The Case

The College received a complaint from the Insurance Bureau of Canada (IBC) about the billing volumes of a physiotherapist at a single physiotherapy clinic.  

The IBC explained that based on data pooled from a group of insurers, the PT had billed insurers for over 30 hours of treatment per day on more than 50 separate occasions. On the highest billing dates, the physiotherapist billed for almost 52 hours for 30 patients and 51 hours for 23 patients.

The IBC was concerned about the volume of billing per day and questioned how quality care could be provided.

According to College records, the physiotherapist worked at the clinic part-time and worked with up to six physiotherapist assistants (PTAs).

The College reviewed a selection of patient records as part of the investigation. A number of concerns were identified including assessments without analysis linking objective findings to a diagnosis or treatment plan, repetitive goals and treatment plans for different patients, inadequate re-assessments, and missing details such as documentation of informed consent and the names of the PTAs who provided treatment.

The PT explained that they were able to bill insurers for over 30 hours per day because they typically worked 12-hour days and they involved PTAs in the care.

According to the physiotherapist, they can provide direct supervision of the PTAs because the clinic has several treatment rooms that are adjacent to a large, open exercise treatment space. They also said they verify the PTAs competency by directly observing them administering treatment to patients and during debriefs following treatment.

The PT acknowledged gaps in their record keeping and said they have already taken steps to address the issues.

The Standards

While physiotherapists often work with PTAs to assist in the delivery of physiotherapy care, the Working with Physiotherapist Assistants Standard requires that the care be adequately supervised by the physiotherapist. Based on the volume of PTAs and the volume of patients involved in this case, it seems unlikely that the physiotherapist would have been able to provide an appropriate level of supervision.

The Working with Physiotherapist Assistants Standard also requires that physiotherapists obtain consent from patients for the involvement of a PTA in the delivery of their physiotherapy care. Unfortunately, there was no documentation in the patient records to show that the PT had discussions with patients about involving PTAs in their care or that they obtained consent from patients to involve PTAs on an ongoing basis.

Record keeping is a key component of patient-centred care. The principal purpose of record keeping is to capture information relevant to the patient’s care for the benefit of the patient and future caregivers. Clinical records provide the ability to track a patient’s course of treatment, determine future care needs and give evidence of and rationale for the care provided.

In this case, many clinical records failed to meet the requirements of the Record Keeping Standard as they lacked relevant information about patient care, objective data and rationale for the care provided.

The Outcome

In considering the number of hours billed to insurance companies per day and the fact that the PT only worked part-time at the clinic while supervising up to six PTAs, the Committee was concerned that the PT may have provided inadequate patient care and/or inadequate supervision of the PTAs who were administering the treatment.

There was no clear indication of the patient care provided because the clinical records lacked sufficient detail related to physiotherapy diagnoses, treatment plans and treatment goals, analyses, patient progress, reassessments, and discharge rationale.

The concerns with record keeping, assessment and treatment, and use of PTAs were significant enough to require the physiotherapist to complete a Specified Continuing Education and Remediation Plan (SCERP) and receive a caution.

All costs associated with the SCERP will be paid by the PT and the caution will appear on the Public Register permanently.

Working with Physiotherapist Assistants Standard

Supervision Standard

Record Keeping Standard

Consent Resource