Pro-Bono Work: The Good, The Bad, and The Billing

We’re all taught at a young age that it’s better to give than to receive. This saying helps children develop perspective, and even as adults, few people would argue against the moral truth of this simple axiom. In fact, I’m betting this statement really speaks to the empathetic nature of rehab therapists. Unfortunately, though, when you’re running a business (for the purposes of this blog, I’m referring to a private practice outpatient therapy clinic), you really need to receive as much as you give, because contrary to Anne Frank’s beautiful and moving words, you can go poor by giving. That’s why doing pro bono work is like walking a tightrope: precarious. Still, there are circumstances in which giving is certainly rewarding—and you can genuinely afford it. So, how do you walk the rope—and is it even worth it?

The Definition: What is Pro-Bono Work?

In an article titled “Doing Good While Doing Well,” authors Francis Bisagni, PT, and Ron Scott, PT, EdD, JD, define pro bono PT work as “health professional services provided to patients at a reduced fee or no fee, depending on their ability to pay.” It’s a fairly broad definition, which is why the authors later add this caveat: “Professionalism is the key core value at the heart of pro bono service delivery. Health care professionals should routinely evaluate their professional conduct and always strive to be clearly in compliance with legal and ethical mandates.” And for many, that’s where the waters start to get muddy. The most common example of this practice is waiving copays, which is a form of underbilling, or “the conscious process of not billing for all services provided on a given date,” write David O. Lane, PT, MHS, and Peter R. Kovacek, PT, MSA, in an article titled “Money on the Move.”

The Good: How Do You Do Pro-Bono Right?

Two words: Be ethical. According to the American Physical Therapy Association (APTA), the “Code of Ethics for the Physical Therapist and Standards for Ethical Conduct for the Physical Therapist Assistant specify that APTA members provide pro bono physical therapy services and/or support organizations that meet the health needs of people who are economically disadvantaged, uninsured, or underinsured.” The organization has an entire page of resources devoted to educating PT professionals on how to do pro bono work right (and I strongly urge you to read everything on that page and speak to your lawyer before even considering providing pro-bono services), but author Kathleen K. Cianca, OT, provides a nutshell version of the APTA’s stance in her article “A Better Way to Serve”:

“APTA (2009) outlined four ways that therapists could meet their pro bono ethical requirement:

1. Provide no-cost or reduced-cost professional services to uninsured individuals;
2. Donate therapeutic services to charitable organizations;
3. Participate in volunteer activities to improve access to therapy;
4. Donate money to groups that offer professional services to individuals with limited resources.”

Notice what’s missing? Waiving fees and/or copayments and not billing for all of the services you provide. And that’s how you ensure you’re on the right side of pro-bono work: “The desire to help those in need cannot eclipse the mandate to practice legally,” explain Bisagni and Scott.  

The Bad: Are You Doing Pro-Bono Wrong?

One word: Underbilling. When you provide more units or services than you actually bill for—or worse, waive fees or copays altogether—you lose revenue and leave your practice vulnerable to lawsuits, penalties, or even closure. Why? Because, as Bisagni and Scott explain, “Despite the apparent good intention, this practice violates a contractual agreement between the provider and the [payer], and circumvents the very measure in place to reduce overutilization of health care resources and patient and societal exploitation." Essentially, when you underbill or waive copays and fees, you:

• Lose revenue. This one is obvious, but what’s less obvious is the way that revenue loss scales: the more you see those patients, the greater financial loss your clinic suffers over time.
• Diminish the value of yourself, your services, your business, and your profession. And as Brooke Andrus explains in this blog post, “if you do that, how do you ever expect to negotiate for better payer contracts and reimbursement rates?”
• Risk CMS fraud accusations or investigations. Generally speaking, Medicare and Medicaid prohibit providers from waiving copays. This is because doing so misrepresents the true charge for your services. And although Medicare permits copay waivers in very select circumstances, the exception criteria do not apply to most cases. Sure, the occasional waived copay probably won’t look too fishy, but if you consistently engage in this practice, it’s only a matter of time before CMS takes notice.
• Risk HIPAA violations with commercial payers due to misrepresentation of charges. “For example,” explains Heidi Jannenga, PT, DPT, ATC/L, in this blog post, “if you waive a $20 copay on a $100 charge, then you’re basically admitting that you value that service at $80. Thus, the carrier should actually owe you only 80% of $80 (not $100).” Furthermore, as John Yodonise details in this PT Billing Services article, “HIPAA concluded that free services are likely to influence a patient to receive some other paid services and should be considered a form of remuneration. Since offering remuneration to patients is illegal, waiving copayments and deductibles are illegal.” There are exceptions to that rule—which Yodonise explains later in the article—but in general, waiving copays/fees and underbilling is a HIPAA violation.
• Leave your practice vulnerable to discrimination accusations or lawsuits. Whether you’re breaking or bending the rules—or doing everything copacetic—you have to do it consistently and fairly across the board.

Bottom line: If you’re running a business, be an ethical businessperson. No matter how good your intentions are, you must get paid for what you’re worth and adhere to all legal and compliance requirements.

The Billing: How Do You Ensure You Get Right?

First, nip underbilling—and fee and copay waiving—in the bud ASAP. How? Develop procedures for collecting all patient fees (including copays, deductibles, coinsurances, and payment for noncovered services and supplies) at the time of service. Asking for money can be difficult—especially because copays for physical therapy can be so outrageously high. But remember, not collecting the payment you deserve not only diminishes the value of your practice, but also could prevent you from continuing to help your patients. After all, you won’t do them much good if your clinic goes out of business. So, to ensure proper copay collection in your clinic:

1. Create a copay collection policy and procedure guide, and distribute it to all of your employees.
2. Provide your staff with all of the resources and tools they need to promptly and accurately collect copays.
3. Conduct training and role play exercises to get your employees more comfortable with asking for money, and be sure to practice some of the really tricky scenarios (like when patients push back).
4. Monitor copay collection performance and hold your staff accountable.

Now, regarding genuine pro-bono work, I must again emphasize that you review everything the APTA provides and consult with your lawyer. However, a safe bet—or general rule of thumb—would be to avoid such work with any individual who has insurance. Another safe bet: volunteer work. (You also can investigate community clinic/free clinic models, which Bisagni and Scott define in their article.)

Most physical therapists didn’t get into the business to get rich. The key word in that sentence, though, is “business,” because altruistically speaking, it might be better to give than to receive, but if you want to actually stay in business, you’ve got to make something. More importantly, you’ve got to stay out of trouble. Otherwise you could lose more than just money. So, know the rules, and follow them.