PTO 99 | TelePT Visits

 

Telehealth in Physical Therapy is leading the way of remote healthcare provision. With its rising need, PTs also feel the need to bring more value to patients and make each visit more productive. In this episode, Nathan Shields interviews Daniel Seidler, PT of TelePT Solutions to talk about his experience in making telehealth PT visits more successful. In order to provide value to patients, it will take a different mindset from physical therapists because these are not just follow-ups on HEP's. Daniel can guide you through the steps to make each TelePT visit successful.

---

Listen to the podcast here:

How To Have Successful TelePT Visits With Daniel Seidler, PT

I've got a repeat guest. If you’ve read a few episodes, I talked to Daniel Seidler of TelePTSolutions.com. He helped us as we were getting into the Coronavirus issues in how to start doing TelePT visits. I talked to him and thought, “You've probably learned some things as you've been coaching people, how to transition patients and some things you might recommend since our last visit.” I thought I'd bring him on again and do an update in regard to TelePT. First of all, Daniel, thanks for coming back.

Thank you, Nathan. It’s a pleasure to be here. Thanks for having me on again. It's great.

You've gone through a whirlwind over the past. You're in New York City, so you're seeing the brunt of the Coronavirus cases in the country. As it pertains to looking back, are there some things that you have learned that you'd want to share as you've been helping other PT owners get their telehealth services established?

First off, being in New York, it's been amazing to see how we have mobilized cities. Brooklyn, for the most part, will have stayed at home and followed the instructions of leadership. It's been awesome to see what healthcare workers are doing, the commitment that people have made and sacrifices that people made. One cool thing that happens here, and you experienced it one time, is at 7:00 PM every night, people get out, open their windows, get on the rooftops, go out to their terraces and cheer for the healthcare workers and people who are putting in the sacrifice and putting in the work. Anyone who's reading, who's been on the frontlines, it's amazing. I give you lots of kudos for doing that.

That's when the shifts change. People usually work from 7:00 to 7:00. That's cool that you guys would do that as a community for your frontline workers there.

New Yorkers very rarely come together for something. I think everybody recognizes the value that's being put in. Thank you to the PTs who are there on the frontlines. I’ve been reading blogs, Twitter and LinkedIn posts about people who are acute care PTs and other PTs who are still working their clinics and taking all the precautions to do it as safely and sanitary as possible. Going into hospitals, you guys are heroes. Also, doing it safely. People need us. I've been seeing everything happening from the telehealth perspective and PTs are doing everything they can to connect with their patients and make themselves available to patients and accessible to patients.

There have been a lot of challenges. Reimbursement is still a challenge in many places, particularly with Medicare. The concessions and everything going on with being able to do some visits and some connections with patients. That's still a struggle. It makes it very hard for a lot of private practice owners who we're talking to. There are a lot of tough decisions to make in terms of keeping their practices open, physically open just through telehealth or bare-bones. I don't envy you. I knew it’s a tough spot.

It's been a weird challenge for people to keep their PT doors open not necessarily because they're getting a decrease in referrals, but because patients don't want to come. They don't want to get out of their houses and submit themselves to being out in the environment and risk getting sick. It's hard to convince those patients to come to their therapy visits 2 or 3 times a week. As I've been talking to owners, it's been hard for them to stay in connection with them and almost having to convince them about the necessity of continued PT services even through telehealth services. It's been hard for them to stay afloat in those instances. They've got their post-op patients that they're continuing to work with. Maybe occasionally they'll get an acute injury that comes through the door, but they're not getting referrals and it's been hard to connect with them and convince patients to get out of their homes it seems.

In some cases, patients shouldn't be coming out of their homes in areas like New York and other densely populated areas. I don't think patients should not be going to an outpatient PT clinic unless it's absolutely necessary that they see somebody in person. In that case, oftentimes a home visit might be more appropriate. That's one part of it. I know in other parts of the country it's viable, but at the same time, high-risk patients with other comorbidities should not be going to PT clinics. They shouldn't be going out into the public. That's a major challenge and I get that. That is one place where telehealth absolutely should be a priority.

I've had this conversation multiple times with multiple owners. The conversation that their front desk and their clinicians have to be having with those patients would be their services is, “This is how we're going to do it. This is how you are going to get the essential services that you need. You need to be getting PT right now.” If you have a frozen shoulder and a post-op total knee, unless you're well-guided and know what you are doing on your own completely, then you need PT right now or you're going to have major complications down the road.” It’s not a threat. This isn't trying to scare a patient. This is how rehab works. That knee is not going to heal. You're going to get back to normal function if you're not diligent about it with the guidance of a professional. PTs often think of themselves as only manual therapists and can't get much done without using their hands. What we do is based on our knowledge, our problem-solving skills and our compassion. That message has to be brought across the patient.

Even going back, I think it's a physical therapist nature based on our culture. It's hard to push physical therapy on people. When we're trying to push our services on our patients, it feels awkward. I think I'm speaking for the majority of PTs out there. Maybe you've seen it as well, but to take a firm stance and say, “You need to do this and this is how we're going to continue.” It's hard for us to do, but it seems like those PT companies that have taken a firm stand and said, “This is the way we're doing things going forward,” have been a little bit more successful at implementing TelePT services. Am I right?

Yes, and there are different strategies. One in particular is having the patient acknowledge that they need PT. If you ask most patients after surgery, “How was your knee going to heal after the surgery?” “I need PT, but I'll wait until you reopen your doors.” The conversation then is, “We're not sure when we're going to be open for you to come in or when you are going to be comfortable to come in. Let's get the ball rolling. Let's give this a shot. I know it's going to be helpful. You may not be convinced yet. I know it's going to be helpful. As soon as you do a visit with me, you're going to recognize how helpful and effective this can be.”

Successful telePT visits are largely dependent upon the provider's mindset - 'How can I provide the most value?' Click To Tweet

I think another avenue that's very important is to communicate with your docs. Anybody who has referred a patient to you, they send you a patient because they trust you. Have a conversation with them and tell them, “This is how we're doing it right now. This is how we can be most effective. This is how we can be safe. This is how we can contribute to the public health most effectively is by keeping people at their homes. I am trained to do a telehealth visit as effectively as an in-person visit.” I'm not using my hands, but I'm going to make every visit valuable and we're going to progress towards the patient's goals. We all know that when a patient hears it from their doctor, it means something more to them than just hearing it from the PT. Not downplaying the fact that we should be communicating with the patients as well. If they hear it from their doc, it can bring even more emphasis to it.

Anything else that you found with the PT owners that have been successful in transitioning patients over? Any tips? Any guidelines in that regard?

Communication is the key. I give my clients other resources. Some people want to see research, particularly doctors. There's research out there. There's not an abundance of convincing research that telehealth is as effective as in-office care, but there are some studies that say exactly that. There will be many more after this moment in time. I know that there are several studies going on already that are very relevant to what we're doing and what we're talking about. I've always said that telehealth is not for every patient, every visit, but it can be extremely effective with a lot of your patients for the bulk of their visits and particularly at this moment when they can't get other care. It's going to be effective and it's the most effective thing we can do for them.

Other strategies are communication. For a lot of patients, it's about technology. Elderly patients may feel like, “I don't know how to use a computer. I'm not sure how I'm going to get on my phone. I have to download an app.” My advice to PTs when you're choosing your platform for telehealth is to start with simple, particularly on the patient side. PTs are not necessarily the savviest technological population of people. We’re PTs because we're not into technology or we're not in technology because we're PTs. Either way, besides writing notes, we don't use computers for our daily functions. We're not an IT department. You have to make it as simple on both sides. Choose a very straightforward, easy to use platform.

Where are you pushing people or what are you recommending because they loosened the HIPAA guidelines? We talked about that. They changed it and said that you don't have to have those HIPAA-compliant programs. What are some of the better programs that you're seeing now?

The clients I work with are looking to use telehealth in the long run. Whether you are or not, I still suggest you get on a HIPAA-compliant platform unless it's completely obstructing you from connecting. First, we want to connect with the patient. Patient care first but beyond that, you want to protect their privacy. Security and privacy are important, so get on a HIPPA-compliant platform. I tend to like BetterPT. I find it easy to use. It's very functional in basic functions like scheduling and connecting. Their customer service is excellent. They're a PT-focused technology company. They have other products for the PT profession and the PT industry. They're drilling in on telehealth and they're doing a great job. People tend to like Docsity. They find it easy to use. One of my clients is using and they're pretty happy with it is thera-LINK. I've heard about Zoom. I'm not going to bash Zoom. It's a way to connect. You can get a HIPAA-compliant version. They're not looking at the PT industry. They're not directed at PT. They’re connections.

What are you recommending for the PTs to feel comfortable? I'm certain that not all the PTs are totally comfortable on the telehealth calls. What kind of input and feedback can you give them from your experience on how to get them comfortable in treating patients over a call?

First off, you have to have specific training for being a telehealth PT. This means when I train PTs, I'm working with them on what they already know and helping them apply what they already know to the telehealth environment. Be comfortable speaking to the camera. Connect with your patient as best you can because that is one way that we're most effective. Almost every PT who is an effective one will tell you part of their value and part of their effectiveness with a patient is the connection and the trust. You have to be able to do that through a camera and through video connection and just making that eye contact and speaking directly to them. Even when you're one-on-one with a patient, there are distractions. Make that connection first and foremost.

Secondly, come back to the things that you know as a PT. What are you going to do at the beginning of a visit and depending on the patient? Maybe you put them on some heat at the beginning of a visit. Instruct them to do that on their own. Get a heating pad, heat yourself and be ready for our visit. The first visit is prepped for the rest of it. They will do some things in the first visit, maybe review home exercises, but set the stage for your following visits. On the first visit, you talk with your patients about any equipment or tools that they might have in their house and instruct them on the equipment that you want them to buy.

Depending on the patient and your situation, I like a $100 limit. Tell a patient, “Keep us under $100 and I'm going to give you 2 or 3 things that you need to have to help us be more effective.” Things like a foam roller, a stretch strap, self-mobilizations with a sport band, a pulley, a yoga mat if they're going to be on the floor and things like that. I have my list and I'm putting together a little shop for PT practices to use to instruct the patients to go to the shop. These are our top ten recommendations for home use for your telehealth visits. From that, you're doing a lot of the things you would do in a clinic except you are not touching the patient. You're instructing them to do a lot of things on their own. If there's a foam roller, you're talking them through that foam roller session. You're showing them how to position their legs and how to position their rotator cuff muscles on the foam roller as they roll side to side, up and down.

Are you doing a lot of mirroring? Do you find that works best?

It depends on the patient. I try to do as little of that as possible. I try to challenge myself and communicate verbally as much as possible, but with certain populations, you do need to mirror and demonstrate. I have a group that has a lot of patients with Parkinson's. As some of us know, Parkinson's patients respond very well to mirroring, seeing a demo and repeating what the therapist does. What they've done is they've set-up a room at their clinic that's strictly for telehealth. Some groups are doing that, some are not. Some people are treating from home, but I can't exactly do that. They have a treatment table and the therapist will lie down on the table to supine, to sit, transfer to a sit, to stand transfer and then have the patient repeat. Some practices are home exercise programs and using streaming videos to instruct, which is a helpful tool. I tend to work with what the clinic has. I don't personally have a preference. My ideal scenario is that the PT can talk a patient through a visit without any video demonstration if it's not necessary and then you can reinforce it with home exercise sheets or videos.

PTO 99 | TelePT Visits
Becoming a Supple Leopard 2nd Edition: The Ultimate Guide to Resolving Pain, Preventing Injury, and Optimizing Athletic Performance

I'm sure part of your training then is going to be some role-play, “I can act like the patient.” Maybe you recommend they do that within their clinics and go through a treatment program, especially as it pertains to looking forward to the patients that are doing telehealth is to say, “What exercises are they going to be doing? What kind of equipment are they going to need?” The PTs need to be well-prepared going into that call. Just like you're saying, the patients need to be prepared. The PTs need to be prepared with what kind of equipment they're going to ask for, what kind of exercises they're going to instruct and follow up on and what kind of input they're going to give that is successful. Doing that role play, you can have it in your mind that it's going to go a certain way and I'm going to say certain things. Once it comes out of your mouth, it's a completely different ballgame and then it's received in a completely different way. You've got to make sure that your wording is correct.

Going back a step, at the beginning of every visit, you're reassessing your patient too. You may go in with a plan as what we like to do, but that plan may be completely confounded if the patient re-injured their shoulder trying to open a window so then you're taking a step back. Still, your verbal communication has to be precise. It has to be directed in terms of what exactly you want the patient to do. Oftentimes, you tell the patient to turn right and they turn left. It’s like, “Let's reset. Let's start again.” I think most PTs will realize when you pivot a lot in the clinic, meaning like you change your plan or depending on how the patient is tolerating something, you can progress it or even regress and exercise.

Maybe it's going back to starting with some foam rolling maybe to soften up soft tissue and get some blood flowing in the area. Patients doing their exercises and they're still stiff. Maybe you go back to doing some more soft tissue work or modify that soft tissue work a little bit and then come back to exercises. Still being very agile in your care, compassionate and patient with the patient. They'll get better as patients as well.

With the telehealth care, in their response and they get used to it, do you find it's been difficult for owners to not only transition patients into doing TelePT but also then maintaining their visits after doing the first couple? Maybe they get frustrated a little too quickly and have a little patience for it?

Most of my clinics have told me the patients that they can get started tend to keep going. They're not pulling back. They're not saying, “This wasn't worth it.” These are not home exercise program review sessions. You may trickle some of that in, but this is a real therapy session. Each of the PTs has an understanding that they need to be dynamic in their care. They need to connect with their patient. They need to help them progress towards their goals just like they would clinic. As long as that message is getting across, patients tend to get it and they realize like, “This is how I'm doing my PT now. This is it. It’s just like I'd be going to the clinic.” It seems to me that patients who have bought into the premise of PT, once they start telehealth, they're going with it. It's not that tough of a sell once you show them what you can accomplish.

From what it sounds like, I'm thinking the PTs also have to have the mindset. This isn't home exercise follow-up time. This is a treatment session. Maybe you've come against some of those hurdles, but maybe they get stuck on just following up on their home exercises and making sure that they're doing them right instead of considering it a full-blown therapy session and there's a different mindset there.

That's one of my first messages to every PT. The first thing we talk about in the clinical training component of my training is exactly that. If you're thinking that you're getting on a video call with a patient and you're going to review their home exercises and that's what you're going to do every session, then this is not going to work. You need to have the mindset that this is how you're treating your patient for now. Maybe in the long run too, but this is a new thing for you. Have the idea in your mind that these are real treatments and that message has to be getting across to the patient as well. That’s the message from the clinician, from the front desk, from the practice in general and from docs that we're doing real care here by video. That in itself, as you said, is the mindset for the PT. Once the PT understands that, it makes the whole thing a lot easier.

The PTs got to come at it like, “How can I provide real value in this situation?” Simply looking over some exercising and some of their exercises and watching them do it isn't going to be sufficient and it's not going to be valuable. That's something that patients are going to turn off fairly quickly. Whereas if they have the right mindset and they go into it seriously and look for opportunities to provide value and follow up like it's a regular session, but you just can't touch them, then they can provide some added value and stretch their brains a little bit.

It is stretching your brain. I had this conversation with a PT, the director at one of my clinics and he was stuck. He's like, “I have this patient that I've seen three times already and she's done great, but I'm getting to a point where I'm not sure I can still be effective with her.” I had to ask him like, “Has she reached her goals? Does she still need PT?” He's like, “Yes. That's why we're doing this and that's why she's still engaged. I'm not sure what else.” I'm like, “What's her condition and what are her goals?” She had a total knee replacement and she’s towards the end of her care with him. She's doing well, but she still can't go up and down out of a chair without a crutch.

I'm like, “Think about function first but also think about how you can progress things in terms of making them more challenging, and the more challenging situations that she might be in, in her life.” Low surfaces and adding a weight component to an exercise. I'm a PT, but I also have a CrossFit training background. I was a CrossFit coach for about a couple of years. The things you want to change your variables are increase volume, increased resistance, increased time or decrease as a patient needs to regress a little bit. Change planes and think of doing things on different planes. A bell rang in his head and he was like, “I think I have about 40 more exercises I can do with her.”

At first, he was just like, “We're doing stuff in her home.” I'm like, “Bodyweight.” Whether it's one leg, eyes closed, balanced stuff or have her stand on a pillow. All these things that she's going to face in her everyday life, you can help her with that. I'm mixing your mobility and your standard. Have a base of what you're going to do. A warm-up, stretching and mobility stuff that you're going to start with. There are a lot of ways to progress even with no equipment. If you use equipment as a crutch for a long time, her hands are in a way, a little bit of a crutch to use your brain a little bit more.

Part of a PT’s effectiveness with a patient is the connection and the trust. Click To Tweet

What a great challenge to physical therapists to stretch them a little bit. What would you do if you couldn't use your hands? Many times, we get into that rut and that comfort zone while this patient, this is how I treat them and it's going to involve this kind of manual work and these kinds of exercises and here's my protocol. What if you can't do the manual work anymore and you don't have access to all the equipment? Can you still perform as a physical therapist? That's a serious challenge you can lay down on somebody.

I did that myself. When I first started experimenting with telehealth about a few years ago, I was working in a clinic at the time. I challenged myself a couple of days in successive weeks. One day a week, I would try to treat all my patients without touching them and I could do it. Once I told myself, “I'm not going to touch the patient,” I could do it. I was educating them on how to do self-mobilization, soft tissue work and walking in through programs. Oftentimes, I'd walk up to a patient to give them tactile cues and you have to check myself, “Don't touch the patient.” I think it's a great exercise. It is a brain exercise. To me, I needed to do that to prove to myself that I could do a telehealth visit.

It also requires you to do some study. You're probably studying self-mobilization techniques if you hadn't brushed up on those before and stuff like that.

I like Kelly Starrett. He's a PT and he's a CrossFit guy in the Bay Area. He put out a book called Becoming a Supple Leopard. A portion of the book is about self-mobilization and it's fascinating. You can do a lot of mobilizations on your own maybe with a piece of equipment, a band or some other device on and be effective. It's just another way that PTs can educate their patients to help themselves. Use caution. Use your clinical decision-making skills and don't have patients doing great fives on their cervical spine. Traction on the shoulder and the humeral joint with the help of a sports strap can work wonders. Now, that patient has that tool to do it on their own, but you're guiding them through that.

That kind of instruction can be powerful because now they know how to care for themselves going forward. Maybe you don't promote it so much but to an extent, they can then help the people around them with some of the minor issues that they come up with and that's an opportunity to promote your services as well.

If a patient is taking great care of themselves and their family members or other people see them doing that, they've suddenly become more knowledgeable about how to care for themselves. They'll ask them, “Where did you learn that?” “My telehealth PT. Nathan told me these great little tricks.”

Anything else that you're finding that might have changed in your approach as you're talking to PTs about establishing TelePT services for their clinics?

Technology is still a challenge, but I've learned some techniques on how to get around it or get better at helping patients with the technology challenges. The most obvious is the connection, Wi-Fi or whatever but I've also learned to work with a group in rural Texas that there are no wires to where their patients are. Everyone gets their internet access by satellite. There are times of day when everyone's on the internet in the area. Internet access is low. Here's one thing I learned. Don't do a telehealth visit with a person in rural Texas between noon and 2:00 PM because that's when everyone's on.

Early morning, late afternoon or evening is usually pretty good. We're joking about it but that's real. It's like you don't want to be driving traffic in New York City during rush-hour or scheduling appointments at 5:00 PM somewhere where you're going to have to drive because you're going to hit that traffic. That's the reality of the situation. Work with what's going on around you and be sensitive to it. If you know a patient has a bad connection, particularly at a certain time. Another PT who's working from home told me that her internet resets every day, 2 or 3 times a day. She goes, “I don't know the exact times except for one time. At 1:36 PM every day, my internet resets and it drops everything.” I'm like, “I guess you're not doing any 1:30 sessions.” They’re like, “Yes, I hadn't thought about that. That's probably a good idea.” Be aware of your technology and the weaknesses of your technology. You can work around them.

Any successful stories of providers that you've been dealing with? People that have been able to successfully transition directly out of the majority of brick and mortar care to the telehealth services?

It's generally because there are so many, but the biggest is that certain clinics are shut down. They're not seeing patients. In the New York City area, there is no in-office activity going on. I have a client and they were doing over a thousand a week before in their office. Now, they have hundreds of telehealth visits a week. They've been very aggressive. They contacted every patient. They're doing telehealth visits, they're doing eVisits and they're connecting as many of their PTs that are willing to participate. Every one of them is reaching out to all of their patients and making sure that they're getting the care that they need.

You said it before, it's like if the groups that are communicating with their patients and letting them know how helpful they can be, they're the ones who are succeeding with this. If being willy-nilly about it, then as an owner, your PTs are not going to feel that urgency and patients aren't going to understand how valuable you can be. There are plenty of examples out there of practices. I still speak with practices that are not sure that they want to open. They haven't seen patients in weeks and they're not sure what they want to do. They’re waiting around and they're not being effective with their patients.

PTO 99 | TelePT Visits
TelePT Visits: Showing what can be accomplished changes a patient’s mindset about telePT visits.

 

The last thing you want to do is to lose communication with those patients.

It’s for a couple of reasons. Some patients will fall off the map and have problems down the road, but others are going to go to your competitor. They'll find somebody who does need telehealth.

They'll find someone who can do it successfully.

I'll emphasize it again. There are clinics that have taken the bull by the horns and they've trained their staff. They figured it out. They have the resources to do it themselves. They have their policy and procedure manuals. They have their consent forms. They have their forms for patients to fill out and tip sheets and everything that I think is super relevant doing this successfully. A roadmap for telehealth success and they've figured it out themselves, but I know that there's plenty of practice owners out there that they don't have the time or the resources to do it on their own. It's become draining for them emotionally and financially to do all this research and do all this.

It was simple to pick up a phone and do it through a FaceTime chat. At this stage in this Wild West, you can do that. If you want to do it right, you have to have a roadmap. You have to know what you're doing and to do it legally. Either do that research, if you have the resource to do it or get somebody to show you the ropes. It doesn't have to be me, but there are other people out there who are doing something similar to what I do. I suggest you get professional advice on this.

I'm assuming that you're finding the most successful clinics are the ones that are saying, “We're going to do this for the long haul. This isn't a two-month Band-Aid. We're going to implement this now and continue to offer it as a service going forward.”

There are some that are doing the Band-Aid. Depending on how much effort they're putting into it, they're either doing well in treating the patients who are reaching out to them or they're actively contacting patients and letting them know that this service is available. Some of them are doing fine with that, but my clients are all in for the long run. Those are the people I want to work with that they're looking to build this as part of their practice. Whether it's by necessity or to get a leg up on your market, I think telehealth is going to be a huge part of physical therapy care delivery in the future. This moment in time is a game-changer. It's going to create a shift for healthcare models, reimbursement models and legal models as well. The environment that we practice in is going to be significantly different a year from now than it is right now.

What are you seeing now in regards to reimbursement for telehealth PT?

What I'm seeing nationwide is most of the major commercial payers are paying for telehealth. Medicare is the biggie. I don't know what percentage of Americans or people who need physical therapy are covered by Medicare in some capacity. It's probably around 30% or so. Medicare is not paying for telehealth yet. PT codes are authorized to be utilized, but unfortunately, PTs are not authorized, providers. We’re eligible providers of telehealth physical therapy. It is what it is for the moment. I've spoken with Kara Gainer at APTA. She's the director of advocacy at the APTA. She has weekly conversations with CMS and she's pushing so hard to make this happen. There are other forces in play to make this happen for PTs, for the short-term and the long-term. You're still pushing against it. It's still a government agency and red tape and it's very challenging to make these things happen. As much as I'm frustrated and annoyed by that, I feel for her and the effort that the APTA is putting in. Support the APTA, support the private practice section, go to their site and write letters. They have template letters for advocacy about CMS and Medicare reimbursement. It's super important at this time.

What about Medicaid?

Medicaid in most states is covering telehealth PT. Every state is set up differently in terms of Medicaid. New York had Medicaid coverage for telehealth PT as of January 1st. Nothing to do with this. It was advocacy before. Medicaid in New York is, I'm not sure how many States have similar arrangements, but most of the Medicaid is managed by semi-private companies. They're funded companies by the Medicaid program and they administer Medicaid. Those payers were all paying for telehealth prior to COVID. Reimbursement is close to market value. They’re one of the better payers in New York.

You are still using the GT modifier and the place of service code is 02.

Work with what's going on around you and be sensitive to it. Click To Tweet

Every payer is different. UnitedHealthcare, I believe nationwide is using 95 and 02. You can check with your particular payer just to be sure or your provider reps. Cigna was the first commercial payer that came out and agreed to pay for telehealth services. They agreed to pay for evaluations and two units 97110 per visit, which is restrictive. They want the place of service 11 and the code GQ, which is store and forward, but they're using that. Anthem is different in every state. UnitedHealthcare going back to that 95 modifier and place of service 11. Aetna is using the GT modifier. What I've seen so far is they want to see 02 for the telehealth place of service. They said that they want to have a nationwide policy on us, but d different states have gotten different results on their claims. Double-check on that. GT modifier 02, we're saying for now.

At least we can do something and push that narrative a little bit and show that we're still working and still getting results. If we do lay down, that's no way to get our message across that we need to have these services reimbursed to us.

Now is a big moment. It is the moment where we can show patients, payers, our communities, our referring docs that we can be effective with telehealth. We should be getting paid for these services because we can be effective with telehealth. If you have the resources, please do some research, keep your outcomes studies. Keep track of your outcomes. Differentiate between your telehealth patients and your non-telehealth patients in terms of your outcomes, we’re talking to practice owners here. Look for opportunities to get involved in research studies. The APTA private practice section is looking for data points.

If anyone was doing telehealth prior to the pandemic, please also let the APTA and private practice know. Advocacy@APTA.org is Kara Gainer. She wants to hear from people who were doing telehealth before or have good data on what they're doing. This is the opportunity to show everybody how effective we can be. The payers need that data to justify paying for our services. That's their stance on these things. We know anecdotally we can be super effective. We know from research studies we can be effective, but there are not enough data points. That's where we can all work together on that.

Is there anything else you want to share with the audience?

First and foremost, be safe within your home. Be safe with your patients if you're working in a clinic. Be safe within your communities. We're all in this together. We all need to take care of each other. As far as telehealth goes, it's an opportunity to distance ourselves and still be effective. I encourage you all to at least in some capacity be offering telehealth to your patients because I'm sure you all have patients who can use your services and can't get to you even if you are open. Train yourself and staff well. Get everybody on the same page and look at this as a long-term solution. The president may say, “We're good to go back to work now,” but physical therapy practices are still hotbeds for infection. As much as you're wiping down every table three times before and after every patient, you're still in a confined space with a lot of people depending on your practice. Not only is there an actual risk, but there's also perceived risk. There will be patients who are going to be hesitant to come running back to your clinic as soon as you open your doors and you want to be there for them, otherwise.

There's no guarantee that people's fears are going to be subsided. That fear for some patients might take 12, 18 months for them to feel comfortable going back to a healthcare setting like physical therapy where there are multiple patients. They might even deem them as sickly, but they don't want to expose themselves to that. They might be in a demographic where they might have comorbidities that they don't want to go out. With this, it's a fear of simply going out to a confined space with multiple people like you're talking about. You might have an opportunity to still reach them and keep them on as patients and provide service.

Recognize your value. Your patients need you. Telehealth is a way to be there for them when you can't otherwise be.

I'm glad you shared that point because there's no guarantee people are going to flip the switch, change their mindset, go out and do everything they did before. It's going to take maybe a year or two for some people to get comfortable to even go to a place that has a number of other people in the same space.

My company is TelePT Solutions, TelePTSolutions.com. If you want to email me, it's Info@TelePTSolutions.com. Check out my website first. There are lots of free resources and information. Please email me if you have any questions. I'm happy to have a quick consult with you. I'm here for anyone who wants to get things going in telehealth.

You've got some programs online where you can help people get started with a step-by-step process, adding it to the website and setting them up and whatnot.

I'm also about to launch something on a virtual training platform. We're using DigitalChalk to put videos and programs up. It's an intro to telehealth PT for practice owners and clinicians and staff. It’s nine chapters of detailed information, forms and scripts you can use. It’s helpful. It’s all automated and self-directed training. I'm happy to share that with you.

PTO 99 | TelePT Visits
TelePT Visits: Some patients will fall off the map and have problems down the road, but others are going to go to your competitor.

 

I'm assuming based on what you say, you're going to have equipment recommendations on there as well for the patient side of things.

There is even an instruction on how to choose a platform.

My friends who have used your service have said it's pretty easy and they like it a lot. It's been helpful in establishing their telehealth PT services. I highly recommend it. Thanks for your time.

Thank you.

Important Links:

About Daniel Seidler

PTO 99 | TelePT Visits

Daniel is an experienced Physical Therapist, healthcare innovator, entrepreneur and executive. He grew his practice in the Bronx, NY to three successful locations before being acquired by a regional multi-site group. Daniel developed and launched the company's telehealth program in early 2019.

Daniel's passion for PT and desire to dramatically improve care delivery models inspired him to formalize his telehealth PT education programs and offer them through TelePT Solutions.

Daniel now treats remotely, coaches PTs to be telehealth specialists and consults owners on building successful telehealth practices.

Love the show? Subscribe, rate, review, and share!

Join the Physical Therapy Owners Club today:

PTO 92 | Telehealth PT

The Coronavirus pandemic has become a great test for the healthcare systems we have in place. Facing it head on, the time is here for Telehealth in Physical Therapy. In this episode, Nathan Shields speaks with Daniel Seidler, PT of TelePT Solutions about the benefits of the remote provision of healthcare through technology, especially in this time of the outbreak. A relative expert when it comes to providing TelePT services, Daniel has the answers about what you can do to adapt your PT services online. This is a great episode worth listening for any PT owner, to take advantage of the services you can provide, helping those in need in this most pressing time.

---

Listen to the podcast here:

Telehealth PT And The Coronavirus Pandemic With Daniel Seidler, PT Of TelePT Solutions

This interview is scheduled with Daniel Seidler of TelePT Solutions to talk about Telehealth PT services and how we can use it during this Coronavirus outbreak. There's plenty of information to help you get started at least in providing telehealth PT services. Daniel provides those services through his company, TelePT Solutions. I wanted to rush this episode out considering the current nature of what we're dealing with on this outbreak. Let's get to the interview.

---

I have Daniel Seidler, Founder, and Owner of TelePT Solutions, a consulting firm to provide telehealth services for physical therapists. He also is a telehealth Physical Therapist himself. He's got a great story that I want to share with everybody. The topic that we're going to cover is rather timely. First off, Daniel, thanks for coming on. I appreciate it.

Thank you, Nathan. I appreciate you having me. We talked and realized that we should record this podcast as soon as possible. You made it happen, so thanks for that.

Thanks for coming on. We want to talk about telehealth services in regards to PT, especially as it's going to affect our services here by the Coronavirus and what's happening. It’s considered a pandemic. Before we get into that a little bit for the benefit of the readers, if you can share a little bit of your professional story and what got you to where you're at this point.

I've been a PT since 1996. I owned a practice in the Bronx in New York for fifteen years. We were acquired by a larger group and I worked for them for three years, MOTION Physical Therapy and helped develop their telehealth practice, the division of telehealth at MOTION. I decided to go out and start my telehealth practice and help other groups to get telehealth off the ground. I never imagined this scenario would arise but either way, the time is here for telehealth for medicine and physical therapy.

I'm sure you couldn't have predicted that a flu pandemic like this would break out and soon after, the need for your services would be almost immediate. It was great to hear that you've gotten established quickly for people who want to get to your website ASAP. What is the website and how can they get in contact with you?

It's TelePTSolutions.com. That's the best way to reach us. All the other information is on there.

Thanks for sharing your story. Tell us a little bit about Telehealth PT services. Let's start answering some of the general questions that you get from PT owners and providers on a regular basis. 

The first question I usually get is, “Can I do this on my phone? Can I FaceTime or Skype?” The answer to that is no, you need a secure platform. There are plenty of platforms out there that look a lot like Zoom or FaceTime but they secure the communication on both ends to and from the practitioner and the patient. The audio and video can't be stolen and intercepted. It's secure in both directions.

PTO 92 | Telehealth PT
Telehealth PT: People don't love change but this environment changes that a little bit.

 

Do providers need to find something that's going to be shown to be HIPAA-compliant?

HIPAA-compliant and the platform will require a BAA, which is a Business Associate Agreement.

Between the PT company and the software provider as well, that's pretty easy to get that at Zoom?

There are a bunch of software programs. The ones that are most adapted to PT are Doxy.me, BlueJay and Physitrack, and some of them have exercises built-in. A couple of them were built as home exercise programs. Some of the home exercise programs are adding telehealth to their platforms as well making it easy for PTs to do telehealth.

Do you have to have the patient sign anything different or can you use your typical intake paperwork for this?

It’s very similar. You would have them do your typical intake. Any information that you can get in advance is easiest. The answer to a lot of questions about telehealth is different from every state. Different states have different rules about consent. Consent can be verbal, digital or on a sign on paper, and every state is a little bit different. New York State requires only verbal consent. I'm not sure about Alaska and other States but that information is out there.

Do you get patient consent to do telehealth services?

That’s right.

If people wanted to find out those regulations as it pertains to their state, is there a website that has accumulated that information into one website or do you simply have to go through your own state by-laws.

That's always the best idea to go to your State Practice Act and most States at this point have some verbiage about telehealth. One central resource is CCHPCA, which is the Center for Connected Health Policy. They're based in California. They've done the research and plenty of documentation about the changing telehealth laws and they keep it up-to-date.

Telehealth is an opportunity to spread practitioners’ geographic reach so they can treat patients in other counties and states. Click To Tweet

Are there some states that simply don't allow telehealth services?

In some capacity, every state allows it, not necessarily for PT though. It's CCHPCA.org.

You find the software program that you're going to use, you sign the BAA, you have the patient's consent to do telehealth services. Your treatment is like any other except you can't touch them.

That's the simplest form. If you're an independent PT and let's say you treat a patient in their home or at the gym on a regular basis and you have an ongoing relationship with them as a patient-client relationship but they can't make it to one of their visits. It's as simple as that. You have communication. Say, "I'm going to send you a ping. You click on this link, it will take us both to this conference to this BlueJay page and we'll do a telehealth session." That type of session is going to be you much like when you start most PT visits, "How are you? What's going on in your life? What's happened since the last time I saw you? What feels good and what doesn't?"

The subjective stuff, the conversational, comfortable things that you're going to talk about with a patient. That guides your visit like any other visit. If they need to, they can do a warm-up on their own. Someone who you're seeing on a regular basis via telehealth, may heat up a heating pad and sit with it for fifteen minutes before your telehealth session so that they're ready for you going in. Warm-up depending on if they have some exercise equipment at home, they might ride a bike or do whatever warm-up they might do at the beginning of the session. You can guide them through that or have them prepare to do that before you get on the phone with them or visit them.

What are some of your limitations outside of the manual when you can't get yours on them? What do you find is the most difficult thing in treating patients over the phone or through the software?

It depends on the patient and their set-up. I've found that most patients are doing their sessions with a phone. They have to have a good place to put that phone. When you're in front of somebody, you can see their whole body like three feet away from you. With a phone, it's a little bit different. Different accommodations work. You can use speakerphone with some patients in some situations. I always find that wireless earbuds are the best thing for the patient to be wearing so that they can move without a wire. They can hear you, you can hear them.

AirPods are ideal or something similar to that. That one challenge is having a visual and see the patient. The patient might think, "You have to see my arm move." You want to see their whole torso move. You might want to see how the trunk is moving well or even if they're bending their knees as they try to reach overhead or whatever it may be. That can be a challenge. Technology is always a challenge. It seems, for us, as the practitioner who's become used to using the software and it's very simple for me. On the other side, it takes some understanding from the patient.

Especially for those who are not technologically competent, I'm sure that's got to be difficult sometimes.

You've been on the phone with somebody who can't quite figure out how to use their phone. A phone conversation sometimes can be tough.

Do you usually share some of these things with them ahead of time like, “Here’s what is going to make our telehealth visits most successful? Make sure you have wireless earbuds, have your phone set up at a distance where I can see your whole body or you have a telephone stand if you're using one.” Do you list some of those things out for them?

I have a checklist for the patient and practitioners. The other complication or challenge can always be the Wi-Fi or the connection. That depends, sometimes it's perfect. Other times, it's all over the place. You do have to have a contingency plan. You have to have a backup, “If we get disconnected, we're going to reconnect like this, I'll call you, I'll ping you back,” or whatever is going to work for that situation.

You treat as much as you can over the software program. Do you bill as if you had seen them in person with the same CPT codes and time services and all that kind of stuff? 

That’s right. Typically, Medicare does not pay for telehealth services for PT.

We can't expect to get anything from our Medicare patients, unfortunately. These are the people that might be home down more than the others during this outbreak.

I have reached out to people I know who were in Washington who might have the ear of the government to get some accommodations on that. At this point, we all know someone in their 60s, 70s or 80s who is reluctant to go outside and probably is not attending PT right now even if they need it. It's important that those services get covered.

There are lobbyists out there that are pushing for it. If there was a way for physical therapists to do some footwork at the grassroots level to push a little bit, is there any way they can do that? 

I wish I had a solid answer. The best thing to do is to speak with the APTA and to your local representatives, whether it's local reps or federal government. It's the federal government because it's Medicare. I don't know if it's on their radar right now or not but I would think it has to be.

If some of these PT owners could flood the APTA who have lobbyists set already too, "We need to push Medicare somehow to continue to provide these services to the patients that are home-bound during the pandemic." That would be huge, I would imagine.

You would ask about billing and coding.

The billing and coding and then to follow up, since we're talking about Medicare, after you're talking about CPT codes and what insurances do pay for and who can we focus on?

It's different by state. I have found in New York that most of the commercial payers are paying, most Medicaid does cover all teleservices and managed Medicaid. I'm not sure that every state has the same arrangement but administrators of Medicaid.

It’s a matter of the owners simply need to sit down and start calling.

Speak with your payers and make sure you speak with the right person. Sometimes that first rep that you get on the call has no idea what telehealth is. They don't know. They don't see it right in front of them and they're not sure. A supervisor is your best bet.

With your consulting firm, have you made some of those calls on the behalf of some of your clients in different States or do you have some of that footwork already prepared?

I've only covered New York as far as that goes with the clients, but I've gotten some feedback from people in some other states that are telling me mixed things. Some payers are paying, some are not.

PTO 92 | Telehealth PT
Telehealth PT: This is another opportunity for us to speak for our profession and say we do so much more about education.

 

It's up to the individual PT owners to get someone to start making those calls.

As you alluded to, that is part of what we do. If someone does need assistance for that, we're definitely on board. I can be very helpful. I assisted in a lot of calls in New York so I know the conversation.

It’s good to hear that people can reach out to you. It's the person that you talked to, the verbiage that you use, don't take the first answer as the truth as these people are making the call and looking through your contracts and getting that figured out. In terms of billing and coding then, it's the same CPT codes, but there's a modifier.

Most are asking for the modified GT for telehealth and many require that you change the place of service to 02. For outpatient PT or outpatient services, typically is eleven. It's one of those things that's defaulted in most CMRs. Most practitioners have no idea that it even goes in. When you submit a claim, the number eleven goes to the payer. That field needs to be filled with a 02 to indicate that it’s telehealth.

As you've done some of the billing, are you getting denials initially and there have to appeals or are they easy and good about paying considering the modifier and the place of service?

I haven't seen any denials. I and my clients haven't taken too many chances yet. We've gone for the ones that we know will pay. I'm at that point right now where there's more and more demand. Patients want services and we’re going to give you a shot with other payers.

What do you find as you're doing some of this consulting? What are some of the hurdles that you have to prepare the owners for and those coming up against that you have to address?

Part of it is practitioner buy-in. For some PTs, it's completely something new. People don't love change but this environment changes that a little bit. It changes people's mindset a little bit. People are in survival mode and realize that they want to work, they want to reach out to their patients, that patients need the care. They're not going to get it otherwise. It's been a challenge but I suspect that might change. If a PT is sitting around with no patients, they would want to make contact with that patient.

They’ll get some buy-in pretty quick then.

It’s similar on the other side where some patients are very eager to do telehealth because it's so convenient. It's easy but others are not. I always say it's not for every patient, not for every visit but situations change things.

Can PTAs do these in calls?

It depends on the state. In New York, the best answer I've gotten is no. I'm unsure, to be honest with you. I'm hedging a little bit, but we're going with no in New York right now.

That would be up to the owners to call the insurance companies and ask that specific question, I'm assuming.

It's based on the contract. Its two different things. You do have to follow the state law and your State Practice Act and you do have to follow the reimbursement rules or laws from your insurance company if you expect to get paid. We do have clients who do all cash so they only have to follow the state law that they're in. There is no concern for what the payors at. We haven't talked about it yet but another thing to follow is a lot of practitioners now in telehealth recognize it. It's an opportunity to spread their geographic reach so they can treat patients in other counties and states. You do have to be licensed in the state that the patient lives in order to treat there.

You could live in Washington and do a telehealth call to Alaska if you have an Alaska PT license. You can't do a telehealth call to Alaska if you only have a Washington license.

To add to that, there is what's called the PT Compact. The compact is an agreement with, I believe it's eighteen states at this point where if you're licensed in one of those eighteen states, you can get the right to treat in one of the other compact states. Without getting a full-blown license, you can still treat those other states.

Do you have to go through a process in order to get that right?

Each state in the compact has its own process, whether it pays a fee or pass the jurisprudence tests or get approval from your state. Every state is different.

How can we find out about the PT compact from the states involved?

It’s PTCompact.org.

Is that PT compact only for telehealth services? 

I don't think so. I believe it's the right to treat in any state in the compact.

If you live near the border, you could cross state lines and do a home health visit in another state?

I'm sure that's how it started and telehealth got the ball rolling in further.

To back up a little bit, if someone's billing for some of these services, it's the CPT code and the GT modifier on top of the other modifiers that they're using. Whether you go 1st, 2nd or 3rd, it doesn’t matter.

I haven't heard that it matters. You're going to be billing and my experience thus far has been billing for an evaluation, if you do one or re-evaluation, it’s 97161. If you are billing for therapeutic exercise, that's 97110. Neuromuscular re-ed, it’s 97112. Therapeutic activity, that's in 97530. It's limited to that. You could get into 97535 or 97537, I believe it is. It's a functional activity like home activities. Reorient the community, that's community reorientation.

What are some of the difficulties than from the patient side? What are some of their complaints as they're going through this? Is it either they like it or they don't or do you hear some of the same concerns? 

I don't know if they can't stand the sound of my voice in their ears. They don't like how they look on camera. That is one. Some people are very uncomfortable doing video calls which I get it. You get past that quickly. The biggest thing is you're not getting that physical touch. I encourage people to use foam rollers, physio balls, get some of their own home equipment because as we know as PTs, they should be doing home exercises anyway. They should be managing their chronic pain. This is a great way to get them off on the right foot.

How is compliance? Do you have a cancel rate or a no-show rate?

I'm pretty persistent. My patient's schedule is not that packed. I'll find a time for most patients to get in on that day. That is a good thing, meaning flexibility. If someone can't do their 10:00, you don't want to make an open schedule then you'll have that. If someone can’t make their 10:00, they can see you at 2:00 and make that work because you're there and it's at their convenience. I try to make it that way.

Your documentation is no different than when you see them in-house?

That's true. You want to document that you're doing a visit by telehealth secure remote video call.

Where do you put that? Somewhere in the objective?

It doesn't matter, as long as it's on there.

You use the same EMR system. You use this software program with a BAA and it’s HIPAA-compliant. You do the same therapy that you would without the manual. Your billing is the same CPT codes with an additional modifier and a place of service is changed. Make sure you're dealing with the right insurance companies.

I like to take advantage of the fact that we work in the patient's home or at their office. There's the opportunity to do an ergonomic assessment of their desk. There's an opportunity to have them put some plates into a cabinet, do some functional activities, how difficult to open a door or go to a window or something like that. I haven't done any of these treatments of patients with vestibular issues, but I had a very long conversation with someone who does. She makes sure that the patient is in a very safe environment. For her vestibular patients, she does their sessions with them standing in a corner. Nothing else around. They put the phone on a nice platform where it can video them while they're doing their program while they're standing in the corner so that they have something to grab onto at all times.

Back pain heals because patients understand what's going on with them better. Click To Tweet

How does marketing go? Are the doctors receptive to some of this especially now, I'd assume they are more receptive? What is your response from the physicians?

The real answer is everybody's first response is how you can do physical therapy if you can't touch the person. I've always believed that that's a perception of what PT is a problem. Many people still think it's massage and hamstring stretching. That's a problem within our profession. I've addressed that forever and I continue to address it. This is another opportunity for us to speak for our profession and say we do so much more about education. Back pain heals because patients understand what's going on with them better. That's how people get better. That's a lot of it. Once that conversation happens in the right tone and manner, most people tend to be a lot more receptive.

You get referrals directly from physicians to specifically provide telehealth PT services.

I have not marketed it in that way. I haven't pushed it hard in that way but I suspect that it will start happening very soon and not just for me but across the board.

Have you marketed directly to a consumer and gotten patients? How do you get most of your patients this time? You have direct access in marketing your telehealth services directly to the consumer and they're calling you up and starting the therapy.

They either hit on the website or calling. I have some other online referral sources that refer directly to me. I have not made a big push on social media yet. There are regulations.

Advertising for pain relief and that kind of stuff.

Particularly in New York is tough about that. My methodology has always been when I had a brick and mortar practice was we'd put information out there. It's about being a source of information showing you professional knowledge, people respect that and want to learn more from you.

What is your website? How can people reach out to you?

TelePTSolutions.com.

What I'm getting from this is number one, it's not as hard as people might expect it to be. The ins and outs and intricacies are a place where someone like you could help out quite a bit as a consultant and getting this branch or this section of their PT practice off the ground. I'm thinking, not for this pandemic but also snow days. Like here in Alaska, I'm thinking it would be great if you could offer this service to people who live out in the bush that simply don't want to live near other people and don't want to drive two hours for PT three times a week. There are opportunities there for sure, for people to provide those services. It's time that you established your business to help people out like this.

Thank you and I'm looking at this. This is an impetus to get telehealth into the mainstream. I don't think it's a fad or it's something that's going to go away when this pandemic is gone. It might be the thing that makes people comfortable with it. Look at where demographics are going and how people are working now. A lot more people are working from home and recognizing that they can access stores and food via the internet right from the comfort of their homes. It's not every patient or visit, but if you have a total knee replacement and you're expected to go to physical therapy three times a week, maybe you’d go into the office twice a week and the third visit, you do via telehealth. It's convenient.

PTO 92 | Telehealth PT
Telehealth PT: There are plenty of opportunities out there and plenty of ways for us to reach out to patients and our patients to reach us.

 

Even more simply, what about the mother or father that has a child sick at home and they can't leave? Instead of canceling that visit to the out-patient facility, they do their services over the internet. It can be so great. If a patient cancels, no shows or if there's a drop in a provider's schedule, they can make some of those calls to people who couldn't make it and say, “Let's do it right now if you've got time.” There's an opportunity.

Different groups are looking to do exactly what you said in different ways. Some will have the same PT treat that patient later in the day. If that patient doesn't have so much flexibility in their schedule, they might have someone who only does telehealth visits. They might even outsource to a particular group or PT that never comes into their office and just does their coverage work for those next visits. There are plenty of opportunities out there and plenty of ways for us to reach out to patients and our patients to reach us. That's what this is about.

At this point, the important thing is to make sure providers recognize that this is an option, that there are people like you out there that can help them. Lastly, they need to push at the federal level to make sure these telehealth services are covered. Is there anything else you want to share, Daniel?

Be safe out there. It's crazy times. We'll all get through this. Telehealth and other services like this are ways for us to be smart and handle a challenging situation. Going forward, it will be something a lot more fun for us to do.

Telehealth and other services like this are ways for us to be smart and handle a challenging situation. Click To Tweet

Out of every challenge comes an opportunity. Thanks for your time, Daniel. I appreciate you reaching out.

Thank you, Nathan.

It was timely that you did so. I'm glad that we're putting this out.

I appreciate it. I'll be in touch again soon.

Thanks.

Important Links:

About Daniel Seidler

PTO 92 | Telehealth PT

Daniel Seidler, PT, MS
Daniel is an experienced Physical Therapist, healthcare innovator, entrepreneur and executive. He grew his practice in the Bronx, NY to three successful locations before being acquired by a regional multi-site group. Daniel  developed and launched the company's telehealth program in early 2019.

Daniel's passion for PT and desire to dramatically improve care delivery models inspired him to formalize his telehealth PT education programs and offer them through TelePT Solutions.

Daniel now treats remotely, coaches PTs to be telehealth specialists and consults owners on building successful telehealth practices.

 

Love the show? Subscribe, rate, review, and share!

Join the Physical Therapy Owners Club today:

© PTO Club 2018 - 2019
linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram