Post-rehab or aftercare programs are becoming a standard component of the rehabilitation process for patients with neurological, cardiovascular and musculoskeletal disorders. The changes in medical reimbursement over the past decade have made post-rehab a part of the rehabilitation spectrum. Many physical therapy clinics and sports medicine centers are slow to embrace this new concept. Obviously, issues such as "scope of practice" and "direct supervision" are some major concerns for physical therapists and chiropractors when thinking of post-rehab services, but such services can be both profitable and improve positive rehabilitation outcomes.
What Is Post-Rehab?
The definition of post-rehab services is: "The development and implementation of fitness and conditioning services for clients with special population and post rehab disorders." Post-rehab programs may provide: fitness assessments, weight reduction, functional conditioning or strength, flexibility, cardiovascular, aquatic fitness, spinal stabilization and hypertension/ diabetes training. These activities make up the post-rehab "scope of practice." Services that are beyond these activities may encroach into the realm of the licensed medical professional. Post-rehab does not purport to provide any aspect of medical treatment of a client's condition.
Who Should Be Working in Post-Rehab?
The post-rehab program should be staffed with exercise physiologists, kinesiologists, personal trainers or conditioning specialists. These staff members develop, supervise and modify the conditioning programs for clients while working within post-rehab protocols and guidelines established by the client's physician and/or physical therapist. Each staff member must have specific training in post-rehab (through certification), not just simply as a rehab technician. The experience gained in the rehab setting is vital, but a rehab technician does not have the skill to progress the post-rehab client's exercise program. The skills required of the post-rehab professional are beyond those of the rehab technician as well as the majority of exercise physiologists, kinesiologists and personal trainers. These professionals are ideally suited to work in the program after the completion of a post-rehab training and certification program. This professional is not trained to replace the physical therapist or chiropractor, but to work with the client to improve function using exercise after he or she has received the maximum benefit from physical therapy or chiropractic care and has been discharged from their care.
Transitioning to Post-Rehab
A physician or physical therapist must refer all clients entering a post-rehab program. All clients must meet a post-rehab criteria established for the diagnosed condition such criteria are a series of "standards" the client must meet to insure he or she is safe to begin the exercise program. These standards can include post-operative timetables, guidelines on the severity of swelling, pain, joint range of motion and other parameters that determine if the client is "medically stable" to begin an exercise program. The post-rehab criteria assist in preventing the "inappropriate client" from entering the program.
The complete separation of physical therapy and post-rehab services is a must when establishing your program within a physical therapy or chiropractic setting. This will avoid confusion on the part of the patient/client as well as adhering to Medicare and other insurance guidelines. I realize the construction of a separate facility is cost prohibitive, but the establishment of a physical boundary (wall, door or room divider) and separation of paperwork is a must to avoid confusion in the minds of the post-rehab clients. In addition to these steps, I recommend the establishment of a separate business entity with a distinct tax ID number, corporate structure, business name and letterhead. When the patient is discharged from physical therapy or chiropractic care and referred to post-rehab, a new client chart should be established for the post-rehab program. During the first session, the staff must again explain the nature of the program and their roles and functions within it.
The Post-Rehab Program
The post-rehab program should begin with a musculoskeletal screening to assure the client is appropriate for the program. Once this screening is completed, a full post-rehab assessment may be done at the next session, which looks at the involved area and assesses function as well as traditional components such as flexibility and strength. Based on the findings of this assessment, the post-rehab program is established using the standard protocols for the client's condition. Modifications are made to this protocol based on the client's needs and with input from the client's physician and therapist. The final program is forwarded to the client's physician for review and approval program goals, duration and frequency must be included. Use as many exercise diagrams and pictures as possible when forwarding the post-rehab program to the physician for approval. The physician may not be familiar with exercise jargon, and therefore, not comfortable giving his or her approval. Remember to make it easy for the physician to understand the post-rehab program. A picture is worth a thousand phone calls and hundreds of approved post-rehab programs.
Once the post-rehab program is established, the insurance carrier may be contacted to obtain pre-authorization for insurance reimbursement. Let's make it clear Medicare, Medicaid and many HMOs will not pay for post-rehab services. Claims covered by workman's compensation and motor vehicle insurance carriers are most likely to reimburse for these services. Follow these guidelines to improve the chances of pre-authorization and reimbursement:
1 Gather the following information from the client: full name, address, social security number, date of birth and the insurance claim number.
2 Make sure you have the post-rehab program in hand with the physician's signature of approval.
3 Call the claims adjuster before 9 AM.
4 Once you contact the client's claims adjuster, provide the client's name, social security number, date of injury, diagnosis and claim number.
5 Explain to the claims adjuster your role as a post-rehab professional. Indicate you have a signed referral from the physician as well as an approved post-rehab program. Describe the post-rehab conditioning program as well as the benefits and the program goals. Establishing a script to read from may be a great help in clearly describing the program.
6 Ask for pre-authorization for your program for the specified number of weeks or sessions. Provide the cost and reiterate the goals of the post-rehab program. Make sure the goals are functional in nature.
7 You may receive pre-authorization during the conversation or you may receive it after the claim is reviewed. The key is providing as much information as possible to the insurance claims adjuster.
8 Make sure to follow up within two to three days if pre-authorization is not obtained during the conversation.
9 Once pre-authorization is obtained, the billing process begins. Send your invoice and post-rehab session logs for each session to the claims adjuster every two weeks. Follow up on the invoice within five to seven days to insure its receipt and no additional documents are needed. Also, if a re-assessment is completed during the two-week period, it should also be forwarded to the claims adjuster.
10 Post-rehab services are billed 25% above the regional rate for personal training services. The reimbursement may be a percentage of the billed rate. Reimbursement usually takes six to eight weeks. The insurance carrier may use one of three options we commonly see with post rehab reimbursement. The three are:
Medical membership This is a monthly fee the carrier pays for the client to utilize the facility over a 30-day period. The facility must assess the client at the beginning and the end of this. The assessment should be sent to the insurance carrier along with the monthly invoice.
Post-rehab sessions The insurance carrier may opt to pay for individual post-rehab sessions completed one-on-one with a post-rehab professional. Each of these sessions should be documented and the session logs forwarded to the carrier with the invoice.
Client reimbursement With this scenario, the client pays for the post-rehab session at the time of service, and the insurance carrier reimburses the client. The post-rehab facility may provide the client with the session logs and documentation he or she needs to send to the insurance carrier or the facility may submit the necessary documentation on behalf of the client.
The key is clearly explaining your program to the claims adjuster and the benefits to the client. Remember, post-rehab is not a substitute for physical therapy or chiropractic services. As you can see, there are a number of steps required to establish your post rehab-program appropriately, but the benefits are enormous. When you think of the number of patients discharged daily from physical therapy or chiropractic care, the opportunities are tremendous. Post-rehab is here to stay. The question is, will you take the steps to establish your program?
Michael K. Jones, PhD, PT, is president of the American Academy of Health, Fitness and Rehabilitation Professionals (AAHFRP). He has been a physical therapist for 20 years and has taught more than 300 post-rehab workshops throughout