ADDRESSING PUSH BACK TO Obstetric Physical & OccupaTional Therapy

May 28

While sometimes therapists attempting to add postpartum service lines in their acute hospitals encounter limited to no pushback from other stakeholders, for many this is not the case. The US healthcare system is complex with various payors, regional variability and hospital system cultures making implementing innovative programs at scale challenging.

A June 2025 survey of 145 obstetric physical and occupation therapists in a large OB therapy social medial group (OB PT & OT) found the most common barriers faced when pursuing therapy services in acute postpartum units to be:

1. Insufficient therapy staffing to absorb an increase in census

2. Therapy staff not sufficiently trained and/or comfortable with postpartum care

3. Therapy in acute postpartum not seen as skilled care within hospital system

4. Therapy seeing postpartum patients will reduce hospital profits for these patients

5. Postpartum patients will be billed separately for therapy services while inpatient

Only 4% of respondents reported no barriers had been encountered.

Each of these barriers presents unique challenges that require both short-term and long-term solutions.

Concern #1: OBs are concerned patients will be charged more/charged for the individual therapy services provided

Discussion:

Whether a patient gets charged for PT/OT and how much depends on:

1) Their individual insurance – does it reimburse in a lump sum or per item basis? If charged individually, how much does insurance cover of that charge vs makes the patient’s responsibility?

2) Whether your hospital is a critical access hospital or not.

Short Term Solutions:

1) You’ve got to know how reimbursement works in YOUR hospital to know if a patient may get charged for an individual PT/OT session.

a) Most hospitals & most insurances reimburse for birth in a lump sum and patients are NOT charged for individual services so postpartum patients won’t be billed more if they received PT/OT in acute care.

b) In Critical Access Hospitals (CAH), billing may be done on an item by item basis so patient could get charged for PT/OT.

2) If a patient may be charged at your hospital:

a) Can you find out how much? Your supervisor may know, if not contact billing department.

b) Patient should be given choice to consent to cost of PT/OT eval knowing how much they will be charged by the hospital (with caveat that the total amount they would be responsible for will depend on their insurance).

3) Close the loop with your OBs – you have to share whatever you learn – good or bad – with them.

Long Term Solutions:

1) Insurance company change in how PT/OT is reimbursed in hospitals and/or how much is reimbursed for postpartum care.

2) CMS is the leader here – what Mama Medicare does, everyone follows.

a. Legislative advocacy to update our state level Medicaid policies AND federal CMS policy.

b. CMS could require PT/OT evals in postpartum or reimburse more for postpartum care that includes a PT/OT.

Concern #2: OBs think doing a PT/OT eval/treatment in acute postpartum is fraud

Discussion:

Some OBs are under the impression that PT/OT is so clearly unnecessary in acute postpartum and/or that OBs are able to assess for PT/OT need themselves so ordering PT/OT is a misuse of healthcare resources.

OB experience with how billing and their salary work is DIFFERENT than a PT/OT in many hospitals. Many are contractors that have different payment schemes from hospital to hospital. Do they think you get paid per patient you see and so are trying to pump up your own pay by seeing more patients?

Per the AMA CPT codebook, the codes for PT Eval apply to a physical therapy assessment performed by a PHYSICIAN or another qualified healthcare provider. The codes for an OT Eval don’t mention a physician and only mention a therapist. So this is...weird and confusing but maybe could provide insight into why an OB believes they can evaluate for need for therapy services without bringing in another provider like an actual PT or OT. r

Short Term Solutions:

1) We have to be clear on THIS OB’s though process. WHY is it fraud in their mind?

a. You have to ask questions. Ask them to explain that more to you because who wants to commit fraud? No one does.

b. If this OB won’t talk to you, do they work in a practice with others? Can you ask one of their partners for insight here?

c. Once you know their concern details, can you connect with anything they have said to make common ground here?

d. Could you ask if you could do a PT/OT eval with them present so they can see what you do/don’t do?

2) Can you make a case for certain patient populations as particularly needing PT/OT postpartum as a way in the door? Like cesarean?

3) If this OB won’t play ball, can you MOVE ON to other OBs that are more receptive? You don’t have infinite time to bang your head against a wall that isn’t moving. Are there other OBs in your system that you can make connections with instead.

4) Attend postpartum rounds so you build relationships with your OBGYN team.

5) Explicitly ask acute postpartum patients that have good experiences with you to TELL THEIR MD.

Long Term Solutions:

1) Education at OBGYN/Med Schools around postpartum PT/OT including in acute care.

a. Reach out to Medical Schools in your area and ask to be a guest lecturer on this topic.

b. Attend local or virtual OBGYN professional meetings (like ACOG & MFM Society).

2) Research showing benefits of acute PT/OT postpartum compared to standard of care.

a. Ask your department head if you can collect data around certain outcomes for acute postpartum.

b. Reach out to a PT/OT school to form a relationship with a professor to conduct a research study – you’ll need IRB approval and probably help writing it.

Concern #3: Concerns from OBs/RN/Case Management that waiting for PT/OT will delay discharge

Discussion:

Postpartum is a FAST discharge unit – length of stay is usually 1-3 days max and during COVID those DC times got cut down as much as possible. Having to wait until tomorrow or evening late afternoon for PT/OT to get in to see a patient could delay discharge. Delaying discharge often means the hospital makes less money on that patient admission so there is a big incentive for hospitals to get patients out as fast as they safely can.

Short Term Solutions:

1) Have a department policy around this like DC won’t be stopped pending PT/OT eval. Patients in other units DC with a pending PT/OT eval order all the time.

2) PT/OT in postpartum should be in postpartum unit rounding to ID patients that need evals & note the planned DC timeline.

3) Education for OBs/RNs around turn-around time from orders being placed for PT/OT and when patient is typically seen (ex: You can’t put in an order at 3pm and think someone’s going to get seen that day). Let them know when the therapy schedule is usually set for the day and encourage them to get orders in BEFORE that otherwise a patient will likely be seen on as as-able basis that day or have to wait until the following day.

4) Do you have a “stat” therapy orders PT/OT at your hospital? If so, can postpartum (or even a subset of high priority postpartum patients) be added to the stat diagnosis list so orders get sent out to the stat rehab team as they come in during the day?

Long Term Solutions:

1) Auto order sets on admission for L&D for postpartum PT/OT just like other high turn around populations like elective joint replacements. That way patient is on therapy census from day 1 on postpartum. Assure OBs/RNs that being on therapy census immediately on postpartum doesn’t mean PT/OT will see IMMEDIATELY when they hit the floor. Just like for joint replacements, PT/OT will wait until patient is cleared by OB/RN and is appropraite before seeing.

2) PT/OT department has list of planned admissions for the week just like in ortho/elective joint department – planned inductions, planned C-Sections, etc – so they can pre-plan staffing/census.

Concern #4: Your department head says there is just not enough therapy staffing to support adding on postpartum patients

Discussion:

Like a lot of for-profit/shareholder driven industries, healthcare operates on lean staffing models. The goal is to have the absolute minimum number of employees needed to meet your business needs. That means there is no slack in the system to absorb more work. So your boss is probably not BSing you with this concern. Some therapy departments run a staffing deficit DAILY – they have a “no time” list of patients that are on therapy census but aren’t going to get seen today because there isn’t enough staff to see them. So adding patients to a census that is already at the max staff can handle or even above it, is a hard sell.

Short Term Solutions:

1) Find out just how lean your department’s staffing is. What is are the typical numbers for census compared to staffing ability to meet that census. This will tell you if there is any room to add any number of patients to the census right now.

2) IF there is room to add more patients to census at current staffing:

a. Figure out what’s the maximum number of postpartum patients we can realistically see a week.

b. Whatever that max number is, if it’s less than ALL postpartum patients, you’ll have to prioritize postpartum patients (ex: Cesarean, high grade tears, hemorrhage, antepartum admission, whatever it is).

c. Whatever your priority list is, can you get numbers for monthly averages for those diagnoses from the postpartum unit director?

d. Compare the numbers for your prioritization list diagnoses and your max staffing ability and make your choices. Pitch this to director. This can get you in the door in postpartum which will then let you move onto the long term solutions.

3) IF there is NO extra room in staffing/census to add any more patients (for example your in a department that regularly has a “no time” list):

a. If your department ever has a “no time” list, then choices are already being made to priority therapy for some patients more than others. Your department is already choosing to not provide therapy services to patients that could benefit from it because of staffing.

b. How is that “no time” list prioritization happening? What diagnoses or criteria get priority for therapy?

c. Are there any postpartum patients/conditions that you think should be getting priority over some of the other patients that are on therapy census? Can you make that pitch to your director – that we should at least be putting certain high-risk postpartum patients on the list to be seen when we have staffing.

4) PT/OT department has list of planned admissions for the week just like in ortho/elective joint department – planned inductions, planned C-Sections, etc – so they can pre-plan staffing/census.

Long Term Solutions:

1) Staffing is usually reaction – so you need to demonstrate a need for more therapists before the hospital will hire more. Ask for the opportunity to demo a need with these short-term solutions above.

2) Recruiting students that want to/are asking for this population so your director is hearing from therapy schools that their students want somewhere offering postpartum experience.

3) Community education encouraging parents to ask for PT/OT services in the hospital to generate demand from the consumer side and/or to hire a PT/OT that can come see them in the hospital/in the first 6 weeks after birth just like you’d hire a doula.

Concern #5: Other acute therapists are not interested in seeing this population and/or think it’s unskilled

Discussion:

You’re getting pushback from other PTs or OTs in your department that they don’t see a skilled need for seeing postpartum patients and/or they just aren’t interested in learning what they need to know to work with this population. This can look like direct verbal pushback or things like other PTs/OTs ignoring postpartum orders that come in when you aren’t there to take them or going to see a postpartum patient, having them walk a little, saying they are Independent and charging for a PT/OT screen only.

Short Term Solutions:

1) In-services that focus on the multi organ system changes in pregnancy that persist postpartum, postpartum complications that PT/OT can screen for, demands of newborn care.

a. Emphasize that pregnancy is actually a MASSIVE multi organ system event so seeing these patients requires a vast amount of PT/OT knowledge across many systems/domains.

b. Share postpartum complication numbers both acutely and long term – mental health, cardiac, blood clots, incontinence, pain with sex, back pain, etc – to highlight that problems after birth aren’t rare.

2) Offer to let other therapist shadow you so they can see that a quality postpartum session isn’t just walking around at SBA/Independent level and then DCing from services.

3) Explain how postpartum patients fit into different Evaluation complexity levels as opposed to being only a screen.

4) Tough love – acute therapists see everyone, not just their most favorite populations so suck it up ya’ll.

Long Term Solutions:

1) Education at PT/OT schools on postpartum care

a. Be a guest speaker at a local school

b. Present at local/national conferences that tend to have high student & professor attendance

2) Recruiting students that want to/are asking for this population so your director is hearing from therapy schools that their students want somewhere offering postpartum experience.

3) Leave this hospital and work somewhere better if that’s an option for you. Sometimes the culture somewhere is just toxic and you deserve to work somewhere where it isn’t so damn hard. Once other hospitals in the area start offering this, your old hospital is going to feel the pressure to start offering postpartum therapy too. Your rising tide will lift their boat too in the long run.

Concern #6: Other acute therapists don’t have any training/knowledge around postpartum

Discussion:

Pregnancy/postpartum is not a standard part of PT/OT education in most schools and/or what is covered is very basic/short. Therapists come out of PT/OT school with real knowledge/skill deficits in this population that need to be filled for them to provide safe, quality care to this population.

Short Term Solutions:

1) In-services for your department on pregnancy/postpartum care.

a. Emphasize that pregnancy is actually a MASSIVE multi organ system event so seeing these patients requires a vast amount of PT/OT knowledge across many systems/domains.

c. Explain how postpartum patients fit into different Evaluation complexity levels as opposed to being only a screen.

2) Offer to let other therapist shadow you so they can see that a quality postpartum session isn’t just walking around at SBA/Independent level and then DCing from services.

3) Recommend quality continuing education courses your colleagues can take to get up to speed.

4) Partnering with an outpatient pelvic trained PT/OT to float to the hospital/be PRN to provide additional support/mentorship to therapy department.

Long Term Solutions:

1) Education at PT/OT schools on postpartum care

a. Be a guest speaker at a local school

b. Present at local/national conferences that tend to have high student & professor attendance

2) Recruiting students that want to/are asking for this population so your director is hearing from therapy schools that their students want somewhere offering postpartum experience.

Erin Locati

ADDRESSING PUSH BACK TO Obstetric Physical & OccupaTional Therapy

ABUNDANCE PELVIC HEALTH PLLC