Open Book


Using Claims Data to Identify Risks in PT Practice

Claims data can help point regulators to risk areas, thereby guiding regulators in creating more effective support systems to promote public protection. This article is based on an INPTRA webinar presented by Natalie Beswetherick and Jennifer Flynn.


Physical therapy regulators should have a heightened interest in risks and supports for practitioners. Health insurance malpractice information is a rich source of information to identify risks to safe and effective practice. Here we explore data from the United Kingdom and the United States to improve our understanding of these risks.

United Kingdom Claims Studies

Natalie Beswetherick
By bringing together two claims data studies from the United Kingdom, we can get enhanced insight into risks. One study focused on claims made against self-employed PTs. The other study focused on claims made against National Health Service (NHS) physiotherapists who have misdiagnosed Cauda Equina Syndrome.

Claims against Self-Employed PTs

This study analyzed data from 2001 to 2016 while excluding any items of public liability, employer liability, and fitness to practice claims. While claims have increased year-over-year, in more recent years, claims have been more steady.

  • 682 claims over fifteen years
    • Cases rose from seventeen claims in 2001/2002 to sixty-six claims in 2015/2016
  • Spike in 2008/2009   
  • 52% against males and 48% against females

Pattern of Claims Notified over Fifteen Years

The study included five main categories of claims. Most of the claims concerned generic types of treatment, followed by misdiagnoses. This distribution of types of claims remained relatively consistent over the fifteen years of the study.

  • Negligent treatment (n=263)
  • Misdiagnosis (n=124)
  • Negligent manual therapy (n=121)
  • Negligent exercise therapy (n=56)
  • Electrotherapy burns (n=55)

Digging deeper, which categories have the greatest risk? The greatest risk in the United Kingdom is misdiagnoses. When we zero in on misdiagnoses, we see a range of conditions:

  • 30 fractures
  • 30 not specified
  • 10 Cauda Equina Syndrome (5 in just the last year of the study)
  • 8 tendo-achilles ruptures
  • 7 disc prolapse
  • 7 osteosarcomas

The biggest risk is misdiagnosing Cauda Equina Syndrome, as this misdiagnosis usually results in catastrophic and life-changing effects for the patient. If not diagnosed properly and treated as the emergency that it is, Cauda Equina Syndrome can lead to incontinence and permanent paralysis. Given this, it is not surprising that this misdiagnosis also has the largest claims amount.

Claims against NHS PTs Who Misdiagnosed Cauda Equina Syndrome

Because of the high risk involved in misdiagnosing Cauda Equina Syndrome, we decided to examine this condition specifically across NHS physiotherapists. The NHS Resolution supplied ten years of claims that were closed or settled for us to examine.
There were 119 cases involving Cauda Equina Syndrome misdiagnosis, of which 96% were doctors and 4% were physiotherapists. Most of the doctors were general practitioners and were usually on call instead of with their normal patient cohorts. Therefore, we should also consider that as a risk factor.
Unfortunately, the comparison with the previous findings examining the prevalence of this issue in the private sector was not possible as they covered different time periods and different coverage types. However, it is interesting to note that claims against NHS physiotherapists were very low, at only five cases over the ten-year period, which helps us assess that risk among that population.

United States HPSO Claims

Jennifer Flynn

Healthcare Providers Service Organization (HPSO) provides malpractice insurance to individual PTs and PTAs, as well as PT Private Practices. We can gather insight into risks by examining the most recent claims report, which covers January 1, 2010, to December 31, 2014.
There are three areas of focus in the report:

  • Part 1: Malpractice Closed Claims (Study)
    • Analysis of Professional Liability/Malpractice Closed Claims
    • Quantitative Analysis
    • 443 closed claims
    • Standard of Care
  • Part 2: Disciplinary Defense Paid Claims
    • Analysis of state board complaints against a PT/PTA’s license
    • Quantitative Analysis
    • 144 complaints
    • May or may not be related to clinical care
  • Part 3: Work Profile (survey)
    • Highlights from the 2015 work profile survey
    • PT/PTA HPSO policy holders (both with and without claims)
    • Quantitative Analysis

Malpractice Closed Claims (Study)

We only looked at claims that cost at least $10,000 or above because it gave us more detailed insight into the actions and treatment of care that lead to patient injuries. This data highlighted where those deviations from the standard of care occurred. We had 443 closed claims and paid out $42 million. On average we paid $119,000: $95,000 to resolve the claim and an additional $24,000 to defend the claim. We had 447 claims in the previous ten-year study, versus 443 claims in the more recent five-year study, which shows an increase in both claims and severity.
The majority of PTs (84%) were in a PT office or clinic. The next highest location was the patient home (7.5%). The severity of the allegation ranged across the board, but 80% of claims fell into four areas. Therefore, focusing risk management efforts in these areas may be helpful.

  • Improper performance using a therapeutic exercise (18.9%)
  • Failure to Monitor (19.2%)
  • Improper management over the course of treatment (20.7%)
  • Improper performance using a biophysical agent (19.8%)

Biophysical agents include electrotherapy, heat therapy, and cold packs. One example involves a 25-year-old male patient who had a history of diabetic neuropathy of his lower extremities. He was undergoing heath therapy and he got a burn. It resulted in gangrene and he had to undergo several surgical procedures to address the issue. In the end, his right toe was amputated.
The patient sued the PT for not only pain and suffering but also loss of wages. In this case, there was also a lack of informed consent and documentation. Additionally, the PT ignored the diabetic foot precautions. Therefore, this claim became very difficult to defend.

Disciplinary Defense Paid Claims

We also pay defense costs when a PT or PTA goes before their jurisdictional board. In these cases, some allegations relate to clinical treatment, but others relate to inappropriate behavior or fraudulent billing. For example, the claimant charged the PT with putting time into the patient’s record when the PT did not perform those activities or maybe the PT even charged for a session they did not actually hold.

Board Outcomes


Work Profile

For our qualitative survey, we examined the difference in groups of PTs and PTAs who have had claims made against them and PTs and PTAs who have no claims. We used the following criteria to make up the claims group:

  • Claim was against a PT or PTA
  • Claim closed between January 1, 2010, and December 31, 2014
  • Claim indemnity payment was more than or equal to $1.00

There were some interesting trends. For example, gender was an indicator for a claim—more claims are experienced by male PTs. Age was another indicator—the majority who experienced a claim were 41 years old or older. Additionally, practitioners with 11 years or more experience were more likely to experience a claim.

Why do experience and age seem to be indicators? Perhaps, due to experience, practitioners are seeing more patients, seeing acute care patients, or mentoring other PTs and PTAs.

However, interestingly, the amount of patients a PT sees in a day did not tend to be an indicator. On average, respondents who treated six to ten patients a day were more likely to experience a claim. The highest indemnity was actually associated with those who saw three to five patients in a day. Additionally, having a supervisory role was not an indicator.

When we put some of these factors together, we start to see a clearer picture of risks. The data suggests risk is not associated with the overstretched PT—the PT with a high patient workload and supervisory responsibilities—the risk is inherent in the typical workday.

Additional takeaways help us see the practices that reduce risk. For example, an established process for peer review decreased the likelihood of a claim occurring. Additionally, not attending a quality risk management program recently not only put PTs at more risk for experiencing a claim, it also correlated with a higher paid indemnity.

Therefore, what recommendations can we make to increase a positive outcome for patients and reduce the likelihood of a claim? Consistent practices can be very helpful, for example, consistent policies and procedures for handling diabetic patients or specific injuries. Additionally, a good risk management program is vital, as is communications, proper and full assessment, and relating key changes to physicians.

While these may seem like obvious steps, these best practices are not always consistently applied. Often, as we look into these issues surrounding a claim, these simple steps were not done consistently across the organization or, in some cases, they were not done at all. Therefore, consistent enforcement of best practices can help reduce risk and protect the public.




Jennifer Flynn, CPHRM, is Risk Manager for >Healthcare Providers Service Organization in the Healthcare Division of Aon’s Affinity Insurance Services, Inc. Specializing in risk management and having worked in the health care insurance business for over nineteen years, Jennifer is dedicated to educating health care professionals on professional liability risks and offers strategies to mitigate those risks by supporting patient safety principles and developing quality management programs. In addition to being a frequent national speaker on health care risk and liability, Jennifer is also a published author on various risk management topics. Jennifer is a Certified Professional in Healthcare Risk Management and is a licensed Property & Casualty agent. She earned a BA in Psychology from Arcadia University in Glenside, Pennsylvania.


Natalie Beswetherick is Director of Practice & Development at the Chartered Society of Physiotherapy (CSP). Her directorate provides expert advice and services to members and external stakeholders covering the breadth of practice of the profession including research, education, and clinical practice. Her areas of current research interest are learning from medical malpractice claims against physiotherapists in the UK, to reduce risk of future claims. She has specifically researched claims of mid- diagnosis of CES by physiotherapists in the public and private health sectors.