Running a lean outpatient rehab practice doesn’t mean avoiding all costs. In fact, some of the most valuable decisions a clinic owner can make involve knowing when to seek outside help. The key is identifying when internal systems are sufficient and when professional support becomes essential to protecting your business.
Know When DIY Is No Longer Enough
Most audits won’t require legal support, but some do. If more than half of the sample reviewed in an audit results in denials, that’s a red flag. In this situation, practices should not go it alone. Before submitting appeals or responding to further payer inquiries, it’s important to consult with someone who can review the documentation and assess the best next steps.
In many cases, practices can identify and fix documentation issues before records are submitted, reducing the likelihood of denials. But if that window has passed, and the denials have already been issued, professional input becomes crucial. Even well-intended appeals won’t succeed if they rely on after-the-fact addendums or fail to include the necessary components of medical necessity.
When to Call a Healthcare Attorney
If a payer is demanding a large takeback, especially one extrapolated over years of claims, you need a healthcare attorney. A general business lawyer won’t have the expertise to navigate payer appeals or defend your practice in this specific context. Healthcare attorneys specialize in regulatory defense and know how to work with consultants to prepare expert documentation reviews.
These professionals are not cheap. But if your exposure is in the hundreds of thousands or even millions, spending to protect your business is not optional. The right attorney, paired with a qualified compliance consultant, can help resolve the situation more effectively than an internal effort alone.
Affordable Training Options That Work
Preventing compliance issues in the first place is far less expensive than reacting to them. That’s why annual training is essential for all clinical staff. CPT code misunderstandings are one of the most common reasons for denials, so clinics should provide every therapist with a refresher course each year. Many EMRs include built-in access to short training modules, and professional associations like APTA, ASHA, AOTA and state OT Associations offer free or low-cost resources on defensible documentation.
These tools provide a baseline standard for documentation quality and payer expectations. Ensuring your team knows what to document, how to document it, and why it matters is one of the most cost-effective compliance strategies available.
Find the Right Consultants
Whether you’re setting up a compliance program or responding to an audit, the right consultant can make all the difference. Fortunately, practices don’t have to search blindly. State PT and OT associations are excellent starting points for referrals. So are Facebook and LinkedIn groups tailored to rehab practice owners. Many of these groups are highly active and responsive, allowing you to crowdsource trusted names.
Some consultants specialize in compliance audits, payer appeals, and defensible documentation. Some, like Gawenda Seminars, are well-established in the field. Others may operate regionally or by specialty. Regardless, it’s critical to find someone who has experience with payer audits and can offer tailored advice for your setting.
Be Strategic with Payer Contracts
One of the biggest financial mistakes new practices make is signing every payer contract that comes through the door. It’s understandable—when you’re starting out, it feels like more contracts equal more patients. But this approach can backfire.
Every payer brings an administrative burden. If that burden outweighs the reimbursement, you may be losing money on every visit. Before signing, assess how complex the documentation requirements are and how often that payer initiates audits or takebacks. In some cases, it may be better to walk away.
Some payers are known for their aggressive auditing and recoupment practices. If colleagues in your area consistently report issues with a specific payer, take that into account. No referral source is worth a consistent financial loss.
Consider Out-of-Network Models
For some practices, being out-of-network is a viable alternative. It requires more work up front, particularly in billing and patient communication, but often comes with fewer documentation hurdles and a lower risk of punitive audits. Practices that choose this route gain more control over their clinical protocols and reimbursement structure.
Out-of-network models aren’t for everyone. But they’re worth considering for practices that want to grow sustainably while avoiding high administrative burdens. Resources are available through professional associations and online communities to help navigate the transition.
Know Where to Spend and Why It Matters
An efficient, cost-effective practice isn’t one that avoids spending. It’s one that spends wisely. Knowing when to seek legal help, where to find trustworthy consultants, and how to invest in staff education can prevent far more costly consequences down the line.
The goal is not perfection, but resilience. With the right outside support, sought at the right time, practices can withstand audits, protect their revenue, and continue delivering excellent care without overextending their resources.
John Wallace
John Wallace, PT, MS, FAPTA, is chief compliance officer at WebPT.
