Common Medicare Compliance Rules for Substitute, Almost-Credentialed, and Non-Credentialed Therapists

Medicare compliance rules for fully credentialed therapists can be more than a bit complicated, so it’s not too surprising that the rules governing substitute, almost-credentialed, and non-credentialed therapists would be equally perplexing. With that in mind, here are some common rules to help you navigate these murky Medicare waters:

For Substitute Therapists

It is officially summer—and with warmer temps, there will naturally be a lot more vacation requests. If you’re looking to hire substitutes to cover for your regularly employed therapists who are out enjoying the sunshine (lucky them!), you may be wondering how to handle billing for the subs’ services. For starters, your subs should be fully credentialed by the insurance companies whose beneficiaries they are going to treat. An easy way to make sure of that is to bring on contractors from qualified agencies with vetted insurance credentials. While this might cost more than hiring a friend or colleague, bringing on a fully credentialed contractor will save you a lot of time, money, and headaches in the long run.

This is especially important for Medicare. A contractor who steps in for a vacationing therapist who treats Medicare patients must also be Medicare-credentialed—or else you run the risk of more than just denied reimbursements. According to this PT Compliance Group article, if you become aware that a therapist without Medicare credentials is billing for services provided to Medicare patients in your practice (even unintentionally), you should hire a health law attorney immediately. You will need professional help to demonstrate that your practice did not commit Medicare fraud—a pretty serious charge.

For Almost-Credentialed Therapists

A therapist can begin treating patients—even if he or she is not yet officially Medicare credentialed—as long as the Medicare credentialing paperwork is pending CMS’s approval. However, the practice must hold all billing claims for that therapist (up to one year from the date of service, per timely filing rules) until the credentialing approval comes through. Medicare won’t allow credentialed therapists to cosign claims for non-credentialed employees, so the uncredentialed therapist should reassign his or her individual Provider Transaction Access Number (PTAN) to the practice, and that practice should hold all the claims until he or she is fully credentialed.

For Non-Credentialed Therapists

Many non-Medicare insurance companies allow a credentialed therapist to cosign a non-credentialed therapist’s note if the cosigning therapist supervises the treatment. Similar to the rules governing billing for PTA services, the credentialed therapist must provide direct onsite supervision and be immediately available to intervene if necessary. According to WebPT founder and COO Heidi Jannenga, PT, MPT, ATC/L, cosigning should be used as a temporary fix only. It’s definitely not appropriate as a long-term solution. Jannenga also recommends that all practices check with their specific insurance companies to verify the rules governing cosigning and credentialing, as many requirements vary.

If you’re a WebPT Member, you can enable note-forwarding for cosigning within the application by contacting Support at support@webpt.com. Please note that by cosigning a note (either inside or outside of WebPT) you, as the credentialed therapist, are attesting that you actively supervised the uncredentialed PT and are thus responsible for that patient’s care—not something to be taken lightly.

How do you handle credentialing when you bring on a substitute or a new hire? Tell us in the comments below.