Demystifying Direct Access: How to Treat Medicare Patients Without Referrals

In the PT world, there’s nothing straightforward about direct access law. After all, the rules vary from state to state—and even from payer to payer. But that doesn’t mean we should all throw our hands up into the air and refuse to accept any direct access patients at all. If we want to demonstrate to the healthcare powers that be—including payers and legislators—how much our patients benefit from seeing us first (before they visit their doctors), then we have to take full advantage of existing laws allowing us to do just that. And that’s especially true when it comes to one of the largest—and most influential—payers in the PT space: Medicare.

If I had a quarter for every time I’ve heard a therapist say, “I can’t accept Medicare patients on a direct access basis”—well, you know how the saying goes. I get it; when it comes to Medicare, many therapists live by a “better safe than sorry” kind of mantra. And many times, that’s the right thing to do. But in this particular case, I have to put my foot down, because flat-out refusing to treat any and all Medicare direct access patients won’t do anything to advance our profession.

With that in mind, let’s take a look at the actual rules. As of 2005—according to the Medicare Benefit Policy Manual (Publication 100-02)—Medicare beneficiaries are allowed to seek the services of a licensed physical therapist without seeing a physician or obtaining a referral or prescription. But—and this is an important “but”—as CMS states here, patients “must be under the care of a physician or NPP [nonphysician practitioner]” for their therapy services to be covered. Another crucial caveat: You always must comply with your state’s laws regarding direct access—and you also should review your state’s practice act. Generally speaking, though, you can—at the very least—provide an initial evaluation to a patient without a physician referral. Then, per Medicare guidelines, you must:

Develop a Plan of Care (POC)

As you probably already know, you must develop a plan of care (POC) for every Medicare patient. Required elements of the POC include:

  • diagnoses,
  • long-term treatment goals, and
  • the type, quantity, duration, and frequency of therapy services.

Obtain POC Certification

Once you’ve established a plan of care, a physician or nonphysician practitioner (NPP) must certify it no more than 30 days after the patient’s first therapy visit. This rule holds true for direct access patients as well. However, what many therapists do not realize is that Medicare does not require the patient to actually see the certifying provider in person. This is where building good relationships with referring physicians comes in handy, as you may be able to obtain certification more quickly.

Keep in mind that the certifying provider must sign and date the POC (stamped signatures do not suffice). If you receive a verbal certification, the physician or NPP must provide a signature within 14 days of verbally certifying the POC.

Furthermore, you must have the plan recertified within 90 calendar days of the initial treatment—or whenever a patient’s condition changes enough to warrant a revision to his or her long-term goals.

Include Referring Provider Info on Claims

Therapists must fill in the name and NPI number of the certifying physician or NPP under the “referring provider” section of the CMS claim form (even if that provider didn’t technically refer the patient to you). This verbiage, though not accurate for direct access patients, is simply the result of CMS not yet updating that portion of the form.

There are a lot of Medicare myths and misinformation floating around out there; direct access is just the tip of the iceberg. Want to protect yourself and your practice from falling victim to the most common Medicare misconceptions? Then be sure to attend my upcoming webinar—which I’m co-hosting with compliance expert Tom Ambury—on October 26, 2016. We’ll even answer your trickiest Medicare questions during the Q&A portion of the presentation.

Register here.

 

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