ATHLETIC TRAINERS’ PERCEPTIONS OF THIRD-PARTY REIMBURSEMENT
IN THE COMMONWEALTH OF PENNSYLVANIA

A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science

By
Erin Leaver

Research Advisor, Dr. Jodi Dusi
California, Pennsylvania
2014

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ACKNOWLEDGMENTS

I would like to take a moment to thank everyone who
helped me along the way with my research, whether through
editing, reviewing, or simply motivating me to keep my nose
to the grindstone. To all of my fellow graduate assistants,
thank you for being a welcome distraction and most of all
for being great friends. To my family, thank for listening
and nodding your heads when I discussed my work, even if
you had only a small clue of what it was I was talking
about. To my committee members, Dr. West and Dr. Meyer,
thank you for sticking by me even in the throes of zero
motivation and procrastination, with the biggest thank you
of all going to my advisor Dr. Dusi. You were always
interested, engaged, and optimistic, and I thank you for
sticking with me even as I took far too long to complete my
work. The support all of you have given to me is
immeasurable.

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TABLE OF CONTENTS
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SIGNATURE PAGE

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AKNOWLEDGEMENTS .

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TABLE OF CONTENTS

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LIST OF TABLES

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LIST OF FIGURES .

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INTRODUCTION .

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METHODS .

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Research Design .

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Subjects

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Instruments

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Procedures .

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Hypotheses .

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Demographic Data .

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Hypothesis Testing .

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Additional Findings .

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Discussion of Results .

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Conclusions

Data Analysis
RESULTS .

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DISCUSSION .

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Recommendations .

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REFERENCES .

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APPENDICES .

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APPENDIX A: Review of Literature .

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Third-Party Reimbursement in Athletic Training .

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Third-Party Reimbursement in Physical Therapy .

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Evidence Based Practice .

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Barriers to Implementation .

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Summary .

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APPENDIX B: The Problem .

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Statement of the Problem .

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Basic Assumptions and Limitations. .

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Delimitations of the Study

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Significance of the Study .

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IRB: California University of Pennsylvania (C2) .

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APPENDIX C: Additional Methods
Cover Letter (C1) .

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Athletic Trainers’ Perceptions of Third-Party
Reimbursement Survey (C3) .

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References (C4)
ABSTRACT .

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LIST OF TABLES

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Table

Title

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Subjects’ Job Setting .

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Subjects’ Years Work Experience

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Additional Credentials of Subjects .

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Barriers to Implementing Third-Party
Reimbursement .

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Perceived Education of Subjects

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LIST OF FIGURES

Figure

Title

1

Components of the Perception of Third-Party
Reimbursement Survey Listed by Study Aim . .

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1

Introduction

The aims of this study are to: 1. determine the
prevalence of third-party reimbursement of certified
athletic trainers (ATCs) in the state of Pennsylvania; 2.
describe the opinions of ATCs in the state of Pennsylvania
regarding the value of third-party reimbursement; 3.
describe the opinions of ATCs on perceived knowledge of
third-party reimbursement; and 4. identify the barriers
preventing ATCs from receiving third-party reimbursement in
Pennsylvania. Gaining a further understanding of what
athletic trainers have experienced and understand about
third-party reimbursement will help to direct the
profession and professional athletic training organizations
toward appropriate action as well as shed light on how to
best implement reimbursement for athletic trainers.
Third-party reimbursement occurs when an outside
party, such as an insurance company, pays for services
rendered to a patient.1 This form of payment is commonplace
within the medical community, and insurance companies in
the United States are thriving businesses. Insurance
companies come in many forms as well, with many being

2
private companies, such as Health Maintenance Organizations
(HMOs) or Preferred Provider Organizations (PPOs), in
addition to those run by the government, such as Medicaid
and Medicare. In order to receive reimbursement from either
the private or public insurance companies, it is essential
for practitioners to have National Provider Identifier
(NPI) numbers, because having such will increase the
likelihood of receiving payment.2 In addition to this, being
able to show “medical necessity” or having a physician
referral will increase the likelihood of third-party
reimbursement.2
The history of reimbursement in the athletic training
profession begins in the 1990’s, when the National Athletic
Trainers’ Association (NATA) began to see the important
role reimbursement could play. The NATA created the
Reimbursement Advisory Group (RAG) to approach third-party
payers, in the pursuit of reimbursement for the profession.
The RAG worked to create committees at the state level, and
exists today as the NATA Committee on Revenue, working to
create healthcare reimbursement models for athletic
trainers in many different settings.3
In order to get a good grasp on where the athletic
training profession stands in regard to reimbursement,
literature pertaining to third-party reimbursement in

3
physical therapy was gathered and reviewed. One article,
authored by Dode Jackson, a long time American Physical
Therapists Association (APTA) member, discussed the
political lobbying and funding that it took to make
significant strides in reimbursement.4 Similar to the issues
that athletic trainers have faced, many physical therapists
(PTs) have struggled to receive reimbursement without
physician referral, leading them to question how they are
viewed by third-party payers as diagnosticians.5-7 Although
the two professions show many similarities, and in many
ways athletic training is following physical therapy’s road
to reimbursement, the literature also shows that the
relationship between the two has been volatile, especially
in regard to reimbursement. In February of 2008 the NATA
filed suit against the APTA about coding used by insurers
and clinicians. In the suit the NATA claimed that the APTA
was “manipulating the Coders’ Desk Reference for Procedures
to favor PTs and their practice.”8 The suit was settled out
of court, but illustrates some of the adversity that the
NATA and athletic trainers face in the insurance market.
Another important factor to be considered in this
research was the relevance of evidence based practice to
third-party reimbursement. The connection between these two
factors was evident throughout the literature. Hertel,

4
professor and certified athletic trainer (ATC) from the
University of Virginia, states in his editorial “Research
Training for Clinicians: The Crucial Link Between EvidenceBased Practice and Third-Party Reimbursement,” stating
“Third-party reimbursement is a challenge facing athletic
trainers in numerous practice settings. The stark reality
is that without documented evidence showing the
effectiveness of clinical interventions rendered by ATCs,
reimbursement is a pipe dream.”9 In another article, Stevens
and Hootman stated that: “As more athletic trainers bill
third parties for their services, those third-party payers
will require evidence that the interventions are effective.
Reimbursement may be difficult or impossible to obtain for
those procedures not shown to be effective.”10 The
correlation between the two topics, evidence based medicine
and third-party reimbursement, is shown to be strong in the
literature, and in addition to this, the literature shows
that the athletic training profession is lagging behind
many others in the medical field when it comes to evidence
based practice.11
It is also important to understand the barriers that
are keeping many athletic trainers from pursuing thirdparty reimbursement. The literature on this specific topic
was found to be scarce, but did discuss some issues. One

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study by McPherson approached collegiate athletic trainers.
This particular study revealed that some athletic trainers
felt that, while beneficial to the profession, third-party
reimbursement would not benefit a collegiate athletic
trainer. This same study noted some hesitance to charge for
a service not previously charged for.12 Literature also
exists which discusses a lack of education preventing
athletic trainers from pursuing reimbursement, specifically
a lack of education or training at the undergraduate
level.13
Keeping in mind what the literature presented, the
focus of this study took shape. A survey was developed to
send to athletic trainers in the state of Pennsylvania,
with the goal of determining the prevalence of third-party
reimbursement of ATCs in the state of Pennsylvania, the
opinions of ATCs in the state of Pennsylvania regarding the
value of third-party, their perceived knowledge of thirdparty reimbursement, and the barriers preventing ATCs from
receiving third-party reimbursement in Pennsylvania.

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METHODS

The aims of this study are to: 1. determine the
prevalence of third-party reimbursement of certified
athletic trainers (ATCs) in the state of Pennsylvania; 2.
describe the opinions of ATCs in the state of Pennsylvania
regarding the value of third-party reimbursement; 3.
describe the opinions of ATCs in Pennsylvania in regard to
their perceived knowledge of third-party reimbursement; and
4. identify the barriers preventing ATCs from receiving
third-party reimbursement in Pennsylvania. This section
will include subsections of: Research Design, Subjects,
Instruments, Procedures, Hypothesis, and Data Analysis.

Research Design

This research project is a descriptive study exploring
the prevalence of third-party reimbursement in Pennsylvania
and the opinions of certified athletic trainers in the
state in regard to the value of, perceived knowledge of,
and barriers of implementing third-party reimbursement.

As

this is an exploratory study, there is no dependant
variable in the study. Subjects were asked to complete the
instrument, the Perceptions of Third-Party Reimbursement

7
survey. The seventeen-item questionnaire was developed with
the help of a similar survey acquired from the Wisconsin
Athletic Trainer’s Association and with their permission.

Subjects

The subjects of the study are certified athletic
trainers in the state of Pennsylvania that are members of
the National Athletic Trainers’ Association (NATA). There
are 1,632 ATCs in the state of Pennsylvania that are
members of the NATA. The survey was distributed to each
subject via the NATA database, taking into account the
necessary parameters requested by the researcher. Subjects
had to be a certified athletic trainer and a member of the
Pennsylvania Athletic Trainers’ Society (PATS). The survey
was sent to the subjects from the NATA via email and
completed online using SurveyMonkey.

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Instruments

The Perception of Third-Party Reimbursement Survey
(Appendix C) was created by the researcher to assess the
usage of, opinions of, and perceived knowledge of thirdparty reimbursement of ATCs practicing in PA. Additionally,
the survey asks subjects to identify barriers of
implementing third-party reimbursement. The survey consists
of seventeen questions. There are four demographic
questions, including job setting, years as a certified
athletic trainer, years of practice in the state of
Pennsylvania, and other credentials possessed, which was
used by the researcher to classify the subjects, in
addition to perception/opinion questions, and knowledge
questions. The survey is modeled after the Third-Party
Reimbursement and Strategic Planning Survey developed by
the Wisconsin Athletic Trainers Association, and also used
by Indiana Athletic Trainers Association. However, the
researcher modified some specific questions used in the
original survey to make them more applicable to the purpose
of this particular study. In order to assure content
validity, the survey was reviewed and modified by three
experts, three professors from California University of
Pennsylvania, in the field of athletic training. The survey

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consists of open-ended and close-ended questions, in
addition to using a 1-5 confidence rating scale to
determine each participant’s perceived knowledge of
particular aspects of third-party reimbursement. To assess
the prevalence of third-party reimbursement in
Pennsylvania, there are multiple items on the
questionnaire, which asked the subject if he/she utilizes
third-party reimbursement and in what setting. Subsequent
questions address the opinions of ATCs regarding
reimbursement and ask subjects to identify barriers
preventing ATCs from receiving third-party reimbursement.
See Figure 1 for more detail on the components of the
study.

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Figure 1. Components of the Perception of Third-Party Reimbursement Survey listed by
study aim
Prevalence of thirdparty reimbursement

Item #1. Do you have
an NPI number?
Please check “No” if
unsure. **

Item #2. Does your
employer bill for
services that you
provide (CPT series
97000)? **

Opinions of ATCs in
the state of PA
regarding value of
third-party
reimbursement
Item #4. Do you
currently utilize
evidence based
medicine in your
practice? (Such as
implementing
research based care
in your practice.)

Barriers to pursuing
third-party
reimbursement

Perceived knowledge
of third-party
reimbursement

Item #8. What
factors do you
believe negatively
influence athletic
trainers seeking
third-party
reimbursement?
Please check all
that apply. (List
provided)

Item #10. Have you
ever attended or
participated in
workshops or
supplemental
training pertaining
to third-party
reimbursement?

Item #5. If you do
provide medical and
rehabilitative
services, but do not
currently bill for
them, is this
something that you
are interested in
pursuing? **

Item #9. (Likert
Scale) I feel that
my academic training
(didactic or
internship) has
adequately prepared
me to implement
third-party
reimbursement.

Item #11. (Likert
Scale) I feel
comfortable with my
overall knowledge of
third-party
reimbursement.

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Item #3. Do you bill
under the direct
supervision of a
physical therapist?
**

Item #6. Do you
support athletic
trainers pursuing
third-party
reimbursement?
Please explain. **

Item #12. (Likert
Scale) I feel the
need to attend
future workshops or
supplemental
training sessions
regarding thirdparty reimbursement.

Item #7. In what
ways do you see
third-party
reimbursement
helping the athletic
training profession,
if any?

Item #9B. (Likert
Scale) I feel that
my academic training
(didactic or
internship) has
adequately prepared
me to implement
third-party
reimbursement.

**=Indicates that question had been modified from the Wisconsin Athletic Trainers
Association’s Third-Party Reimbursement survey.

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Procedures

The researcher obtained Institutional Review Board
(IRB) approval at California University of Pennsylvania
before beginning any data collection or distribution of
surveys. The researcher then completed the Research Survey
Request Form on the NATA website to obtain their approval
to distribute the survey. After obtaining approval, the
researcher requested that the NATA distribute the survey to
qualifying NATA members via email. Each subject was asked
via an attached cover letter (Appendix C1) to participate
in the study by completing the online survey to assess
their use of third-party reimbursement as an ATC, his/her
opinion regarding the value of third-party reimbursement to
his/her personal practice, patient quality of care, and
profession of athletic training in addition to his/her
perceived knowledge of third-party reimbursement.

Subjects

also were asked to identify barriers they feel hinder the
implementation of third-party reimbursement. Subjects were
assured, via the cover letter, that their participation was
completely voluntary, that they could remove themselves
from participation at any point in the process, and that

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consent was implied if they chose to complete the survey.
Demographic data were collected in regard to the job
setting, with choices including: high school or clinical
outreach, college in athletic or academic setting, clinical
such as a physician extender, industrial, or others. Other
demographic data collected included years of experience as
an ATC and years of experience in the state of
Pennsylvania. All surveys were completed anonymously and
each participant’s identity remained confidential.
The email to prospective participants included mention
of IRB approval and the cover letter outlining voluntary
participation and implied consent. The NATA then emailed
the survey a total of two times to every participant over a
two week period. Following this two week period the survey
link was deactivated and submissions were no longer
accepted. The survey data were kept anonymous and
confidential. The data from the responses were then
collected and entered into an electronic spreadsheet. The
data were then analyzed and organized by demographic
classification.

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Hypotheses

The following are hypotheses of the researcher based
on existing literature and experience in the field of
athletic training.
1. Athletic trainers will support and value the
implementation of third-party reimbursement in the
profession, depending on setting.
2. Athletic trainers will endorse the following barriers
to implementation of third-party reimbursement:
ethical issues based on history without payment,
complication of insurance paperwork, and the time
commitment in setting up a reimbursement program.
3. There will be a lack of understanding about thirdparty reimbursement among athletic trainers.

Data Analysis

Statistical analysis was completed using a
commercially available software package (SPSS version;
Chicago, IL) and the data were analyzed using descriptive
statistics. Data collection for the demographic questions
regarding years experience in athletic training, job
setting, as well as other close-ended questions regarding

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the use of third-party reimbursement, were evaluated using
frequency counts. Qualitative analysis was performed on the
data collected from open-ended questions, utilizing the
grounded theory approach to look for common themes among
the answers. Finally, a Likert scale from 1-5 was used to
assess each individual respondent’s agreement to statements
relating to the respondent’s perceived knowledge of thirdparty reimbursement. For example, the respondent was
presented with the statement “Do you feel that you have a
good understanding of CPT coding” and asked to rate his/her
agreement with the statement on a scale of 1 to 5 with 1
indicating “strongly agree” and 5 indicating “strongly
disagree.”

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RESULTS

The following section is comprised of the information
gathered through data collection and analysis of the
Athletic Trainers’ Perceptions of Third-Party Reimbursement
Survey. This section will include three subsections:
demographic data, hypothesis testing, and additional
findings.

Demographic Data

The survey included four questions in regard to
demographic data about the subjects. These questions were
included to analyze the potential variance in opinion based
on things such as job setting, years of experience, and
other credentials held. Frequency counts were used to
summarize the data for job setting, years as a certified
athletic trainer, and years as a licensed athletic trainer
in the state of Pennsylvania. The survey was distributed to
1,000 certified athletic trainers in Pennsylvania, with a
return of 165, for a return rate of 16.5%.

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Table 1, shown below, lists the frequency counts for
subject’s job setting, listed by both the number of
subjects and the percentage of the total who responded to
each setting listed.

Table 1. Job Setting of Subjects
Setting

Number

Percentage(%)

High School

29

17.6

Clinical Outreach at
High School

43

26.1

College, Athletic Only

43

26.1

College, Athletic and
Academic

10

6.1

College, Academic only

9

5.5

Clinic

18

10.9

Industrial

1

.6

Other

12

7.3

Table 2, listed below, displays the frequency of
subjects by both years as a certified athletic trainer and
years licensed to practice in the state of Pennsylvania.

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Table 2. Years of Experience an ATC
Range in Years

Certified (%)

Licensed PA(%)

<1

1 (.6%)

4 (2.4%)

1-5

39 (23.6%)

50 (30.3%)

6-10

31 (18.8%)

32 (19.4%)

11-15

26 (15.8%)

24 (14.5%)

16-20

17 (10.3%)

14 (8.5%)

21-25

26 (15.8%)

20 (12.1%)

26-30

10 (61.5)

13 (17.9%)

31-35

9 (5.5%)

4 (2.4%)

36-40

4 (2.4%)

3 (1.8%)

40+

2 (1.2%)

1 (.6%)

Frequency counts were also calculated on the data
pertaining to additional credentials held by the subjects.
The question in the survey listed Physical Therapist (PT),
Doctor of Physical Therapy (DPT), Physical Therapist
Assistant (PTA), Occupational Therapist (OT), Medical
Doctor (MD), Doctor of Osteopathic Medicine (DO), Certified
Strength and Conditioning Specialist (CSCS), Performance
Enhancement Specialist (PES), Emergency Medical Technician
(EMT), Certified Orthopedic Technologist (OTC), and Doctor

19
of Chiropractic Medicine (DC), as well as an option for “No
others” and “other (please specify)”. The responses are
displayed Table 3 below.
Table 3. Additional Credentials of Subjects
Credential
Physical Therapist (PT)
Certified Strength and Conditioning Coach
(CSCS)
Performance Enhancement Specialist (PES)

Number
3
20
39

Emergency Medical Technician (EMT)

7

Certified Orthopaedic Technologist (OTC)

4

Doctor of Chiropractic Medicine (DC)

1

Corrective Exercise Specialist (CES)

13

Certified Personal Trainer (CPT)

6

Master of Science (MS)

3

Doctor of Philosophy (PhD)

3

Certified Kinesiotape Practitioner (CKTP)

3

Others (EdD, RMSK, NASE, MHA, ITAT, SFMA,
HKC, PMP, RN, FMS, Med, OBT, SNS, ROT,
Massage, TPI, PA teaching cert)

19

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Hypothesis Testing

The following hypotheses were investigated in this
study:
Hypothesis 1: Athletic trainers will support and value
the implementation of third-party reimbursement in the
profession, depending on setting.
Results: In response to the question “Do you support
athletic trainers pursuing third-party reimbursement for
services provided,” 93.3% (154/165) of subjects said “Yes”,
with 11 subjects, or 6.7%, responding “No”. Of those 11
subjects who responded “no”, there were four in the high
school setting, three in the collegiate athletic setting,
and four in the clinical setting. This data does not
indicate a trend between job setting and the value of
third-party reimbursement in the athletic training
profession.
The subjects were also asked if they would like to
pursue third-party reimbursement in their own practice, to
which 54.5% said “Yes” and 6.7% said that they currently
billed for services they provide.
Conclusion: There were a large number (93.3%) of
athletic trainers who support the pursuit of third-party

21
reimbursement in athletic training, regardless of job
setting.
Hypothesis 2: Athletic trainers will endorse the
following barriers to implementation of third-party
reimbursement: ethical issues based on history without
payment, complication of insurance paperwork, and the time
commitment in setting up a reimbursement program.
Results: Each subject was asked to check off all
barriers that he or she felt were preventing athletic
trainers from pursuing third-party reimbursement, with the
following as options: Ethical Issues (regarding charging
for services not previously charged for), Time Commitment
to Implement, Difficulty of Paperwork and Insurance Related
Work, Lack of Education on Third-Party Reimbursement,
Disparity in Evidence Based Practice Compared to Other
Professions, The Perception of No Benefit to Athletic
Trainers, and an option to list other barriers. Subjects
were free to check off as many as they felt applied. Table
4 lists the results from this question.

22
Table 4. Barriers to the Implementation of Third-Party
Reimbursement
Barrier
Number (#) Percentage (%)
Ethical Issues

41

24.8%

Time Commitment

75

45.5%

Difficult Paperwork

94

60.0%

Lack of Education

116

70.3%

Lack of EBP

33

20.0%

Perceived No Benefit

64

38.8%

There were multiple themes found among the additional
barriers that subjects listed, such as issues with other
professions (such as Physical Therapists, Occupational
Therapists, or Physical Therapist Assistants), difficulty
receiving payment from insurers, and a lack of
administrative support. In regard to issues with other
professions, one subject said “The PTs (Physical
Therapists) don’t want ATs (Athletic Trainers) to get
third-party reimbursement,” while others cited the American
Physical Therapists’ Association (APTA) as a potential road
block. Also found in an open-ended response was this quote
in regard to potential difficulty in receiving payment from
insurers: “Insurance companies haven't paid for athletic
training services in the past, why would they do so in the

23
future when all they do is cut and deny other established
(sic) Health Care providers…(such as) PT, OT, (and) ST.”
Other subjects commented the following in regard to
difficulties with administrative support: “(There would be)
staffing limitations to enact the billing process,” and
“(There would be) a lack of administrative support to
conduct billing.”
Comments in regard to other professions were made by
seven, or 4.2%, of the subjects, while comments in regard
to receiving payment from insurers were made by seven, or
4.2%, of subjects, and comments in regard to administrative
support were made by five, or 3.0%, of subjects.
Conclusions: Athletic trainers do endorse ethical issues,
difficulty of paperwork, and time commitment as barriers to
the implementation of third-party reimbursement. However
they do not view these as the most influential barriers.
Instead, the most common barrier endorsed by nearly 71% of
participants was “lack of education”.
Hypothesis 3: There will be a lack of understanding
about third-party reimbursement among athletic trainers.
Results: As listed in Table 4 above, lack of education
returned the most commonly selected response to the
question of “What factors do you believe negatively
influence athletic trainers seeking third-party

24
reimbursement?” Subjects were also asked if they had
attended any workshops or supplemental training in regard
to third-party reimbursement, to which 25.5% of the
subjects said “Yes.” In addition, there were multiple
questions in regard to each subject’s comfort with thirdparty reimbursement. Table 5 details the data pertaining to
three Likert scale questions posed to the subjects. These
questions asked each subject about their comfort with their
overall knowledge of third-party reimbursement, if they
felt the need to attend future workshops or training
sessions, and if they felt their academic training
adequately prepared them to implement third-party
reimbursement. These questions were answered on a 1-5
scale, with 1 being “strongly agree”, 2 being “agree”, 3
being “neutral”, 4 being “disagree”, and 5 being “strongly
disagree.”

25
Table 5. Perceived Education of Subjects
Statement

Mean
Std
(n=165) Deviation
3.02
1.076

“I feel comfortable with my overall
knowledge of third-party reimbursement.”
“I feel the need to attend future
2.23
.874
workshops(…)regarding third-party
reimbursement.”
“I feel that my academic training (…)has 3.61
1.057
adequately prepared me to implement
third-party reimbursement in my
practice.”
**5=Strongly Disagree, 4=Disagree, 3=Neutral, 2=Agree,
1=Strongly Disagree
Conclusions: Although this survey did not test the

knowledge or understanding of athletic trainers in regard
to third-party reimbursement, it did ask athletic trainers
about their perceived knowledge and comfort with athletic
training reimbursement as well as their opinion on the
knowledge of reimbursement of other athletic trainers. The
survey found a perceived lack of understanding among
athletic trainers, as noted in 70.3% of the subjects
questioned endorsed lack of education as a barrier to
implementing third-party reimbursement. However, subjects
were in general relatively “neutral” in their selfperception of knowledge regarding third-party
reimbursement.

26

Additional Findings

The first study aim was to determine the prevalence of
third-party reimbursement in the state of Pennsylvania.
Most of the respondents, 71.5%, or 118 of 165, had their
National Provider Identifier number (NPI), with 4.2%, or 7
of 165, of the subjects being unsure of whether or not they
possessed an NPI.
To further assess prevalence, respondents were asked
if they billed for athletic training services. The data
showed 7.9%, or 13 of 165, of athletic trainers questioned
billed or worked for an employer that billed under the
97000 CPT code series, which is the code series reserved
for athletic training services. Additionally, 4.8% of
subjects questioned said they or their employer billed
under the supervision of a physical therapist.
In addition to assessing participants opinions on the
value of third-party reimbursement on an individual level,
respondents were also asked an open-ended question of “What
ways do you see reimbursement helping the profession?”
There were two very common responses to this question
including an increased value to employers and an increased
value within the medical community, with 21 subjects citing

27
both in their responses. Things which the researcher
considered to fall under “increased value to employers”
were: increased salary, increased budgets, better hours,
and decreased workload. Things which the researcher
considered to fall under “increased value within the
medical community” included: more credibility, more respect
from PTs and MDs, being recognized as professionals, and
awareness for what an athletic trainer is and does. Other
responses to this question included: increased job
opportunity, increased documentation and outcome based
care, and more athletic trainers staying in the profession.
Finally, because of the intimate connection between
third-party reimbursement and evidence-based medicine,911,13,17-19

participants were also asked if they used evidence-

based medicine in their practice. Most of the participants
(83%) reported currently utilizing evidence based medicine
(EBM) in their practice, with 6.7%, or (10/165), of
subjects listing that they were unsure if they used
evidence based medicine in their practice.

28

DISCUSSION

The overall purpose of this study was to determine the
perceptions of Certified Athletic Trainers’ in Pennsylvania
in regard to third-party reimbursement in the athletic
training profession. Third-party reimbursement is currently
up for debate within the profession. Reimbursement is a
relatively new topic, and as such there a lack of
literature and existing research. Keeping this in mind the
researcher felt that expanding the body of knowledge and
research on the topic would be beneficial to the profession
as a whole. This section will include three subsections:
discussion of results, conclusions, and recommendations.

Discussion of Results

This study found that athletic trainers in
Pennsylvania support and value third-party reimbursement in
the profession, as evidenced by 93.3% (154/165) of subjects
stating that they support athletic trainers pursuing thirdparty reimbursement. This result was not found to be
surprising, as the literature supports that there are many

29
benefits to third-party reimbursement in athletic training,
such as increased value of an athletic trainer,14
advancement of the profession in the medical community,15
and an increase in clinician accountability.10,13
Additionally, third-party reimbursement limits costs and
encourages more use of preventative care.16 Generalization
of results are limited due to the small return rate of
16.5% (165/1000). However, the results were similar to
those found by McPherson in the study entitled
“Intercollegiate Athletic Trainers’ Perception of ThirdParty Reimbursement and Their Steps Toward Its
Implementation.” In McPherson’s study, all nine, or 100%,
of subjects working in the collegiate setting agreed that
third-party reimbursement was of value to the athletic
training profession.12 In doing further analysis of the 11
(7%) of subjects-who did not support third-party
reimbursement for the profession, there were no observable
trends between reimbursement support and job setting or
years of experience. This was found to be somewhat
surprising, as the researcher felt prior to doing the study
that high school athletic trainers would be the most
opposed to third-party reimbursement. In the current study
the breakdown of the subjects who did not support
reimbursement by job setting was: 4 in the high school

30
setting, 3 in the college athletic setting, 3 in the
clinical setting, and 1 working as a physical therapist.
The majority of athletic trainers in Pennsylvania
indicated that they wanted to pursue reimbursement for
their own practice. Just over half of the subjects, 54.5%
(90/165), said that they would like to pursue reimbursement
in their own practice, with 6.7% of subjects already
billing. This 54.5% being compared to the 93.7% of subjects
who support the profession pursuing third-party
reimbursement leads to the question of what would keep the
rest of the respondents from pursuing third-party
reimbursement in their own practice.
Our second hypothesis acknowledges that previous
question by stating that the researchers feel athletic
trainers will support the following as barriers to
reimbursement: ethical issues, complication of insurance
paperwork, and time commitment. The results of our survey
found that all three of these barriers were endorsed by
athletic trainers; however, they were not the most commonly
selected response. The most commonly selected barrier was
“lack of education in regard to third-party reimbursement”,
with 70.3%, (116/165), of subjects selecting it as a
barrier. The researcher feels that there may be other
contributing factors to this high response rate, such as

31
the education level of the respondents and their years of
experience. The question, which asked subjects which
barriers they felt prevented the implementation of thirdparty reimbursement was further analyzed to see the years
experience in relation to whether or not the subject felt a
lack of education was a barrier. 70.3%, 116/165, of
subjects answered that they perceived a lack of education
to be a barrier to third-party reimbursement. The average
range of years of experience as a certified athletic
trainer of those subjects was 11-15 years, with a standard
deviation of 1.96 between ranges, which occurred in five
year increments. However, in the 29.7%, 49/165, of subjects
who did not list a lack of education as a barrier, the
average range of years of experience as a certified
athletic trainer was 16-20 years, with a standard deviation
of 2.22 between five year increment ranges. These average
years of experience ranges shows that those who did not
feel that a lack of education was a barrier were actually
slightly more experienced than those who did feel education
was a barrier. It is still possible that those who
graduated from their undergraduate school prior to the mid1990’s, when the NATA began pursuit of third-party
reimbursement,3 were not exposed to reimbursement during
their academic training. One respondent to the survey

32
backed this claim by stating, “My undergraduate and
graduate education fell well short of providing a base for
third-party reimbursement. My doctoral degree, which
focused on outcomes-based medicine, did. But I concede I am
older and the educational standards in the late 90's fell
way short of today's standard.” Also noted in our data was
that the mean response to the Likert scale statement of “I
feel my academic training (didactic or internship) has
adequately prepared me to implement third-party
reimbursement in my practice,” was 3.61 with a standard
deviation of 1.057. On a scale of 1-5, with one being
strongly agree and five being strongly disagree, the mean
response was between neutral and disagree. The researchers
also calculated frequency counts on this statement, finding
that 37.6%, or 62 of 165, of subjects answered “disagree”
and that 21.2%, or 35 of 165, of subjects answered
“strongly disagree”. The literature on the education
barrier was limited, although one article on the opinions
of athletic training educators did find that these
educators felt the need to educate students on evidence
based medicine tied in closely with the success of thirdparty reimbursement.17
What was a bit surprising in the data was the much
lower response for a disparity of evidence based medicine

33
in comparison to other professions as a barrier to thirdparty reimbursement. The data showed that only 20.0%
(33/165) of subjects endorsed a disparity of evidence based
medicine to be an issue in regard to reimbursement. In the
review of literature completed prior to sending out the
survey, this was the most consistently seen theme.9-11,13,15,1719

While 83.3% of respondents said they implemented evidence

based medicine in their practice, only 20.0% felt that a
lack of evidence based medicine prevented the
implementation of third-party reimbursement, contrary to
what was suggested in the literature. It is possible that
the subjects asked were not aware of the connections
between the two subjects that the literature found,
resulting in the lower level of support for a disparity of
evidence based practice as a barrier. Another slightly
surprising response was only 24.8% of respondents saying
they felt ethical issues were a barrier to implementing
third-party reimbursement. In the McPherson study, this was
listed by six of nine (66.7%) respondents as a barrier, and
the researcher expected similar responses in this study,
although it is noted that the McPherson study had a small
sample size.12
The third and final hypothesis made by the researcher
was that there would be a lack of understanding about

34
third-party reimbursement among athletic trainers. Upon
completing the data analysis the researcher concluded that
the survey did not accurately test the knowledge or
understanding of athletic trainers in regard to third-party
reimbursement. As noted previously, 70.3% of subjects
listed lack of education as a barrier to reimbursement, and
therefore perceive a lack of understanding among athletic
trainers’ in regard to third-party reimbursement, however
the survey did not test athletic trainers’ knowledge on
reimbursement.
One finding that the researcher believes to be
important in regard to the pursuit of third-party
reimbursement was that 71.5% of subjects questioned had
their National Provider Identifier number (NPI). This NPI
number is vital for anyone who wishes to bill for services
they provide, as it is required by insurers in order to
receive payment. The researcher feels that this is evidence
of the NATA’s involvement in educating their members on the
importance and value of third-party reimbursement and the
NATA’s encouragement of their members to pursue
reimbursement in their own practice. The data also found
that 25.5% of subjects had attended a workshop or
supplemental training in regard to third-party
reimbursement, which the researcher also feels is evidence

35
of the NATA and other professional athletic training
organizations stepping in to educate and encourage
participation in third-party reimbursement.

Conclusions

The results of the study revealed the following major
conclusions:
1. Ninety-three percent of athletic trainers in the
state of Pennsylvania support the profession
pursuing third-party reimbursement.
2. Seventy percent of athletic trainers in the state of
Pennsylvania endorse a lack of education on thirdparty reimbursement as the most common barrier to
its implementation. Other commonly identified
barriers include: complexity of insurance paperwork
and the time commitment to implement a reimbursement
program.
3. Athletic trainers in the state of Pennsylvania feel
that were not adequately prepared in their didactic
or internship related training to implement thirdparty reimbursement in their own practice, as
evidenced by a neutral to disagree level response to
the Likert scale question of their preparation.

36
4. We found that 7.9%, 13/165, of our sample currently
utilizes third-party reimbursement, using the 97000
series of codes.

Recommendations

The researchers feel that further research is
necessary both in the state of Pennsylvania and in other
states in order to gain a firm understanding of the
perceptions of third-party reimbursement among athletic
trainers. In addition, the researchers believe that there
is a need for education of athletic training students, both
at the undergraduate and graduate levels, about
reimbursement. In addition to this, workshops and
supplemental educational opportunities must continue to be
made available to athletic trainers to ensure that this
barrier is limited. The researchers believe that the
benefits to third-party reimbursement outweigh the
potential negative effects, and as such the profession
should continue to move forward in its pursuit. Continuing
to have open dialog among all athletic trainers, regardless
of years experience, age, or setting, is very important to
ensure that the profession and the professional
organizations, such as NATA, make choices that are best for

37
athletic training. The researchers also feel that opening
dialogue among athletic trainers and physical therapists
would be beneficial to the profession as well as those who
both professions care for.

38
REFERENCES
1.

Mosby. Mosby's Medical Dictionary. Mosby
Incorporated; 2012.

2.

Harrelson GL, Gardner G, Winterstein AP.
Administrative Topics in Athletic Training, Concepts
to Practice. SLACK Incorporated; 2009.

3.

National Athletic Trainers’ Association. Committee
on Revenue. National Athletic Trainers’ Association.
http://www.nata.org/COR. Published 2013. Accessed
September 22nd, 2013.

4.

Jackson D. Physical therapy under Medicare Part B:
how it all began. PT: Magazine of Physical Therapy
[serial online]. May 2004;12(5):48. Accessed August
5, 2013.

5.

About Physical Therapists. American Physical
Therapist Association Web Site.
http://www.moveforwardpt.com/WhyTherapy/AboutPTs/.
Accessed August 5, 2013.

6.

Mccallum CA, Diangelis T. Direct access: factors
that affect physical therapist practice in the state
of Ohio. Phys Ther. 2012;92(5):688-706.

7.

Davenport TE, Sebelski CA. The physical therapist as
a diagnostician: how do we, should we, and could we
use information about pathology in our practice?.
Phys Ther. 2011;91(11):1694-5.

8.

Herbert D. NATA Antitrust Suit Against APTA Settled.
Sports, Parks & Recreation Law Reporter [serial
online]. December 2009;23(3):33-40. Accessed August
5, 2013.

9.

Hertel J. Research Training for Clinicians: The
Crucial Link Between Evidence-Based Practice and
Third-Party Reimbursement. Journal Of Athletic
Training [serial online]. April 2005;40(2):69-70.
Accessed August 5, 2013.

10.

Stevens R, Hootman J. Evidence-based medicine: what
is it and how does it apply to athletic training?.

39
Journal Of Athletic Training [serial online]. 2004
Jan-Mar 2004;39(1):83-87. Accessed August 5, 2013.
11.

Tweed E, Sauers E, Ratner N, et al. Review for
librarians of evidence-based practice in nursing and
the allied health professions in the United States.
Journal Of The Medical Library Association [serial
online]. October 2007;95(4):394-407. Accessed August
5, 2013.

12.

McPherson B. Intercollegiate athletic trainer's
perception of third-party reimbursement and their
steps towards its implementation. [serial online].
1999; Accessed August 5, 2013.

13.

Parsons J. Reflections on a Season of Reform.
Athletic Therapy Today [serial online]. July
2010;15(4):1-3. Accessed August 5, 2013.

14.

Callahan E, Finkam S. A Case Study in Successful
Third-Party Reimbursement in Indiana. Athletic
Therapy Today [serial online]. July 2003;8(4):28-29.
Accessed August 5, 2013.

15.

Campbell D. Reimbursement For Athletic Trainers in
the Traditional Setting. College Athletic Trainers’
Society. 1996:1. Accessed August 5, 2013.

16.

Streator S, Buckley, W. Risk management in athletic
training. Athletic Therapy Today [serial online].
March 2001; 6(2): 55-59. Accessed August 5, 2013.

17.

Manspeaker S, Van Lunen B. Overcoming Barriers to
Implementation of Evidence-Based Practice Concepts
in Athletic Training Education: Perceptions of
Select Athletic Training Educators. Journal of
Athletic Training [serial online]. September
2011;46(5):514-522. Accessed August 5, 2013.

18.

Streator S, Buckley W. Clinical outcomes in sports
medicine. Athletic Therapy Today [serial online].
September 2000; 5(5):57-61. Accessed August 5, 2013.

19.

Ingersoll C. It’s Time for Evidence. Journal of
Athletic Training [serial online]. January
2006;41(1):7. Accessed August 5, 2013.

40

APPENDICES

41

APPENDIX A:
Review of Literature

42
REVIEW OF LITERATURE

The National Athletic Trainers’ Association (NATA)
defines athletic trainers as “health care professionals who
collaborate with physicians to optimize activity and
participation of patients and clients across age and care
continuums.”1 The Athletic Training profession has grown to
encompass many different employment settings, such as work
in an outpatient clinic; in a high school, collegiate, or
professional sport setting; work in the industrial setting;
as well as work in the military.2,3 At the core of it all, an
athletic trainer’s primary goal still remains the health
and well being of their athlete or patient. However, just
as every other profession, the overarching goal must be
professional success and growth. This type of professional
growth is achieved in part with respect from peer groups
and financial compensation. The average salary of an
athletic trainer according to the NATA Salary Survey was
$51, 483 in 2011, up from an average of $44, 335 in 2008,
which

included

those with bachelor’s, master’s and

doctoral degrees spread across the many different settings
for work.4 While salary has increased, the NATA and athletic
trainers continue to work toward gaining respect among our
peers, one of the biggest differences between athletic

43
trainers and similarly trained health care professionals
remains as third-party reimbursement.
The purpose of this literature review is to introduce
the topic of third-party reimbursement in athletic
training, discuss the importance of third-party
reimbursement in a similar health care profession, such as
Physical Therapy, show the connection between reimbursement
and evidenced based practice, and identify the barriers
that remain in the way of athletic trainers receiving
payment.

Third-Party Reimbursement in Athletic Training

Third-party reimbursement occurs when an outside
party, such as an insurance company, pays for services
rendered to a patient.5 This form of payment is commonplace
within the medical community, and insurance companies in
the United States are a thriving business. Insurance
companies come in many forms as well, with many being
private companies, such as Health Maintenance Organizations
(HMOs) or Preferred Provider Organizations (PPOs), in
addition to those run by the government, such as Medicaid
and Medicare. The private organizations tend to follow the
lead of the government bodies with regards to approving

44
care, and as such it is of the utmost importance at the
current time to have a National Provider Identifier (NPI)
number to receive reimbursement from both the government
and private insurers. Having this number does not ensure
payment from companies, but not having one will all but
guarantee no payment.6 In addition to this, the provider of
care must be deemed “capable” of providing appropriate
care, and “medical necessity” must be proven, often in the
form of a physician referral. Another important factor is
that the physician prescription should specifically state
the need for athletic training services, not physical
therapy, to increase the likelihood of approval.7
In the 1990’s the NATA saw the importance of
reimbursement in the profession, and by 1995 had created
the Reimbursement Advisory Group (RAG). The goals of this
group included education of athletic trainers on
reimbursement, development of a model approach to thirdparty payers for reimbursement of athletic training, and
design and implementation of a clinical outcomes data
study. The RAG met its original goals and moved toward the
implementation of state reimbursement committees,
continuing the education of athletic trainers, approaching
national allied health groups to seek representation,
approaching payers on a national level, establishing

45
liaisons for support, and coordinate reimbursement work
with the Governmental Affairs Committee and the three
employment setting committees of the NATA.8 Today the NATA
has a Committee on Revenue at the national level, whose
goal is to “Develop and provide resources to help athletic
trainers create healthcare models that enhance business
opportunities and return on investment.”

9

Successful examples of reimbursement exist in the
athletic training world. Eric Callahan published a case
study entitled “A Case Study in Successful Third-Party
Reimbursement in Indiana” in which he highlights a sports
medicine clinic’s successful adoption of insurance billing
with ATCs. Callahan highlights which codes were billed with
the most success, one for therapeutic exercise, and which
the least, one for evaluation by an athletic trainer and
reevaluation by an athletic trainer. For those which were
least reimbursed, for evaluation and reevaluation, the
author notes: “we think that this lower rate is a result
of…being new codes and their lack of use by ATCs.” It is
also important to note that this specific case study only
highlighted commercial insurance companies. Overall, the
findings of this case study showed encouraging results for
athletic trainers in the clinical setting, and the revenue
made was put into the high school outreach athletic

46
training program run by the clinic.10 While it this example
is certainly encouraging, there still remains a general
lack of literature on the topic of third-party
reimbursement in athletic training, making it difficult to
form any conclusions on the subject.

Third-Party Reimbursement in Physical Therapy

Comparing athletic training to physical therapy is
easy in many ways, as they share similar professional goals
in regard to patient care. At the core of physical therapy
is rehabilitation of patients, which is also a domain in
athletic training. A staunch difference in the professions
is the amount of education necessary to practice. Physical
therapists must now achieve a doctorate in physical therapy
degree, in addition to passing a licensure exam, in order
practice

11,12

, while athletic trainers need only a

bachelor’s degree, although nearly 70% of athletic trainers
have a Master’s degree or higher.1,13
Dode Jackson, a long time American Physical Therapists
Association (APTA) member, wrote an article entitled
“Physical Therapy Under Medicare Part B: How It All Began,”
which begins to shed some light on the strides that their
profession has taken in the past forty years. Dode explains

47
his involvement in ensuring that private practice physical
therapists were a part of Medicare coverage, and goes into
some detail about the amount of work it took to reach their
goal. He explains the lobbying, politics, and financial
backing that were all necessary to be sure that this large
step forward occurred for physical therapists. Dode speaks
of having to personally fund some of his work, the
connections he had to make, and the politicians he had to
please and those he had to fight. Although his experience
was in the 1960’s and 70’s, this article is a glance into
what it takes to cause reform in the government.14
Even with the advances that are described in Dode’s
work, many issues related to reimbursement remain for
physical therapists as well. Perhaps the biggest barrier
that their profession faces is a lack of “direct access”.
The APTA lists the problem as: “In many jurisdictions, the
practice of physical therapy is contingent upon the
prescription or referral of a physician. This requirement
does not recognize the professional training and expertise
of the licensed physical therapist nor does it serve the
needs of those patients who require physical therapy but
must first be seen by a physician.”11,12 Todd Davenport and
Chris Sebelski write that this idea undermines the
abilities of physical therapists as diagnosticians and that

48
physical therapists “must decide the appropriateness of
physical therapy for patients.”15 A study by McCallum and
Diangelis showed that a large proportion of physical
therapists would like to use direct access in practice,
however many are blocked from doing it because of company
policy, likely because they work for larger corporations as
opposed to smaller privately owned companies. In fact, this
study noted that many who claimed to be using a direct
access model still were required to receive a physician
referral for care. The greatest reason cited for the need
to stick with the status quo and continue to obtain
referrals from physicians is a fear of denied insurance
claims. The study showed some success in receiving
reimbursement without a referral, but this was deemed the
exception and not the rule.12
Perhaps the most stressed point in the literature is
the need for education on the rules and regulations both
nationally and within the state. Michele Wojciechowski
wrote “Third-Party Payers: Strategies for Private Practice
PTs” in which she discussed the ins and outs of third-party
payment with various physical therapists. Physical
Therapists working in a private practice setting must
negotiate with different groups in order to have a contract
with them to receive reimbursement from patients. This fact

49
alone shows the need for physical therapists to know
everything they can. The article quotes Rich Katz, the
director of contracting and business development for
Therapeutic Associates Inc., “What’s important is to become
as knowledgeable about health plan contracting and the
business analysis that should be applied to it.”16
Chris Hayhurst also discusses how physical therapists
can work to address reimbursement issues in his article
“How PTs are Influencing Reimbursement at the State Level.”
In this Erik Van Doorne is interviewed to discuss his
experience in working with insurers one on one to
communicate the needs of the profession in the state of
Delaware. The solution that he discovered was creating a
“payer-relations” committee to communicate directly with
the companies. In other states groups looked toward
professional advisors with a background in insurance
policy, and in other areas they pursued the use of
lobbyists. Throughout the article it seems that the desire
to communicate was mutual between the companies and the
physical therapist groups.17
However comparable athletic training and physical
therapy may be, the relationship between the two
professions has been nothing short of volatile. In February
of 2008 the NATA filed suit against the APTA, alleging

50
antitrust violations in efforts to limit competition. Among
the claims made by the NATA in the suit were accusing the
APTA of “manipulating the Coders’ Desk Reference for
Procedures to favor PTs and their practice” as well as
“misstating the proper and appropriate use of the physical
medicine codes of the Current Procedural Terminology, as
issued by the American Medical Association, by falsely
informing physical therapy students that certain codes are
exclusively for use by PTs.” The article on the suit goes
on to state that the APTA had an agreement with the
publisher of the Coders’ Desk Reference for Procedures to
approve certain descriptions to hinder athletic trainers
practice, all in the hopes of creating a monopoly in the
market. In this case the APTA moved to have the suit
dismissed, but the court found that the NATA sufficiently
pleaded their claims. Eventually the suit between the two
associations was settled, with both noting specific codes
were reserved for each profession, and other codes were not
exclusive to any one profession.18
Regardless of the relationship between the two
professional associations, the professions themselves could
learn a lot from each other, in particular with regard to
third-party reimbursement. Physical therapy has been an
established profession and had the respect of the medical

51
community for many years, while the athletic training
profession continues to strive for the respect of its
peers. Chronicling the struggles that the APTA had in
regards to receiving fair compensation from insurers is an
important step in considering the path that athletic
training must take. The NATA has worked tirelessly to
follow in their footsteps, and as shown in their lawsuit,
will not let the profession be trampled upon.

Evidence Based Practice

The subject matter which was most consistent
throughout the search of literature the integral
relationship between evidence based practice and
reimbursement. Evidence based practice is defined as “the
use of systematic decision making processes or provision of
services which have been shown, through available
scientific evidence, to consistently improve measurable
client outcomes.”19 Jay Hertel, a professor and certified
athletic trainer (ATC) from the University of Virginia,
states in his editorial “Research Training for Clinicians:
The Crucial Link Between Evidence-Based Practice and ThirdParty Reimbursement,” stating that “Third-party
reimbursement is a challenge facing athletic trainers in

52
numerous practice settings. The stark reality is that
without documented evidence showing the effectiveness of
clinical interventions rendered by ATCs, reimbursement is a
pipe dream.” Hertel continues on to state that although
this will be a challenge for athletic trainers, it also
will force accountability for the treatments given and be a
positive for the athletes and patients cared for.20
This point is further discussed by Christopher
Ingersoll in his editorial “It’s Time for Evidence.”
Ingersoll discusses the duty that athletic trainers have as
health care professionals to have the patient and athlete’s
best interest in mind, and as such it is the athletic
trainer’s responsibility to ensure the products being used
have a clinical significance. In his piece he notes how
others within the medical community work hand in hand with
manufacturers of products to ensure positive results. In
order for this to be a viable option for athletic trainers,
real research, and not a mere gut instinct, must occur.2,21
Continuing with the discussion of the importance of
published evidence on the effectiveness of treatment
methods, Stevens and Hootman state that: “As more athletic
trainers bill third parties for their services, those
third-party payers will require evidence that the
interventions are effective. Reimbursement may be difficult

53
or impossible to obtain for those procedures not shown to
be effective.”22
While third-party reimbursement remains a goal in
athletic training to achieve success and financial
compensation, it must also be noted that it is a
responsibility as well to hold ourselves accountable. This
statement is echoed by John Parsons in his piece entitled
“Reflections on a Season of Reform.” Parsons states that he
supports athletic trainers pursuing third-party
reimbursement, not necessarily for the financial
compensation it could bring, but because it will “subject
the profession to a set of external forces, in the form of
policy and procedural requirements that will bring
necessary change and quality control measures that will
ultimately be beneficial to the profession and our
patients.”23
An educator interviewed for the research done by
Manspeaker and Hootman noted that the importance of
accountability, saying this of physical therapists: “They
have to answer somebody. They have to answer to the public.
They have to answer to insurance companies. They have to
answer to physicians;” with yet another educator agreeing
stating that “We are not held accountable to outside
stakeholders.”24

54
In “Clinical Outcomes in Sports Medicine” by Stephen
Streator and William Buckley, a point is stressed that the
evolution of health care has led to a focus on limiting
costs and preventative care. Third-party payers, the
article states, will scrutinize any treatment or care until
they are convinced that the care rendered was appropriate.
This once again illustrates, albeit in slightly different
terminology, evidence based practice. The core concept
remains that results have to be seen, and documented, in
order for third-party reimbursement to work in sports
medicine.25 This point is further made by Buckley and
Streator in which they state: “In every aspect of health
care, trends point toward increasing data collection to
satisfy the demands of third-party payers, the government,
and others wanting proof that health care workers are
meeting the standards of quality.” Documentation of care
and results is vital, and a major responsibility of
athletic trainers to ensure not only their standing as a
health care professional, but their standing in the eyes of
third-party payers.26 Dan Campbell speaks to the issue of
documentation in his piece “Reimbursement for Athletic
Trainers in the Traditional Setting.” Here he speaks of
some of the issues perceived with insurance billing, such
as the history of the profession being “non-revenue

55
generating” and the “desire to serve the needs of others
without having to worry about the financial element
associated with providing that care.” However, Campbell
goes on to note that the profession must take a hold of the
opportunity to advance and run with it.27

Barriers to Implementation

Many barriers exist to hinder the progress of
implementing a working reimbursement system in athletic
training. Among these is a perception of no benefit among
athletic trainers, a disparity of evidence based practice
in comparison to other professions, and a lack of
education.
In regard to athletic trainers’ perception of
reimbursement, the literature is light at best; however,
one study was found, entitled “Intercollegiate Athletic
Trainers Perception of Third-Party Reimbursement and Their
Steps Toward Its Implementation.” In this paper the author,
Benetta McPherson, approached intercollegiate level
athletic trainers and surveyed them on their opinions on
third-party reimbursement. Her findings showed that while
athletic trainers thought seeking reimbursement would be
beneficial to the profession, they did not see the benefit

56
of pursuing it as a collegiate level athletic trainer. Some
respondents also noted their feelings that it would be
unfair to athletes to charge for services that they had not
charged for in the past, and others also noted they felt it
would create more work for athletic trainers. Of her nine
respondents, only three had billing and insurance
coordinators, and eight had not developed a strategic plan
for pursuing third-party reimbursement.8
Contrary to athletic trainers’ perception, literature
does exist pointing out the fact that the athletic training
profession is far behind when compared to their peers.13,22
An article highlighting evidence based practice in many
professions across the United States discusses the state of
evidence based practice in athletic training. To summarize,
the authors state that “Overall, EBP’s penetration into
athletic training is in its initial steps…work still needs
to be done to increase the body of athletic training
evidence.”13
Further literature delves into a related issue:
education of undergraduate students.2,24 One article, written
by Manspeaker and Van Lunen, discusses some topics which
are perceived by many educators to be under emphasized in
entry-level and continuing education programs, including
evidence based practice and third-party reimbursement.24

57
Education on the topic needs to begin with students to
fully prepare them for life as a working professional.
While the NATA has worked toward educating certified
athletic trainers, the literature asserts that there
remains a gap in young professionals and athletic training
students.

Summary

In the ever changing world of health care it is vital
that professions adapt to the changes they are faced with,
and in order to remain competitive and gain respect within
the medical community and financial compensation, athletic
trainers must adapt. Moving toward the implementation of
third-party reimbursement is one opportunity to ensure
competitive balance as a profession, and in order to
accomplish this, the profession must make moves to please
third-party payers. Just as important as third-party
reimbursement is that of evidence based practice, as the
two go hand in hand. In order to prove their worth to
outside forces, athletic trainers must document and
scientifically support their claims. In addition to this,
educating athletic training students and young
professionals remains a key to the understanding and

58
further implementation of third-party reimbursement.
However, wanting to help themselves and having the desire
to pursue third-party reimbursement is of equal importance
to the success of this movement and the growth of the
athletic training profession.

59

APPENDIX B:
The Problem

60
STATEMENT OF THE PROBLEM

Athletic trainers have struggled for years to gain the
respect and recognition of their fellow medical
professionals as well as the general public. Recent
legislation has allowed for athletic trainers to apply for
provider numbers, the numbers which are necessary for
professionals when working under the government insurers
Medicare and Medicaid, opening up opportunities to bill
insurance companies for their services. However, in
particular settings the ability to bill for services seems
daunting, with many barriers such as a lack of education
and battles with insurance providers standing in the way.
Having the ability to bill for services will help athletic
trainers gain respect amongst their peers in addition to
bringing in greater revenue for the company for which they
work. On the other hand, the issues logistically, and in
some eyes morally, remain a problem. The purpose of this
study is to question athletic trainers in the state of
Pennsylvania to discover their opinions and ideas about
third-party reimbursement in the profession, as well as
adding to the current literature.

61
Basic Assumptions and Limitations
The following are basic assumptions of this study:
1) Subjects have completed the survey accurately and
honestly.
2) Respondents completing the survey may have a greater
interest in reimbursement compared to non-responders.
3) Subject pool was limited to those with online access.

Delimitations of the Study
The following are possible delimitations of the study:
1. Data from 165 subjects were analyzed.
2.

A reminder email was sent to participants (one week

after initial email) to encourage participation.
3.

The NATA selected 1,000 ATs randomly to complete the

survey.

Significance of Study
Athletic Trainers exist in many different professional
settings, from the clinical setting to the high school
setting, and from college setting to the professional
athletics; and just like most other professions, the value
of an athletic trainer is often linked to the revenue he or

62
she is able to bring in to their company. Because of this,
discussion exists within the athletic training community
that third-party reimbursement would increase the value of
athletic trainers, thus increasing the salary of athletic
trainers. However, there are perceived issues with thirdparty reimbursement, such as the difficulty and time
commitment of paperwork and the possible ethical issues for
charging for services previously provided free of charge.
It is important to understand the current reimbursement
practice of athletic trainers as well as their perception
of reimbursement. In doing so, this research may shed light
on identifying barriers that may hinder reimbursement
implementation.

63

APPENDIX C:
Additional Methods

64

APPENDIX C1:
Cover Letter

65
Dear Certified Athletic Trainer:
My name is Erin Leaver and I am currently a graduate
athletic training student at California University of
Pennsylvania performing thesis research. I am conducting
survey research to evaluate Pennsylvania athletic trainers’
perception of third-party reimbursement. A survey is being
distributed to add to the literature on third-party
reimbursement in athletic training in Pennsylvania in
regard to the prevalence of reimbursement, the opinions of
athletic trainers’ on the value of reimbursement,

the

barriers that exist in the implementation of third-party
reimbursement, and athletic trainers’ perceived knowledge
on reimbursement.
You are being asked to participate due to being a certified
athletic trainer practicing in the state of Pennsylvania,
as well as being a member of NATA; however, your
participation is voluntary and you do have the right to
choose to not complete this survey. You also have the right
to discontinue participation at any time during the survey
completion process at which time your data will be
discarded.

The California University of Pennsylvania

Institutional Review Board has reviewed and approved this
project. The approval is effective 03/31/14 and expires
03/31/15.

66

All survey responses are anonymous and will be kept
confidential, and informed consent to use the data
collected will be assumed upon return of the survey.
Completed surveys will not have any information that will
allow you to be identified or allow for your data to be
associated with you. Completed surveys will be kept on a
password protected online database until they are entered
into a spreadsheet for data analysis after which they will
be removed from the database.

Electronic data will be

stored in password-protected files on a University server.
Minimal risk is posed by participating as a subject in this
study.

I ask that you please take this survey at your

earliest convenience as it will take approximately 15-20
minutes to complete. If you have any questions regarding
this project, please feel free to contact the primary
researcher, Erin L. Leaver, LAT, ATC at Lea9932[REMOVED] or
[REMOVED]. The faculty advisor for this research is Jodi
Dusi, MPT, PhD, and she may be reached at [REMOVED].
Please use the below link to access the survey:
[REMOVED]
Thank you for taking the time to take part in this
research. I greatly appreciate your time, thought and
effort you have put into completion of the survey.

67

Sincerely,

Erin L. Leaver LAT, ATC
Primary Researcher
California University of Pennsylvania
250 University Ave
California, PA 15419
[Contact information removed]

68

APPENDIX C2:
Institutional Review Board: California University of
Pennsylvania

69

Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP, Chair

Dear Erin Leaver,

Please consider this email as official notification that
your proposal titled "Athletic Trainers’ Perceptions of
Third-Party Reimbursement in Pennsylvania” (Proposal #13051) has been approved by the California University of
Pennsylvania Institutional Review Board as submitted.

The effective date of the approval is 3-31-2014 and the
expiration date is 3-30-2015. These dates must appear on
the consent form .

Please note that Federal Policy requires that you notify
the IRB promptly regarding any of the following:

70
(1)

Any additions or changes in procedures you might wish

for your study (additions or changes must be approved by
the IRB before they are implemented)
(2)

Any events that affect the safety or well-being of

subjects
(3)

Any modifications of your study or other responses

that are necessitated by any events reported in (2).
(4)

To continue your research beyond the approval

expiration date of 3-30-2015 you must file additional
information to be considered for continuing review. Please
contact instreviewboard@calu.edu.

Please notify the Board when data collection is complete.

Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

71

APPENDIX C4:
Athletic Trainers’ Perceptions of Third-Party Reimbursement
Survey

72

73

74

75

76

77

78

79

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81

APPENDIX C5: References

82
REFERENCES
1.

Profile of Athletic Trainers. National Athletic
Trainers Association Web Site.
http://www.nata.org/sites/default/files/AT_Facts_revSe
pt2011.pdf. Published September 2011. Accessed August
5, 2013.

2.

Delwiche F, Hall E. Mapping the literature of athletic
training. Journal Of The Medical Library Association
[serial online]. April 2007;95(2):195-201. Accessed
August 5, 2013.

3.

Hazelbaker C. Perceived Skills and Abilities Required
by Athletic Trainers in Hospital and Clinical
Management Positions: A Delphi Study. Journal Of
Athletic Training [serial online]. January
2013;48(1):87-91. Accessed August 5, 2013.

4.

Lowe R. Athletic Training Salaries on the Rise
According to Latest Survey. National Athletic Trainers
Association Web Site.
http://www.nata.org/sites/default/files/SalarySurvey11
.pdf. Published November 2011. Accessed August 5,
2013.

5.

Mosby. Mosby's Medical Dictionary. Mosby Incorporated;
2012.

6.

Harrelson GL, Gardner G, Winterstein AP.
Administrative Topics in Athletic Training, Concepts
to Practice. SLACK Incorporated; 2009.

7.

Centers for Medicare and Medicaid Services. National
Provider Identifier Standard. Centers for Medicare and
Medicaid Services. http://www.cms.gov/Regulations-andGuidance/HIPAA-AdministrativeSimplification/NationalProvIdentStand/index.html?redir
ect=/nationalprovidentstand/ Published April 5th, 2013.
Accessed September 22nd, 2013.

8.

McPherson B. Intercollegiate athletic trainer's
perception of third-party reimbursement and their
steps towards its implementation. [serial online].
1999; Accessed August 5, 2013.

83
9.

National Athletic Trainers’ Association. Committee on
Revenue. National Athletic Trainers’ Association.
http://www.nata.org/COR. Published 2013. Accessed
September 22nd, 2013.

10.

Callahan E, Finkam S. A Case Study in Successful
Third-Party Reimbursement in Indiana. Athletic Therapy
Today [serial online]. July 2003;8(4):28-29. Accessed
August 5, 2013.

11.

About Physical Therapists. American Physical Therapist
Association Web Site.
http://www.moveforwardpt.com/WhyTherapy/AboutPTs/.
Accessed August 5, 2013.

12.

Mccallum CA, Diangelis T. Direct access: factors that
affect physical therapist practice in the state of
Ohio. Phys Ther. 2012;92(5):688-706.

13.

Tweed E, Sauers E, Ratner N, et al. Review for
librarians of evidence-based practice in nursing and
the allied health professions in the United States.
Journal Of The Medical Library Association [serial
online]. October 2007;95(4):394-407. Accessed August
5, 2013.

14.

Jackson D. Physical therapy under Medicare Part B: how
it all began. PT: Magazine of Physcial Therapy [serial
online]. May 2004;12(5):48. Accessed August 5, 2013.

15.

Davenport TE, Sebelski CA. The physical therapist as a
diagnostician: how do we, should we, and could we use
information about pathology in our practice?. Phys
Ther. 2011;91(11):1694-5.

16.

Wojciechowski M. Third-Party Payers: Strategies for
Private Practice PTs. PT: Magazine Of Physical Therapy
[serial online]. April 2009;17(3):32-37. Accessed
August 5, 2013.

17.

Hayhurst C. How PTs Are Influencing Reimbursement at
the State Level. PT: Magazine Of Physical Therapy
[serial online]. September 2009;17(8):34-36. Accessed
August 5, 2013.

18.

Herbert D. NATA Antitrust Suit Against APTA Settled.
Sports, Parks & Recreation Law Reporter [serial

84
online]. December 2009;23(3):33-40. Accessed August 5,
2013.
19.

University of Washington School of Medicine. What is
EBP? Department of Psychiatry and Behavioral Sciences.
http://depts.washington.edu/ebpi/. Published 2008.
Accessed September 22nd, 2013.

20.

Hertel J. Research Training for Clinicians: The
Crucial Link Between Evidence-Based Practice and
Third-Party Reimbursement. Journal Of Athletic
Training [serial online]. April 2005;40(2):69-70.
Accessed August 5, 2013.

21.

Ingersoll C. It's Time for Evidence. Journal Of
Athletic Training [serial online]. January
2006;41(1):7. Accessed August 5, 2013.

22.

Stevens R, Hootman J. Evidence-based medicine: what is
it and how does it apply to athletic training?.
Journal Of Athletic Training [serial online]. 2004
Jan-Mar 2004;39(1):83-87. Accessed August 5, 2013.

23.

Manspeaker S, Van Lunen B. Overcoming Barriers to
Implementation of Evidence-Based Practice Concepts in
Athletic Training Education: Perceptions of Select
Educators. Journal Of Athletic Training [serial
online]. September 2011;46(5):514-522. Accessed
August 5, 2013.

24.

Parsons J. Reflections on a Season of Reform. Athletic
Therapy Today [serial online]. July 2010;15(4):1-3.
Accessed August 5, 2013.

25.

Streator S, Buckley W. Clinical outcomes in sports
medicine. Athletic Therapy Today [serial online].
September 2000;5(5):57-61. Accessed August 5, 2013.

26.

Streator S, Buckley W. Risk management in athletic
training. Athletic Therapy Today [serial online].
March 2001;6(2):55-59. Accessed August 5, 2013.

27.

Campbell D. Reimbursement For Athletic Trainers in the
Traditional Setting. College Athletic Trainers’
Society. 1996: 1. Accessed August 5, 2013.

85

ABSTRACT
Title:

ATHLETIC TRAINERS’ PERCEPTIONS OF THIRDPARTY REIMBURSEMENT

Researcher:

Erin L. Leaver

Advisor:

Dr. Jodi Dusi

Date:

May 2014

Research Type: Master’s Thesis
Context:

This study evaluated the perceptions of
athletic trainers in Pennsylvania in regard
to the topic of third-party reimbursement in
the profession.

Objective:

The aims of this study were to: determine
the prevalence of third-party reimbursement
by certified athletic trainers (ATCs) in
Pennsylvania; describe their opinions on the
value of third-party reimbursement; identify
barriers that prevent the implementation of
third-party reimbursement; and describe
their perceived knowledge of third-party
reimbursement.

Design:

Descriptive research study

Setting:

The researcher distributed a cover letter
containing a link to an internet based
survey to NATA, who then sent this cover
letter and survey to 1,000 athletic trainers
in the state of Pennsylvania.

Subjects:

Certified athletic trainers practicing in
the state of Pennsylvania.

Interventions: The survey was created by the researcher,
with some questions modified from a similar
survey by Wisconsin Athletic Trainers’
Association, and the survey was administered

86
to subjects via email from the NATA. The
data were analyzed using SPSS.
Measurements:

Frequency counts were utilized to summarize
data. Mean scores were also determined for
the Likert scale questions. Open-ended
comments were analyzed for common themes.

Results:

Most of the survey respondents (93%)
supported the pursuit of third-party
reimbursement by ATCs in Pennsylvania and
55% of respondents would like to pursue
billing in their own practice. However, only
8% of respondents currently utilize thirdparty reimbursement for athletic training
services provided. Barriers to
implementation of third-party reimbursement
include a lack of education, complexity of
insurance paperwork, and time commitment to
implementing a reimbursement system.
Additionally, subjects were in general
relatively “neutral” in their selfperception of knowledge regarding thirdparty reimbursement (mean score 3.02±1.06).

Conclusion:

The study revealed that athletic trainers in
the state of Pennsylvania support the
profession pursuing third-party
reimbursement despite low prevalence rates.
Lack of education was the most commonly
endorsed barrier and respondents lacked
confidence in their self-perceived knowledge
regarding third-party reimbursement.