I’ve recently received quite a few questions about how therapists can best meet conflicting billing and state practice requirements. Today, I thought I’d provide some clarity on that and explain why documentation is important for cash-based practices when it comes to addressing liability.

Billing Requirements

All payers—Medicare and private health insurance companies—maintain requirements that you must meet to receive reimbursement for your services. Additionally, each state has its own supervision requirements (based on license type) as documented within its state practice act.

For the purposes of this conversation, let’s focus on Medicare. Medicare pays licensed PTs/PTAs, OTs/COTAs, and SLPs for performing reasonable and medically necessary services. However, if an assistant provides services within an outpatient independent physical therapy practice, he or she must be under the direct supervision of a fully-accredited therapist who is onsite and available to step in if necessary. While some state practice acts allow PTAs to practice with indirect supervision (i.e., the PT does not have to be physically onsite during the visit), if a PTA is treating a Medicare patient, the licensed PT always must be onsite. So what’s the point of having an indirect supervision license if, according to Medicare and/or state regulations, you can’t ever use it? Well, keep in mind that Medicare has different supervision requirements depending upon the setting. For example, in a comprehensive outpatient rehabilitation facility (CORF), it is completely legal for a PTA to treat a patient with only general supervision (i.e., without a PT onsite).

Documentation Requirements

As a result of declining insurance reimbursements, many therapists are moving toward a cash-based business model, wherein they no longer accept insurance. And while you might also think that this will get you out of all those pesky documentation requirements, it won’t. There are many reasons for documenting your services—documentation for payment is only one of them. In fact, some state practice acts require that rehabilitative services be provided only under a prescription or referral from a physician, which necessitates a thorough evaluation and plan of care. And even if you can see a patient under direct access—without a referral from a physician—you should still complete this documentation to demonstrate that the patient received—at minimum—the standard of care. In fact, documentation for treatment of a patient without a referral might be more stringent than documentation for a patient who comes from the doctor. How so? Well, for a patient sans referral, you also need to document your review of systems and your differential diagnostic process (but that’s a whole other blog). If for any reason the patient ever questioned his or her treatment from you—or even sued you for malpractice—your documentation would be your main line of defense; it’s your proof that you operated with the utmost of professionalism and clinical expertise.

Additional Certifications

In order to go the cash-based business route, many therapists are obtaining additional certifications, like becoming a Certified Strength and Conditioning Specialist (CSCS). However, it’s important to note that legally speaking, you can be held accountable to your highest level of training. So if a licensed therapist conducts personal training as a CSCS—especially if it’s in that therapist’s PT clinic—it might still fall within the realm of physical therapy. If you’re interested in providing personal training or any kind of similar service, I highly suggest you consult your liability insurance provider contact; he or she may want to attach a rider to your policy.

If you have any questions, please contact me at questions@ptcompliancegroup.com or 888-680-7688.


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