Case of the Month
The Case
The College received a complaint from an investigator with an insurance provider. While undercover, the investigator had attended physiotherapy appointments to investigate incentive/benefits fraud at the clinic.
At their second physiotherapy appointment, the clinic’s receptionist suggested that the investigator consider orthotics, noting that they would be beneficial because of the investigator’s height.
At their next appointment, the investigator spoke with the physiotherapist about getting orthotics and shoes. The PT asked the investigator who their insurance provider was and how much coverage they had for orthotics. The physiotherapist had the investigator stand barefoot and looked at their feet before determining that orthotics would help the investigator’s “activity tolerance.”
The physiotherapist told the investigator that orthotics and shoes would cost $550, however since the insurance company would only cover $500 for orthotics, the physiotherapist would bill the remaining $50 as an additional physiotherapy session.
Although the physiotherapist specified that the investigator would need to see a doctor in the same building for a referral for the orthotics, this appointment never happened. The investigator received their orthotics and shoes with a false prescription from a doctor they never saw. The investigator did not receive wearing instructions or dispensing advice when picking up the orthotics.
The investigator also booked a massage therapy appointment at the clinic. They were informed by the receptionist that half of the cost would be charged as physiotherapy since the investigator’s insurance wouldn’t cover the full massage therapy fee and the clinic doesn’t like to make patients pay out of pocket.
In reviewing the insurance claims that the physiotherapist submitted, the investigator noted false documents regarding a gait analysis that was never performed for the orthotics, invoices for physiotherapy sessions that they never attended, and invoices for additional physiotherapy sessions to offset the cost of the orthotics and massage therapy.
The Standards
The College has a zero-tolerance approach when it comes to inappropriate business practices.
According to the Fees, Billing and Accounts Standard, physiotherapists must ensure that any fee, billing or account that uses their name and registration number is an accurate reflection of the services and/or products provided. Physiotherapists must never charge fees or create billings or accounts that are inaccurate, false or misleading.
In this case there were numerous falsified records and invoices for physiotherapy services that never occurred or were not necessary for the patient. The physiotherapist was intentionally submitting false invoices to take advantage of insurance payments.
The Outcome
The physiotherapist agreed to enter into an undertaking (agreement) with the College to voluntarily resign their registration. They also agreed to never reapply for registration with the College, along with additional terms conditions and limitation. The details of the undertaking are posted on the Public Register.
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