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Physical therapist license protection case study: Aiding and abetting unlicensed practice

State Board of Physical Therapy (SBPT) complaints may be filed against a physical therapist (PT) by a patient, colleague, employer, and/or other regulatory agency, such as the State Department of Health. Complaints are subsequently investigated by the SBPT to ensure that licensed PTs are practicing safely, professionally, and ethically. SBPT investigations may lead to outcomes ranging from no action against the PT to revocation of the PT’s license to practice. This license protection case study, presented by HPSO, involves a licensed PT who worked at a wellness center with several other licensed health care providers.


The insured physical therapist (PT) was employed by a “wellness” clinic specializing in pain management that was owned by an osteopathic physician (DO). The clinic also employed a nurse practitioner (NP), two chiropractors, and a massage therapist. All other staff, except for the insured PT, the DO, and the NP, billed for their work at the clinic as physical therapist aides and worked under the direction of the PT.

The patient in this case was a woman in her mid-60s who was experiencing lower back and hip pain. The PT did not document an initial evaluation of the patient, a treatment plan, or goals for the patient. The PT scheduled the patient for 20 sessions at the clinic over the course of three months. During some sessions, the patient was scheduled for more than one treatment session per day. All of the skilled physical therapy treatment that the patient received was performed by one of the other staff members, working as a “physical therapist aide,” rather than the PT.

After completing the 20 sessions, the patient noticed discrepancies in the treatment billed to her insurance company. For example, the PT billed the patient’s insurance on twelve occasions for “manually applied electrical stimulation performed under constant attendance.” However, the patient recalled that she only received electrical stimulation on three or four occasions. Moreover, the patient later stated that she was always left unattended when she received electrical stimulation. The patient filed a complaint with the SBPT, which opened an investigation into the PT’s conduct.

Enforcement Investigation

According to SBPT interviews with the staff members, the clinic’s patients were typically first seen by the NP.  Each patient was then referred to a chiropractor for creation of a general treatment plan. The NP would approve the treatment plan, which was then sent to the relevant insurance company for authorization. If the plan was authorized, the patient forms were then created. After the first visit, billing codes were established and entered onto a daily care plan for each subsequent appointment. The medical patients were treated under the direction of the NP and the physical therapy patients were treated under the direction of the PT.  At times, patients were treated twice during the same day. For the second treatment occurring during the same visit, the second treatment would be billed under the DO’s name, rather than the name of the PT or the NP, even if the DO was not overseeing the treatment.

During an interview with the SBPT, the PT stated that she did not determine the billing codes. The PT asserted that she would co-sign patient care notes about once a week when she reviewed the notes of the other staff members. The PT further asserted that the practice owner, the DO, would periodically review the patient records. She stated that although the DO evaluated the records, she was unable to recall the last time that the DO was physically present at the clinic.

The PT also represented that she, the massage therapist, and the chiropractors would monitor patients when electrical stimulators were applied and in use. She stated that patients were never left unattended. If the PT, the chiropractors, or the massage therapist were unavailable, the NP or a staff member from the front office would monitor the patient.


The SBPT determined that the PT aided and abetted in the unlicensed practice of physical therapy and failed to appropriately supervise the support personnel who provided treatment to patients.

The PT’s repeated negligence was difficult to defend, especially considering that her documentation was sporadic and incomplete. Therefore, it was recommended that she agree to a consent agreement, rather than risk revocation of her license.

Under the consent agreement, the PT was placed on probation for five years, fined $10,000, and required to comply with various reporting and continuing education requirements.

Total incurred: More than $12,700.

(Note: Monetary amounts represent solely the legal defense expenses paid on behalf of the insured PT.)

Risk Control Recommendations for Physical Therapists

Below are some proactive strategies to include in your practice to help mitigate the risk of SBPT complaints:

  • Direct staff (including physical therapist assistants, physical therapist aides, students, and other unlicensed assistive personnel) to perform only those tasks that are within their training, skill set and appropriate for the patient.
  • Provide clinical support and supervision for physical therapist assistants, physical therapist aides, and students in compliance with standards of practice for physical therapy.
  • Be knowledgeable about the levels of supervisory responsibility of a PT and know when it is acceptable for a PT to have general, direct, or indirect personal supervision of physical therapist assistants, physical therapist aides, physical therapy students and any other clinical provider working at your place of business.
  • Maintain documentation regarding the competencies of physical therapist assistants, physical therapist aides, and students, updating as necessary.
  • Refer to the American Physical Therapy Association (APTA) published information regarding a PT’s responsibilities on delegation and supervision and the roles of PT aides.
  • Document your patient care assessments, observations, communications and actions in an objective, timely, accurate, complete, and appropriate manner. Documentation should support the treatment plan and also satisfy SBPT, regulatory and third-party billing requirements. When more than one requirement applies, adhere to the most stringent policy.
  • Document, date, and authenticate services provided by physical therapist assistant(s) who are under your direction and supervision, unless physical therapist assistants are permitted to authenticate documentation under state laws/regulations.


These are illustrations of actual claims that were managed by the CNA insurance companies.  However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and Aon, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., HPSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.

Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.