LYNN — A longtime local physical therapist said the regulation at the center of improper billing accusations made against him is at odds with other insurance practices and his methods for most effectively treating patients.
Lynn native Joseph O’Connor said he will fight to get the regulation struck down and reach out to Lynn’s legislative delegation to begin that process.
“The whole issue is one of style and how we perform our services,” said O’Connor who has run Advance Physical Therapy & Sport Rehabilitation at 1 Market St. for 22 years.
The state auditor’s office last fall reviewed O’Connor’s MassHealth billing practices between 2015-2018 and released a report in January ordering O’Connor to pay back $359,266.
MassHealth therapy provider regulation Section 432.412 of Title 130 of the Code of Massachusetts Regulations (CMR) does not allow payment for therapy services provided by physical therapy assistants, even if they are provided under the supervision of a licensed therapist.
“Dr. Joseph O’Connor improperly submitted claims to MassHealth using his own billing provider identification number for physical therapy that was provided by physical therapy assistants,” the audit stated.
State Sen. Brendan Crighton said he and fellow legislators are aware of O’Connor’s concerns.
“We’re certainly happy to help out,” Crighton said.
O’Connor does not dispute that physical therapy assistants in his practice were treating patients who had MassHealth as their insurance. But he said the MassHealth regulation fails to reflect the complex health insurance billing system care providers must negotiate. MassHealth is just one of almost 20 insurance plans O’Connor does business with and almost all of them, including public insurance plans like Medicare, allow physical therapist assistant billings.
Several private health insurance providers with which he does business allow billing by physical therapy assistants. In addition, some of the 300 patients he treats a week have a combination of insurance providers, including MassHealth, with one plan allowing billings by a physical therapy assistant even though MassHealth prohibits the practice.
Physical therapy assistants are board-certified and licensed by the state.
“Every busy professional has an assistant. To minimize a physical therapy assistant’s importance is disappointing,” O’Connor said.
Working out of an office and small gymnasium, O’Connor and his half dozen employees, including therapists and assistant therapists, help patients recover from injuries, strokes and other medical problems.
O’Connor explained he takes a team approach to helping people that means several people in his office work together on the patient.
“It’s common for a patient to see two or three people over the course of therapy,” he said.
He said auditors visited Advance Therapy four or five times last year and ultimately “came up with a formula” computing how much money he is required to pay back to MassHealth.
The audit’s findings posted on the state Auditor’s website conclude: “… Dr. O’Connor should collaborate with MassHealth to establish a plan to repay the $359,266 in overpayments he received from improper physical therapy billings. Dr. O’Connor should bill MassHealth using his billing provider identification number only for services he personally provides. Dr. O’Connor should periodically review all the billing requirements in MassHealth’s regulations.”
Stressing that his patients received all of the services billed to MassHealth, O’Connor said, “If I’ve got to pay it back, I’ll pay it back.” He added: “I’m hoping to convince them that the services provided were top quality and served patients.”