Billing, Payment

Alternative Payment Models: Not just an “Ortho Thing”

By NaKisha Jackson, PT, DPT

NaKisha Jackson shares an update on PT reimbursement actions. The new craze is all about “alternative payment models” (APM). In January 2015, the Department of Health and Human Services (HHS) announced a plan to move aggressively on its goal to transition 30% of traditional fee-for-service Medicare payments to APMs such as the Comprehensive Care Joint Replacement (CJR) program by the end of 2016, and 50% by the end of 2018.

HHS noted it has reached the 30% goal ahead of schedule and will move toward the next milestone.1 The concept seems instinctive for the move toward the “fee-for-outcomes” model that no one could argue is unreasonable. As physical therapists we are a very intricate detail in the overall picture of these clients’ recoveries. However, according to the American Physical Therapy Association, physical therapists are not as strongly considered in this model as we should be in comparison to our impact on those outcomes.

At first glance this may appear to be an “ortho thing.” In our Section, we could assume that this may not have as drastic of an effect on us as it does our other colleagues, whose caseloads are inundated with clients pre- and post-joint replacement surgery.

While orthopaedic surgeries may be on the forefront of this experiment, does it not seem fathomable that other specialties may be on a short list of the HHS? The first two suspects that come to mind are the ever so popular bladder and urethral suspension/sling procedures for incontinence and hysterectomies for complaints of pelvic pain.  How many of these have you seen with poor outcomes and thought to yourself, “I could have helped prior to surgery, and she may have had a better recovery?”

Complications vary from mesh erosion and worsening urgency to increased pain and a host of other issues. What about the other very common and easily justifiable radical prostatectomy? With quality of life being a major outcome focus of most insurers, stress incontinence that was unresolved or not even addressed may also be a red flag for scoring the success level of this surgery.

While our specialty is flying under the radar, this is the perfect time to make sure you are crossing your t’s and dotting your i’s. If this comes down the pike, as all things usually do, to begin to incorporate all major surgical areas that cost insurers and beneficiaries enormous amounts of money, we need to be ready to stake our claim as major players in these outcomes.

Have your personal therapy outcomes ready and in a readable format, so when surgeons and general physicians need convincing that you are the missing piece to the puzzle, you have your ammunition. Use your results as marketing tools, not only to physicians, but to clients and their families and friends as well.

This is especially necessary for those therapists striving for a cash-based practice. What better way to ask clients to forego their insurance and pay you cold hard cash up-front, with no tangible evidence that you know what you are doing?

We are in a prime situation to be proactive and able to advocate for ourselves in a system that continues to underestimate the undeniable benefits of physical therapy to clients and insurers in the form of quality of care and cost control.


  1. APTA Statement on Transition to Alternative Payment Models (Including CJR). 04/16/2016

Author: NaKisha Jackson, PT, DPT, practices in Arlington, Texas, in an outpatient setting solely devoted to enhancing the pelvic health of men and women. She can be reached at

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