Medicare Compliance & Reimbursement

New rule would redefine who provides therapy in doctors' offices.

Therapists tired of Medicare allowing under-qualified practitioners to perform therapy "incident to" a physicians' services finally have some good news.

The Centers for Medicare and Medicaid Services is giving two thumbs up to therapists' professional qualifications by including more restrictive requirements for therapy in physician practice settings and loosening oversight rules in private therapy practices.

No Incident-to Pay Without Proper Credentials

The 2005 fee schedule, published in the Aug. 5 Federal Register, proposes that "only individuals meeting the existing qualifications and training standards for therapists (with the exception of licensure)... qualify to provide therapy services incident to physicians' services."

Translation: If a physician practice bills Medicare for incident-to therapy services, the person providing the therapy must have the appropriate physical therapy credentials and meet specific training standards, under the proposed regulation.

"The change in the reg would require that people in physicians' offices providing incident-to services follow the same qualification guidelines as in a physical therapy office," explains Michael Weinper, CEO of Physical Therapy Providers Network (PTPN) of Calabasas, CA.

Bad news for docs: Many physicians delegate therapy services to staff who are not properly trained and receive reimbursement at a physician's rate, Weinper says. Often, Medicare recipients are not getting what they're entitled to, he adds.

"Indeed, physical therapy professionals are more likely to give goal-driven and function-focused care, whereas a non-professional in a physician's practice is likely to provide only a palliative treatment," comments Irene Bartlett, rehab director for Mercy Medical Center in Des Moines, IA.

Clearly, there's a huge financial advantage if physicians can use exercise physiologists or rehab techs, for instance, because they make significantly less money than a physical therapist, occupational therapist, physical therapy assistant or occupational therapy assistant, observes Rick Gawenda, director of rehab services for Detroit Receiving Hospital.

Who's qualified: Under the proposed rule, individuals providing therapy services in physician practices must have graduated from a physical therapy curriculum approved by the American Physical Therapy Association, the American Medical Association's Committee on Allied Health Education and Accreditation, or the AMA/APTA's Council on Medical Education. PTs, PTAs, OTs, COTAs, and SLPs would meet these requirements, Gawenda explains.

CMS will also allow a physician assistant (PA), clinical nurse specialist (CNS) or nurse practitioner (NP) to provide outpatient physical therapy services, so long as those services fall within their scope of practice under state guidelines. Therapy professionals would prefer that the proposed rule not include PAs and NPs, but this is unlikely, Bartlett observes.

Take action: CMS is accepting comments on the proposed regulation through Sept. 24. Therapists can write letters to CMS advocating these tightened standards before the rule comment period ends.

Tip: Therapists should describe to CMS the specific situations they've encountered in which a patient comes to a physical therapy practice seeking help after having received treatment in a physician's office, Weinper suggests. Detail how the patient's problem worsened because she did not receive the correct services, thereby prolonging her disability. "And point out that prolonged treatment costs Medicare more," Weinper notes.