The Case

The College received a complaint from a patient who attended four physiotherapy appointments, with the expectation that she would be able to bill the sessions to her insurance provider.

The patient indicated that during her first appointment she told the clinic receptionist she would be using insurance, and that she would send the claims to her insurer herself.

After four sessions, the patient sent the receipts to her insurance provider and was surprised when they refused to reimburse the $350 to cover the treatment. The insurance company informed her that they stopped covering services from that particular clinic six months ago.

The clinic had been delisted because of fraud concerns. According to the patient, the insurance company informed her that the clinic would have been made aware of its delisted status.

The patient said the receptionist never mentioned that the clinic did not work with certain insurance companies, and further, that she never had a conversation with the physiotherapist about fees, billing or insurance coverage. The patient was upset that neither the PT nor the receptionist asked for more details about her insurance before starting treatment.

The physiotherapist indicated that she asked the patient if she had insurance coverage, and the patient said she had already discussed insurance with the receptionist. Further, the PT did not see any details about an insurance provider in the patient file.

The physiotherapist himself was not delisted by the insurance provider—only the clinic. He asserted that once staff knew that the clinic was delisted, they were careful not to accept any new clients with coverage from that provider or bill that provider directly. He also indicated that the patient never expressed any concerns about billing prior to submitting the complaint.

The Standards

The Fees, Billing and Accounts Standard states that before providing treatment, physiotherapists must ensure that patients are given clear information about fees and that they understand the information. This includes any financial policies that might affect the patient, such as payment expectations and late payment charges.

In this case, the patient indicated that there was no discussion between her and the physiotherapist about fees and billing and she was unhappy to learn that her treatments would not be covered by insurance after she already attended four sessions.

PTs have an ethical responsibility to act with honesty and integrity. This is crucial in the delivery of high-quality patient care.

The Outcome

More and more clinics and/or physiotherapists are being delisted by insurance providers. The physiotherapist is accountable for making sure patients understand the fee and billing structure, and any fees that might apply to them.

If a physiotherapist is aware that they, or the clinic they work for, have been delisted by an insurance provider, they have a professional and ethical responsibility to inform patients. In this case, the Committee advised the PT to review his practices related to fees, billing and accounts and implement improvements.

Fees, Billing and Accounts Standard
Ethics
Delisted: Make Sure it Doesn't Happen to You
Canadian Physiotherapy Association—Delisting of PT Services by Insurers