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Aquatic Therapy Sessions - Choosing the Long Visit

Updated: Jan 16

Once upon a time, insurance served as a buffer against dreadful rehab skills. Because patients did not have to reach into their pockets to pay for services, they were more willing to attend appointments where the care was marginal and the benefit was negligible.

That is no longer the case, and hands-on therapy clinics should be grateful. In today's economy, patients can pay $10 to $40 copayment for each visit. That means they are now paying attention. When their own dollars are at stake, patients notice the not-so-subtle distinction between a 30-minute and 45-minute treatment.

Thirty-minute treatments used to be the norm. In my opinion, they remain possible under three scenarios.

  • You have no natural competitors;

  • Shorter, frequent visits are not perceived as a hardship. The patient who lives close, who does not work, and/or who does not have to make child-care or transportation arrangements may not experience difficulty with a 3x/week for 30-minute plan. However, even that patient will hesitate when asked to pay a $10 to $40 co-pay 3x/week instead of 2, especially if the total minutes of care remain the same;

  • The patient understands and accepts the therapy clinic as a "Walmart" of sorts (the price is cheap, some corners are cut).

There will always be therapy mills among us. Some clinics thrive under this model. They create a boisterous, high charged, gym- or pool-based treatment plan for almost 100 percent of patients. Therapists see three to four people an hour. The place is packed. It's fun, social and--for a few souls--the highlight of their lonely day. Whether it's therapy or not is another matter.

It is equally helpful to remember that the 1:1 model is how therapy is supposed to be performed. Medicare Part B and some other payers will no longer pay for therapy performed in a group setting. Unless a patient has been approved for group therapy sessions (97150), there is no way for a therapist to bill for more than one patient at a time.

In other words, the "mill" model may be legal, but it is often not reimbursable. This means that the clinics that gravitate toward a longer session will not lose out in the revenue wars, because it is often not permissible for a provider to bill for more minutes than the therapist worked. If the therapist is on the clock for 60 minutes, Medicare Part B says he can bill for 4 units, no more, no matter how many people he sees during that one-hour time period.

Keep in mind that the too-short treatment session can also be a huge barrier to patient follow-through and per-visit benefit. By elongating treatment sessions from 30 minutes to 45 minutes, a clinic will experience the following benefits:

  • Patients who are running "5 minutes late" will not automatically abandon the attempt to come;

  • Patients who require more time to complete a task (e.g., walking in from the parking lot; donning/doffing bathing suits) will not automatically abandon the attempt to come;

  • Patients who have high co-pays will get more bang for their co-pay "buck;"

  • Therapists will have the time to stop, breathe, ask questions, process the answers, innovate and perform hands-on care during every session;

  • Therapists will be able to do some "point of service" documentation (which is billable) without compromising a large chunk of the session to charting. This will increase accuracy of documentation and reduce end-of-day documentation time;

  • Full-time therapists will see 25 percent fewer patients daily (without a change in total units charged), permitting them to focus their energies on solving puzzles, not managing traffic. This will also reduce end-of-day documentation time, as the therapist may be charting on nine to 12 people, not 16 or more.

As appropriate, patients may be reduced from a 3x/week schedule to a 2x/week schedule. From the patient's perspective, this reduces out-of-work time, reduces co-pays, reduces the need for child care, and minimizes transportation hassles. From the therapist's perspective, this allows therapists to provide the same minutes of hands-on care without the loss of "transitional" minutes. It also reduces documentation time per patient by 33 percent.

In my opinion, there are two principle drawbacks to shifting to a 45-minute session. The first concern is scheduling. To prevent chaos in the scheduling books (envision orphaned 15-minute blocks scattered through the day), all visits must shift to 45 minutes. This includes evaluations.

Many therapists balk at the idea of a 45-minute first appointment (which, in most clinics, must also incorporate at least 15 minutes of treatment). There is no question, it is difficult to cover all the bases and perform a meaningful first treatment in 45 minutes. The relief comes in the second visit - and every visit after that.

In a perfect world, therapists should perform a mini-evaluation every time they see a patient. When the 2nd, 3rd and 10th visit allows for that, it frees the therapist to constantly re-assess and proceed with forethought, not simply react to pain or other "loud" symptoms.

The second drawback to scheduling 45 minute sessions is the lost productivity from a late cancellation or (worse) no-show client. Instead of losing a 30-minute block of productive work, the clinic loses 45 minutes. To counteract this valid concern, consider the following strategies.

  • Consider establishing a "two strikes, you're out" policy for no-shows. Ensure the patient knows this policy up-front so there is no confusion;

  • Have front desk staff call any person who no-shows. Determine if future appointments need to be

  • canceled;

  • Only schedule appointments 1-2 weeks in advance. Keep patients "soft scheduled" in their time blocks, but do not confirm the appointment until the patient verifies it the week before;

  • Educate the patient about the commitment your clinic has made to providing 45 minute sessions and the value these 1:1 sessions provide. Stress the need to attend appointments religiously -- or to call and cancel well in advance;

  • Leave patients wanting more. The best way to ensure patients will return is to provide great care,

  • improve function, decrease pain and for the therapist to share their plan for what the next visit will bring;

  • Intermittently, offer a way to incentivize the front desk beyond the norm. For instance, consider making August "No Holes Barred Month." At the end of the month, issue thank-you bucks (good for groceries, massages, movie tickets) for every day that passed without a schedule hole. Or, consider issuing a bonus of $5 to $10 for every same-day cancellation hole that is filled. Instead of paying a PT/PTA $25 to $40/hour for down-time (and losing $100 in potential revenue) you may pay $200 in August bonuses to a hard-working receptionist;

  • Maintain a list of existing patients who wish to be notified of any cancellations. The scheduling team should gather a master list of home, work, cell and email contacts on these people and use them. Call new patients who were already on the books for a later date and offer to move up their appointment.

Remember, the hole in the schedule tomorrow is easier to fill than the hole looming large today.

In my opinion, there is very little down-side to shifting to a 45-minute treatment. Some manual therapy oriented clinics have even gravitated toward the one-hour long session, although the hit from a no show or late cancellation is a bitter pill to swallow. In either case, longer visits can result in happy patients, thrilled therapists, and - when done right - healthier bottom lines.

Copyright 2023. Andrea Salzman, MS, PT. All rights reserved Andrea Salzman is Director of Programming for Aquatic Therapy University (ATU). ATU offers post-graduate studies in aquatic therapy, including 7 certificate tracks, allowing a tiered progression of aquatic skills. Information about ATU may be obtained at

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