to focus equally on the other side of the communication equation, listening.

The core skill of good communication is listening. Listening requires that we put aside any thoughts of what we want to say next and just attend to the person talking. It requires that we be curious enough and interested enough in the other person to make sure we are clear about what they are saying, asking for clarification and reflecting back to make sure we have heard correctly. It is about taking seriously that the conversation is not about us but about the other.

Good listening is about understanding that good listening is often enough. Do patients want an answer to a question or do they just want me  — as the therapist — to listen to them? They want to be heard and, through that hearing, respected. Do they want my words or do they want my attention and presence? Even when the patient is looking for an answer, listening and creating a space for the patient to reflect may be all they need to come to the answer themselves rather than having me impose it on them.

 Don’t minimize listening by saying we “just” listened. This so simple but so powerful that often it is one of the best interventions we can make with our patients and their families.


Having certain Medicare claims re-opened without the appeal process!

Medicare Claim Re-openings and How to Request a Reopening

In the case where a minor error or omission of your Medicare claim submission resulted in a claim denial, you can request Medicare to reopen the claim so the error or omission can be corrected, rather than having to go through the appeal process. There is no need to request an appeal/redetermination if you have made a minor error or omission in filing the claim, which, in turn, caused the claim to be denied. You can request a reopening for minor errors or omissions either by telephone, in writing or via NGSConnex. You have one year to request a reopening from the date on your RA.

The clerical error reopening process is not a part of the formal appeals process, but it allows providers to make a minor change to a previously filed claim, if the original claim has been denied or reduced. CMS provides the instructions for reopening activities conducted by MACs. Section 937 of the MMA required CMS to establish a process whereby providers, physicians, and suppliers could correct minor errors or omissions outside of the appeals process.

Clerical error reopenings can be done on the phone, in writing or via NGSConnex, for providers to correct minor errors, clerical errors, or omissions. The MAC reserves the right to refuse to adjust a claim as requested if it appears that such an adjustment would risk incorrect payment on any claims not identified for correction.

A provider, physician, or supplier may request a reopening up to one year from the receipt of the initial remittance notice. If the provider, physician, or supplier would like to request a reopening after the one-year time limit has expired, they may request the reopening in writing. Documentation supporting good cause to waive the timeliness requirement must be included.

CMS issued interim final regulations, which state clerical errors (which CMS likens to MMA’s minor errors or omissions), are defined as human or mechanical errors on the part of the party or the contractor, such as:

  • Mathematical or computational mistakes;
  • Transposed procedure or diagnostic codes;
  • Inaccurate data entry;
  • Misapplication of a fee schedule;
  • Computer error; or,
  • Denial of claims as duplicates which are denied as a result of a clerical error or minor omission and require a change on the face of the claim (i.e., adding or removing a modifier) in order for the claim to be reopened. (Exception: We will reopen claims that denied as a duplicate when multiple services have been billed and some are denied due to a separate claim submission; i.e., when three radiology services have been paid on one claim and a fourth one denied as a duplicate due to a separate claim submission and a request is made to allow a total of four services. A reopening can be performed even though the claim was submitted correctly and no change is being made.)
  • Incorrect data items, such as provider number, use of a modifier or date of service.

The basis of a clerical error or minor omission reopening is to correct the minor clerical or minor omission that resulted in an initial claim denial or reduction.

Types of Issues that can be performed as clerical error or minor omission reopenings:

  • Increase number of services or units (without an increase in the billed amount)
  • Add/change/delete modifiers such as 24, 25, 54, 57, 58, 59, 76, 77, 78, 79, 80, AS, or AQ (Note: Postoperative modifiers 24, 25, 57 and 58 can be added to a paid claim so the provider can submit a procedure code without having it reduced by the unrelated visit.)
  • Procedure codes
  • Place of service
  • Add or change a diagnosis on a denied service
  • Billed amounts
  • Incorrect provider number to deny
  • Incorrect HIC to deny
  • MSP unrelated – non-GHP records
  • Correcting rendering provider PTAN/NPI
  • Addition of referring provider PTAN/NPI
  • Add date last seen on the claim
  • Date of service – the date of service change must be within the same year
  • Services billed in error
  • Refunds (except 935 refunds)

Types of Issues that cannot be performed as clerical error or minor omission reopenings. For these issues providers must submit a redetermination request in writing:

  • Comprehensive Error Rate Testing (CERT)
  • Provider enrollment issues
  • Claim denial due to no response to a development request
  • Established Recovery Auditor (RA) overpayment (Telephone only)
  • Services with a high dollar amount ($7,500 or more)
  • Wrong payee
  • Complex claim situations (such as ambulance, anesthesia, Not Otherwise Classified codes, claims with modifiers 22, 23, 53, 62, 66, GA or GY or any other claim which requires analysis of documentation).
  • CMS input (e.g. services after date of death)
  • If there are multiple surgeries on multiple claims for the date of service in question

Some situations would not be appropriate for the reopening or redetermination process:

  • If the original denial is rejected as unprocessable, submit a new claim
  • If the claim in question is in process, you must wait until after the claim has processed before requesting a reopening
  • If there has been no claim submitted, submit a new claim
Level/Type Time Limit Amount in Controversy
Required (after deductible and coinsurance)
Telephone Reopening Within 1 year of receipt of the notice of initial determination. No minimum
Written Reopening Within 1 year of receipt of the notice of initial determination and within 4 years after the date of the initial determination, when the situation establishes good cause. No minimum

Telephone Reopenings

Providers may request a reopening of the original claims processing decision by contacting the Appeals Telephone Reopening Unit (TRU).

The TRU can be used when you wish to revise the initial determination or redetermination of a specific service or claim for minor clerical errors. If you have a general question or need to talk to someone about an issue that cannot be reopened, please contact our Provider Contact Center.

TRU representatives will reopen claims to correct minor, uncomplicated, provider or contractor clerical errors or omissions. However, TRU representatives cannot add items or services that were not previously billed. Please Note: Reopenings are granted at the contractor’s discretion; a claim may not be appealed if contractor decides not reopen the claim.

With the availability of the electronic remittance advice you can know the outcome prior to the complete finalization of a claim. Please ensure the claim has finalized prior to calling the TRU line to request changes to the claim.

Note: Unsolicited faxes will be returned to the sender unprocessed.

Using NGSConnex to Submit a Redetermination or Reopening Request

NGSConnex, a free and secure web-based application, has a convenient option available that providers can use to submit an appeal request for a claim redetermination or reopening online instead of submitting a paper appeal. Providers can also check the status of redeterminations/reopening requests.

For complete instructions on using NGSConnex for submitting a reopening request, visit our Reopenings for Minor Errors and Omissions section of our website.

Written Reopening Requests

Jurisdiction 6 providers in Illinois, Minnesota and Wisconsin should mail written reopening requests to:

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Jurisdiction K providers in Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont should mail written reopening requests to:

National Government Services, Inc.
P.O. Box 7111
Indianapolis, IN 46207-7111

Be sure to include the following information with your reopening request:

  • The beneficiary’s name
  • The Medicare HICN of the beneficiary
  • The specific services(s) and/or item(s) for which the reopening is being requested and the specific date(s) of service, and
  • The name and signature of the person filing the request

Reopening requests for issues requiring documentation such as adding modifier 22 and redetermination of overpayments are not permitted. These must be submitted as a written redetermination request.
Info from:

Will the FTC Slow Down the Current Medical Merger Mania????

Many of us remember the merger mania in healthcare that occurred in the 1990’s, and how the push toward consolidation that started with hospitals trickled down to the private practice  therapy sector. If we fast forward to 2014, it is readily apparent that the “urge to merge” is back.  We see local hospitals in a merger frenzy, and local MDs leaving private practice to become hospital employees. I have more and more therapists contacting me about practice sales. Yet, a strong but dominant voice, namely the Federal Trade Commission, is beginning to weigh in on the topic. Citing antitrust laws, particularly the Clayton Antitrust Act of 2014, they have successfully blocked some deals using antitrust enforcement as a powerful tool to dampen  conglomeration fever.

Hospitals say they are acquiring other hospitals and physician groups to comply with provisions
of the Affordable Care Act and take advantage of incentives that encourage hospitals and doctors to integrate their operations and collaborate to control costs and improve care.
 The concern is that hospitals that face less competition can charge substantially higher prices, which according to Martin Gaynor, Director of the FTC’s Bureau of Economics could be as high as 40-50%.  In the last two years the FTC intervened and blocked hospital mergers in Albany Georgia, Toledo Ohio and Rockford Illinois. Although the decisions are currently being appealed, the message is strong. “Vague promises and aspirations that an acquisition will reduce costs and improve care are not sufficient” said Julie Brill, a member of the FTC.

When hospitals and doctors join forces, their goal is not just to control costs or improve care, but to “get increased leverage” in negotiations with health insurance companies and employers, according to
  Ms. Feinstein, Director of the Bureau of Competition at the FTC. “They say they need better rates so they will have more money to invest in their facilities.When you strip that down, it’s basically just saying, ‘We want a price increase.’ Even if the price increase is motivated by a desire to invest more in the business, that’s problematic. That incentive to invest may not be there if you don’t have competition as a spur to innovation — if you’re not worried about losing business to the hospital down the street.”

Look back to the first merger mania in the 1990’s particularly the state of Massachusetts, which let its two most prominent hospitals — Massachusetts General Hospital and Brigham and Women’s Hospital, merge into   as Partners HealthCare. Investigations by the state attorney general’s office of that state have documented that the merger gave the hospitals enormous market leverage to drive up health care costs in the Boston area by demanding high reimbursements from insurers that were unrelated to the quality or complexity of care delivered. Twenty years later, the current Massachusetts Attorney General,  Martha Coakley is trying to rein in the hospitals with a negotiated agreement that would at least slow the increases in Partners’ prices and limit the number of physician practices it can acquire.

What’s the take away for therapy practices?? Carefully examine your “urge to merge” or be acquired, probably the second most important decision of your professional career. Make sure your motivation is not based on panic, and that you are not being re-active rather than pro-active. As hard as it is to bring a merger to fruition, it is harder still to undo!


Thoughts on the Ice Bucket Challenge

There is no denying that the ice bucket challenge continues to be an unqualified success, despite the naysayers who have negated and criticized it from many angles – waste of water, and more of an exercise in raising awareness of one’s own craziness, altruism, “slacktivism” and/or attractiveness in a wet T-shirt.

Here’s why I am so happy it has taken off.  Back in the day (30 plus years ago), I was one of the first OTs to consult with  the MDA ( Muscular Dystrophy Association), and provided services to children and adults  with  many neuromuscular diseases. I was always hardest hit by the people with  ALS. The decline in function, and decrease in strength was steady, apparent and ongoing. The impact on families was huge. Living rooms became makeshift bedrooms to accommodate hospital beds, hoyer lifts and the like. Spouses became caretakers, while secretly mourning the loss of their spouse as they knew them. Looking back, the challenges as an OT were paramount. With the  physical and functional decline so swift and non forgiving, I was constantly challenged to think on the spot, make immediate accommodations, re-purposing and intuitive adaptations to the environment.  All in the hope of making the moment, or the day more tolerable for the family and patient.  What worked one day didn’t the next as the disease ran its course.  My feelings of inadequacy and frustration matched the family’s feelings of desperation and isolation, yet in a way it was OT at its finest.

The Ice Bucket Challenge is raising public awareness of ALS  in addition to raising money for research on the disease. Like most fundraising, the efforts will focus more on the cure while families and therapists focus on making day to day living as tolerable as possible. ALS is classified as an “orphan disease”, since fewer than 200,000 people get the diagnosis annually. Generally that means there is less research and clinical trials for treatment.  ALS has never been and never will be  as profitable a target for pharmaceutical companies to invest millions of dollars in as they do with  more prevalent diseases ( ie cancer, arthritis etc.).

The New York Times reports that in the last few weeks, ALSA has received $13.3 million and welcomed 260,000 new donors.  While the President of the Association Barbara Newhouse says she appreciates the monetary aspect of the Ice Bucket Challenge, she says, “the visibility that this disease is getting as a result of the challenge is truly invaluable.” Monetary donations coupled with social-media-friendly stunts build awareness and encourage others to give in a way that quietly donating cash does not. That’s what that silly tub of cold water does; audiences get a little entertainment, which helps the viralness of the cause and encourages donations. It also strives to make people want to learn more about the disease, and what organizations like the ALS Association are doing to fight it and provide assistance to those living with it.”

Practice owners who work with neuromuscular conditions may want to jump on this bandwagon- a twin win situation, and what I call “cause –related” marketing. It can be  great publicity for your practice and a great way to help raise money and awareness.  ALS is not only an incurable disease, it is an underfunded one as well.



A Shift in the Healthcare Dollar Pie

By my second lecture, I have taught my students about the healthcare dollar pie and its 3 pieces:

Piece 1 for the patient or consumer
Piece 2 for the service/medical provider
Piece 3 for the insurer/payor

I always tell them how the size of the pieces shift over time reflecting the cycles within healthcare delivery. Most of my students were not even born when patients got a big piece of the pie – that is, when patients received the services they needed for the amount of time that they needed them, all without pre-authorization! Many students can barely remember when the piece for the medical provider was big- when doctors were “rich” and therapists could become financially successful. My students do learn about the big piece of the pie that the insurers are eating, how well their stocks are doing, how much their CEOs are making, and how big their pended/denied departments are. And just in time for this fall’s lecture, the pie is shifting again, and in the wrong direction.

Yesterday, I received a letter from my insurance company (BCBS), informing me, as is required by law, that they are seeking a 17% increase in the premium for the new policy I got in January 2015. This both shocked and bothered me on many levels. Year one and the insurers are already taking “affordable” out of the Affordable Health Care Act. More disturbing is that this insurance company has systematically been lowering the fees paid to private practitioners –lowering the fee, eliminating CPT codes and time/ modality based payment in favor for flat fee methodology and bundling. While they systematic deny therapists a rate increase, even one based on cost of living and instead are lowering fees or canceling contracts, they claim they need a 17% increase in part because of the rising costs of medical care, a new pool of customers, and new providers.

I am beginning to no longer see the 3 pieces of the healthcare dollar pie. Instead, slowly it is becoming one pie solely for the insurers and payors, with 2 crumbs, one for providers and the other for patients.

Table of Contents- Starting a Professional Private Practice




Business Plan …pg.17-18
Insurance Information …pg.19-20
The Place of Business …pg.21-23
Contracting With Insurance Carriers – Medicare Enrollment, Plan- Lock out
The Perfect Storm: Cash based versus Insurance …pg.24-25
Financial Considerations – Budgeting, Securing a Loan …pg.26-33
HIPAA/ FERPA Compliance …pg.34-37

6. STEP SIX – MARKETING …pg.38-41

APPENDIX …pg.47-67


Why Are There So Few Adult OT Private Practices?

Re-printed from the Advance POV blog

Published January 29, 2014 8:41 AM by Iris Kimberg

Thanks to everyone following my blog  I have already received many fantastic questions to answer for several weeks to come. This one really struck a chord:

Question:  Why do you think there are so few OT practices that treat adults, and so many that treat children??? Is there not a market for adult services in OT private practices???


I have often asked this myself – well over 60% of the OTs I consult with are pediatric private practitioners, and only a few work with adults. I think the answers lies in the cyclical nature  of therapy services. Like  everything else, there is a life cycle of therapy services – back in the 80’s healthcare, especially in rehabilitation  was adult driven. Private practices (mostly PT because very few OTs dabbled in private practice then outside of hand therapists) treated adults, there was no managed care, and very little was done in pediatrics.

Fast forward to the 90’s when 2 things happened:

1) Managed care rolled out across the country from West to East in part due to billing/therapy treatment abuses of the system by those providing  rehabilitation services
2) Parents of children with special needs woke up and began demanding the services their children were entitled to under Federal law PL 94-142, its expanded version, PL 99-457, and PL 105-17 (in 2004)

These two scenarios lead the cycle shift in therapy services from adult driven care to pediatric care. There was a significant increase in OTs developing private practices to serve the demands of the pediatric community nationwide starting in the 90’s and continuing fr the next 20 years. Guess what cycle watchers – it should come as not new news to pediatric practices, that the cycle is shifting again. Funding for pediatrics is declining and at the same time, baby boomers are living longer, and demanding to live better. This points to a very ripe opportunity for OTs to offer adult driven services. Right now, certified hand therapists who have always offered adult services will continue to do so, and there are some OT private practices who specialize in niche offering like low vision rehabilitation, drivers rehab, home modification services, vestibular rehab etc.

The time is  now for additional OTs to enter the world of private practice and succeed. The cycle is in your favor, the ACA is already addressing habilitative services in addition to rehabilitation services as an essential health benefit, more and more elderly want to stay and live in their homes, every day 10,000 people in the USA become baby boomers. Opportunity is definitely knocking – it is up to you to answer the call!

For the next few weeks, I will be opening this blog up for questions which may be answered in subsequent blogs.  My goal is to help therapists understand the business end of therapy provision through many lenses and achieve the success that they want for the mutual benefit of themselves and their patients.

Questions relating to the following topics can be submitted to me at

  • Finances/ Billing
  • Legal  and Risk Management Considerations
  • Strategic Marketing and Business Communication
  • Day to Day Operational Issues
  • Ethical Considerations
  • Long Term Growth and Development

I look forward to hearing from many of you in the weeks to come!

Using Inbound Marketing For Your Practice

Chances are if you are reading this column, that you and I have developed a relationship, though we may not have met in person. That is because over the years, I have been developing relationships with therapists and creating trust through content via inbound marketing techniques. These same techniques that I have used to gain your trust, you can use to gain the trust of consumers in the hope they will become your clients when the need arises. The internet affords all of us the vehicle to meet new prospects and build trust without having to resort to cold calling, which has a notoriously low success rate in bringing in new clients. Inbound marketing focuses on creating quality content that pulls people toward your practice and services you offer. By aligning the content you publish with your niche areas of expertise, you automatically attract inbound traffic that you can then convert, close, and work with over time.

Creating trust through content means that a great way to start a conversation is by continually publishing some type of educational/meaningful content to your website. Your article choices, blog posts and opinions will begin to engage website visitors, FB fans and LinkedIn connections well before they may actually contact you for services or make referrals to you. What this means is that instead of spending time talking on the phone trying to make contacts, you are instead allowing consumers to get to know you and learn from your experiences. Professional services will always be relationship based, and consumers look to educate themselves before selecting a service provider. Sharing knowledge is an effective way to gain trust quickly – if you are still reading this, this is a live example of what I am talking about!

Become a magnet, attracting those who need your services by owning your space and your niche, and becoming the “go to” person for a particular skill and bolstering this by your targeted content. This is when you are educating “early stage” prospects who may contact you at some point down the road. No doubt there will be consumers who may look to you for content and information, and never take the relationship to the second stage, but others will, and you will be ready when they do. Using words that are “calls to action”, such as ready to get started? helps to move the relationship along to the point where you are contacted. Consumers that have been reading your material and learning to trust you will contact you when they are ready to start or need your services. You want to make sure they have an easy way to move into this stage of the relationship so keep your “contact us” form easy to fill out, and your telephone number/ personal email address readily visible to use. ( Case in point – are you still reading? Have I moved you to action to contact me so we can work on the targeted content for your practice’s website??)

There are no true substitutes for a personal meeting, and gaining the trust of your clients and referral sources in the traditional sense, so I would not be concerned that it is becoming obsolete. But in this age of the internet as a primary source of information in healthcare, content marketing and online nurturing is becoming more and more important as a tool to utilize in forming solid long term relationships.

Iris Kimberg, MS PT, OTR, has worked in the non-clinical aspect of therapy for the past 30 years. She is the founder of New York Therapy Guide (, a site dedicated to the growth, viability and success of therapists in the private sector. Iris now enjoys sharing her expertise with others in the field through workshops, webinars and private consultations. She can be reached at