In this post we are hiding the name of the Clinic but calling it “RS Tampa Clinic” because the purpose of this post is to educate Florida medical providers about a landmark change to the way they treat PIP patients. The name of the clinic doesn’t really matter because EVERY clinic is using LMTs improperly. We realize that we have links to the Orders which contain the clinic name but we had to include them so you can read the Orders for yourself.
On April 7, 2020, Geico sued RS Tampa Clinic along with their medical director, LMT employees, and four other clinics that shared the same medical director.
In this post we are hiding the name of the Clinic but calling it “RS Tampa Clinic” because the purpose of this post is to educate Florida medical providers about a landmark change to the way they treat PIP patients. The name of the clinic doesn’t really matter because EVERY clinic is using LMTs improperly. We realize that we have links to the Orders which contain the clinic name but we had to include them so you can read the Orders for yourself.
On April 7, 2020, Geico sued RS Tampa Clinic along with their medical director, LMT employees, and four other clinics that shared the same medical director.
The main allegations were that:
(1) the medical director was not performing the duties required under Florida Statute 400.9935; because if he had been performing those duties then he would not have allowed:
(2) LMTs to perform and bill physical therapy; and
(3) the clinic to bill 99204 for examinations that did not meet the requirements of a level 4 examination;
(4) the clinic to provide every patient with an “emergency medical condition” regardless of pain reported, injuries sustained, and extremely low property damage;
(5) treatments were unnecessary because RS Tampa Clinic’s patients “received a substantially similar physical therapy treatment plan.”
On July 6, 2022, the Middle District Court issued an Order ruling in favor of Geico stating:
Does the No-Fault Law prohibit reimbursement for physical therapy services that LMTs perform? If it does, Geico was not required to pay $690,251.44 because it is undisputed that LMTs provided all of RS Tampa Clinic’s physical therapy services. . . .The statute prohibits billing for an LMT’s services, thus Geico is entitled to summary judgment on the unjust enrichment claim as it relates to physical therapy services.
In other words, the statute “excludes massage from the types of health care services that are eligible for PIP reimbursement” and it “prohibits massage therapists from receiving PIP reimbursement.” Geico Gen. Ins. Co. v. Beacon Healthcare Ctr, Inc..
The latter exclusion is determinative. It is undisputed that LMTs performed all the physical therapy services that RS Tampa Clinic billed to Geico. The No-Fault Law “flatly precludes reimbursement from LMTs providing advanced physical therapy services. See State Farm Mut. Auto. Ins. Co. v. Muse. And so, RS Tampa Clinic’s services are not reimbursable. See S. Owners Ins. Co. v Hendrickson (concluding that the statute “explicitly prohibits” an LMT “from being reimbursed for medical benefits”).
Defendants doubt that Florida law would completely exclude LMTs from the PIP regime. But it does. And it does so “explicitly” and by its “plain text.”
A doctor’s supervision is not an exception to the rule prohibiting LMT reimbursement.
Florida law limits a doctor’s ability to delegate duties. For example, doctors may delegate some tasks to a registered nurse, a licensed physician’s assistant, or a medical assistant. See FS 458.303(2); FS 458.347(4)(d), (h); and FS 458.3485. . . . Defendants cite no case, statute, or regulation suggesting that a doctor could legally delegate physical therapy services to LMTs.
Basically, the Court’s ruling held that if an LMT touches a patient then the bills are not reimbursable. The Court also stated that “a doctor’s supervision is not an exception to the rule prohibiting LMT reimbursement.” RS Tampa Clinic lost the case on that issue and was ordered to pay $690,251.44 to Geico for the PT codes that were billed. The other issues on the case like upcoding exam codes, providing all patients with EMC opinion, and pre-determined treatment protocol were set to go to trial before a jury. RS Tampa Clinic decided to appeal the Order to the 11th Circuit Court of Appeals.
On October 24, 2024, the 11th Circuit Court of Appeals issued their Order. It agreed 100% with the Middle District Court’s ruling. The Court made things clearer by stating:
. . . massage therapists cannot be reimbursed under Florida’s PIP law for the services they provide, regardless of whether they are supervised.
So, what are medical providers billing therapy to PIP going to do?
Before jumping to conclusions, remember “high emotions = low intelligence”. Let’s take a practical approach and look to the laws to come up with a sound plan. I am laying it out here so all the chiropractors/medical providers in Florida billing PIP can utilize the information for free.
The simple answer to this question, is hire licensed Certified Chiropractic Physician Assistants (CCPA) and/or get your current staff to get the license. There is currently only one provider for this course that I am aware of. See link.
I’m providing citations to the materials I used so your lawyer can fact check the information.
1.If you have an LMT working for you then you need to have them put their license “inactive” in the immediate future. I wouldn’t fire them. They have worked for you and are hopefully a good employee. If they are not an active LMT you should be fine. This is assuming that the LMT is full time and exclusive to your chiropractic office. If they are performing massage on their own time or working at Massage Envy outside your office this will not work for them.
2.I’ve heard many chiropractors say, “I’m going to hire someone off the streets with no prior experience and train them to treat my patients.” Let’s discuss this statement from a legal perspective.
First, FS 627.736(5)(d) states that medical providers must comply with (1) the CMS 1500 instructions on the backside of the form; (2) the AMA CPT Editorial Panel and HCPCS; (3) the CPT codebook; and (4) the statement of medical services may not include charges for medical services of a person or entity that performed such services without possessing the valid licenses required to perform such services.
So, let’s see what the CPT Codebook says about having a person off the streets with no prior experience treat your patients.
Codes that do not require direct one-on-one patient contact:
97010 hot or cold packs; 97012 traction mechanical; 97014/G0283 electrical stimulation unattended; 97016 vasopneumatic devices; 97018 paraffin bath; 97022 whirlpool.
For these codes an unskilled person off the streets can absolutely perform them according to the CPT Codebook definition of those codes.
Codes that do require direct one-on-one patient contact:
97032 attended electrical stimulation, 97033 iontophoresis, 97034 contrast bath, 97035 ultrasound, 97036 hubbard tank, 97039 unlisted modality (specify type and time if constant attendance)
For these codes, the CPT Codebook states “require direct one-on-one patient contact” but it DOES NOT STATE one-on-one with “who”- i.e. unlicensed vs licensed person. You can see the next section starting with 97110 states very clearly “by a qualified healthcare professional”…this is very interesting. Words matter! However, to play it safe, I would suggest having a person with a license perform this work.
Codes that do require direct one-on-one patient contact by a qualified healthcare professional:
97110 therapeutic exercises to develop strength and endurance, range of motion and flexibility; 97112 neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and or proprioception for sitting and or standing activities; 97113 aquatic therapy with therapeutic exercises; 97116 gait training includes stair climbing; 97139 unlisted therapeutic procedure (specify); 97140 manual therapy techniques; 97530 therapeutic activities direct one-on-one patient contact (use of dynamic activities to improve functional performance); 97535 self-care/home management training (i.e. activities of daily living and compensatory training, meal preparation, safety procedures, and instructions in the use of assistive technology devices slash adaptive equipment) direct one-on-one contact
For these codes, when billing PIP, a qualified (i.e. licensed) healthcare professional must perform these services. This would include a chiropractor or a CCPA. The Florida PIP statute very clearly adopts the rules from the CPT Codebook so only a licensed healthcare professional can perform these services. When billing health insurance the CPT Codebook would allow you to use an LMT, however, the PIP statute does not.
Just to be clear, an LMT cannot perform any of these services if PIP is involved based on the Court’s ruling in the RS Tampa Clinic case.
Also, the CPT Codebook defines “qualified healthcare provider” as a person with a license; anyone else involved in patient care would be considered “clinical staff” (i.e. a person without a license but who is operating under the direct supervision of a qualified healthcare provider).
Clinical staff can perform services, even without a license as long as the supervising provider feels he/she is able to perform the service. See link. See link.
Clinical staff are employees (leased or contracted) who do not individually report their service. Clinical staff includes medical assistants, licensed practical nurses, registered nurses, and others. See link.
However, if your state requires these certain services to be performed by a licensed individual, then he/she must be licensed. In this scenario where the individual is not licensed, the service would be provided incident-to.
Just an FYI, the definition of “clinical staff” is very vague. Either way, an LMT cannot touch a PIP patient based on the Court’s interpretation of the PIP statute in the RS Tampa Clinic case.
3.Interesting plot twist: Florida Board of Chiropractic
Presumably, based on this “clinical staff” rule, the Florida Board of Chiropractic issued an Order (link) stating that a person who is not licensed, whom the chiropractor knows to be trained and competent, perform under myofascial release either mechanically or manually.
This doesn’t mean that a person with an LMT license can perform these services. This would only apply to a person with no LMT license “off the streets.” It only apply to myofascial release. None of the other codes.
The Florida Board of Chiropractic also issued an Order (link) stating that a chiropractor may lawfully delegate the performance of PT modalities to unlicensed assistants, whom the chiropractor knows to be trained and competent.
Where there a rule or law is vague the Florida Board of Chiropractic can provide clarity. However, the Board does not override the PIP statute where it says that the CPT codebook is controlling which states that manual therapy must be performed by a qualified healthcare professional (i.e. licensed) direct one-on-one.
Also, when a trillion dollar insurance company wants to sue a doctor who doesn’t have $1,000,000 to spend in legal fees who is going to care what the Board’s Order says? I would always recommend acting like your family’s livelihood depends on it and play it safe- start the process of getting your staff registered for the CCPA course. Better to be one step ahead of the insurance company.
4.What can a licensed CCPA do by law?
Florida Statue broadly states: A certified chiropractic physician’s assistant may perform chiropractic services in the specialty area or areas for which the certified chiropractic physician’s assistant is trained or experienced when such services are rendered under the supervision of a licensed chiropractic physician. Click here to read FS 460.4165.
Florida Administrative Code more specifically states: A certified chiropractic physician’s assistant may perform case histories, diagnostic testing, physical examinations, and therapeutic procedures under indirect supervision. However, a certified chiropractic physician’s assistant cannot be assigned any tasks requiring manipulative or adjustive techniques, the rendering of diagnostic results or interpretations, or the rendering of treatment advice, or the taking of x-rays unless properly certified. Click here to read FAC.
5.What the Hell Am I Supposed To Do?
1.Have all your LMTs give up their license and/or inactivate their license
2.Get your former LMTs to immediately register for a CCPA license. See link.
3.Remove the LMT licenses off the walls in your lobby since they are inactive
4.Stop listing staff names in your notes “therapy provided by Katie”
5.Only have the supervising doctor or CCPA sign the notes and bills;
6.Hire unlicensed people “off the street” to perform 97010, 97012, 97014/G0283, 97016, 97018, and 97022 under your supervision.
7.Perform the higher paying CPT codes by a qualified healthcare professional (i.e. licensed) which will usually be the chiropractor.
6. Can I use LMTs to bill Medpay only or LOP only?
Medpay doesnt have the same restrictions against LMTs but (1) very few people have Medpay and (2) Medpay pays the 20% that PIP doesn’t pay. They are intertwined. You cant bill one without the other.
The same applies to LOPs. They dont have the same restrictions against LMTs either but the LOP covers the 20% that PIP doesnt pay, the deductible, and any DOS after PIP exhausts.
As my mom always says “no inventes”… i.e. stop making up ideas. Just follow the information on this page. Unlicensed people can perform the codes in green and possibly yellow. Have the licensed chiro or CCPA or APRN perform the codes in red. Get your LMTs to go inactive immediately or find a new person if they refuse. And register your best longtime staff for the CCPA course…. and as always, thank me for the free detailed information by calling Josie Luna at my office to schedule a date for us to review your PIP files: 561-479-7831
7. Can I have a PTA treat the patients in my office if a PT is not on-site?
Let’s start with the Florida laws on PTAs. FS 486.021(6) says that a “Physical therapist assistant” is licensed in accordance with the provisions of this chapter to perform patient-related activities, including the use of physical agents, whose license is in good standing, and whose activities are performed under the direction of a physical therapist.
The statute breaks down two different requirements for supervision:
Option A: Treatment performed “for” a board-certified orthopedic physician, physiatrist, or a chiropractor shall be under the general supervision of a physical therapist, but shall not require onsite supervision by a physical therapist. This means a PTA working “for” a chiropractor does not require onsite supervision by a physical therapist.
Florida Administrative Code 64B17-6 defines “general supervision” as supervision of a physical therapist assistant, other than by direct supervision, whereby the physical therapist is accessible at all times by two-way communication, available, to respond to an inquiry when made and readily available for consultation during the delivery of care, and is within the same geographic location as the physical therapist assistant
Option B: Treatment performed for MD, DO, Podiatrist, or Dentist shall be performed under the onsite supervision of a physical therapist.
Other rules regarding using a PT that you need to be aware of (it is not as easy as a CCPA!):
Florida does not have a PT to PTA ratio meaning there could be one PT to ten PTAs assuming (a) the PT could was in fact properly supervising the PTAs and (2) the offsite/onsite rule from Options A and B above were properly setup first. The law also requires that the needs of the patient are met and quality care provided.
Florida Statute 486.021(11)(a) says “if physical therapy treatment for a patient is required beyond 30 days for a condition not previously assessed by a practitioner of record, the physical therapist shall have a practitioner of record review and sign the plan.” They said it weird. What they meant to say was that a PT can treat a patient for the first 30 calendar days without having an MD, DO, DC, Podiatrist, Dentist, APRN assess/evaluate the patient. This also means that on or before the 30 calendar days is done that the PT is required to have an MD, DO, DC, Podiatrist, Dentist, APRN review and sign the plan.
Florida Administrative Code 64B-6.001 Minimum Standards of Practice (3)(f) states:
(f) Physical therapist’s professional responsibilities include, but are not limited to:
1. Interpretation of the practitioner’s referral.
2. Provision of the initial physical therapy assessment of the patient.
3. Initial identification and documentation of precautions, special problems, contraindications.
4. Development of a treatment plan including the long and short term goals.
5. Implementation of or directing implementation of the treatment plan.
6. Direction of appropriate tasks.
7. Reassessment of the patient in reference to goals and, when necessary, modification of the treatment plan.
This means the PT needs to evaluate the patient and create an initial physical therapy assessment. This means you can’t pay a PT to bullshit and say they are supervising the PT offsite. The PT must also evaluate the patient and develop a treatment plan before the PTA can touch the patient.
Let’s do the math if you think a PTA is better than a CCPA:
If you are considering using PTAs instead of CCPAs at your clinic let’s talk costs. Let’s assume you properly setup Option A above and you have a PTA working “for” a chiropractor which allows for offsite supervision of a PTA. You still need to pay the PT to evaluate the patient and create an initial physical therapy assessment. You also need to pay the PT to supervise the PTA offsite. To avoid a lawsuit from Geico/State Farm you should have the PT come a couple times a month to shadow the PTA so the PT can say “I saw the PTA a couple of times a month, I worked on patients with the PTA a couple of times a month, and the PTA does good work.” So you need to hire a chiropractor, PT, and a PTA under this model. If you hire a CCPA you just need a chiropractor. It is impossible to find a PT from what I hear.
I “dumbed” this down as best I could. The supervision of the PTA can be much more complex. I highly recommend you consult with a healthcare attorney before implementing a PT/PTA care model as there are many requirements to do this right. Call Attorney Carlos Arce, a healthcare regulatory attorney, to make sure you set this up properly and have proper documentation.
This is general legal information and does not constitute legal advice. I am not your corporate lawyer. If you need someone to review your practice setup please let me know and I will be happy to connect you with an expert.
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