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Tricare Physical Therapist Assistant Not Allowed

February 13, 2014 42 Comments

Tricare does not reimburse for therapy provided by therapy assistants, and in fact excludes from reimbursement outpatient physical therapy that is Tricare Manual2performed by physical therapist assistants in the private practice setting (2/24/14 – clarified for private practice setting).  This may be a surprise to many providers, in that Tricare, like Medicare is a federal healthcare program, and of course we all know that Medicare allows therapy to be provided by a qualified physical therapist assistant.  I suspect many reading this post are wondering “when did this policy change”?  Well, actually it has been in place some time that Tricare does not allow the use of therapy assistants.  Let’s take a look at the manual from one of the 4 regional providers: Tricare North Region Provider Manual.  Therapy benefits are described like this:

Physical Therapy.  Physical therapy is covered to aid in the recovery from disease or injury to help the patient in attaining greater self sufficiency, mobility, and productivity by improving muscle strength, joint motion, coordination, and endurance.  Coverage is based on the beneficiary’s medical needs and generally limited to 24 visits within a 60 day period. Physical therapy must be prescribed and supervised by a physician, certified physician assistant (PA) working under the supervision of a physician or certified nurse practitioner (NP). Physical therapy is covered when rendered and billed by a licensed registered physical therapist or other authorized individual professional provider acting within the scope of his or her license. Some benefit exclusions apply – see “Exclusions” in this section. Outpatient therapy is authorized based on one visit per day. TRICARE Prime and TPR beneficiaries require a Health Net referral for physical therapy services.

Here is where it gets tricky – notice the reference to “Exclusions”, well the exclusions appear later in the section and you will see in our picture above (an actual screen shot from the provider manual) that “physical therapy services performed by a physical therapy assistant: are not covered!  Not you see it in black and white.  Tricare physical therapist assistant not allowed!

Tricare Physical Therapist Assistant Not Allowed – What to Do?

Your first response may be to think that since “supervision” was in place, that there is not a problem.  However, that is not the case with Tricare.  If you have been routinely providing services to Tricare covered individuals and billing Tricare for those therapy services I recommend a few things from a compliance perspective:

  • Secure an updated copy of the Tricare Manual from your regional Tricare provider that you are contracted with.  The version linked above is 2013, and most current version for the Tricare North Region.
  • Update your current policies and procedures (including scheduling) to reflect the Tricare physical therapist assistant not allowed policy.
  • Educate staff, both clinical and billing on the policy.
  • Reference your compliance policies and procedures – the section which provides policy on guidance on maintaining reimbursement to which you may not be entitled.
  • Gather a general sense of impact on your practice.  This will give you some direction moving forward.  For a very small Tricare patient base, you may elect to review the cases to determine payback liability for any reimbursements received for treatment rendered by an assistant.  If you have a high caseload, prior to conducting an audit or an investigation you may want to privilege that investigation activity by reviewing with compliance counsel and placing it under privilege.

The strengthening of the False Claims Act under the Affordable Care Act requires a provider to reimburse federal healthcare programs for money to which they are not entitled within 60 days of the discovery.  Depending our your exposure you may want to seek advice from a compliance expert, and that may in turn lead to your “investigation” that is done under privilege.  Don’t let the word “investigation” scare you – it is you reviewing internally what happened, then correcting the problem identified, and preventing it from happening.  That’s the compliance cycle of DETECT-CORRECT-PREVENT.  Depending on your volume of Tricare you may decide to protect your findings under attorney-client privilege so that the work product of your investigation remains confidential, and from there you will have a partner to assist you in the correct solution to the problem.  Hopefully this involves a voluntary refund, but may involve a self-disclosure.

Effective compliance programs provide guidance in doing the right thing.  Do you have a compliance program?  Do you have compliance questions?

 

 

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (42)

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  1. Angela Cox says:

    Nancy: Upon reviewing the 2013 Tricare South Provider Handbook, I did not find any reference in regards to the exclusions of physical therapist assistance. However, on their website is a link which takes you to the Defense Health Agency’s website and that is where I found the parent policy on the exclusions of PTAs providing care to Tricare beneficiaries.

  2. anamarie says:

    So it is my assumption that the ‘no pta rule’ applies to patients with Tricare as a 2nd insurance as well? is this correct?

  3. anamarie says:

    I recommend that everyone research the provider handbooks language for all 3 regions of Tricare. The North Region is the only only that specifically excludes the services of a PTA. The South and West Regions do not. I even contacted Tricare about this and they were unable to confirm any PTA exclusions for West and South. If anyone else have found documentation to the contrary, please post so we can all keep up on these changes. Thank you.

  4. Phillip says:

    I have not been able to confirm this for the South region either. Does this also apply to COTA’s as well or just PTA’s?

  5. anamarie says:

    Found out this rule does not apply to facility/OP hospital who bill under the facility NPI. Applies to private practice only.

  6. Anamarie – You are indeed correct, and I probably should have clarified that in my original post (I will go back and edit). Many federal healthcare programs adhere to different rules for facilities (hospitals, rehab agencies, CORFs, SNFs) vs. suppliers (private practices including physicians).

    As Angela noted, PTAs in private practice is in the federal guidelines, but, may not always be stated as such in the regional provider manuals. Similar concept to Medicare and local coverage determinations may not necessary contain all related to Medicare that is in Social Security Statute.

    Thanks for contributing to the conversation. And I think we can all agree that it seems odd that Tricare would disallow PTAs in private practice, where there are direct supervision requirements (only general supervision is required in the facility setting.)

  7. Joan says:

    We are in Tricare West region and their handbook does not stipulate that PTA’s can not treat patients. I called them this morning and was told to go by the handbook of whatever region you’re in.

  8. The prevailing Tricare regulations (TRICARE POLICY MANUAL 6010.54-M) in Chapter 11, Section 10.1 state under (EXCLUSION): Services performed by a physical therapy assistant who is employed by an independent
    provider, may not be cost-shared. The underlying Code of Federal Regulations that is cited as 32CFR199.6(c)(2). The exclusion speaks to independent providers, not to institutional providers.

    It has been my experience that in the event of an audit the hierarchy of rules and laws will apply: Laws, Code of Federal Regulations, Manuals, Provider Manuals. While the South and West provider manuals do not specifically prohibit PTAs in independent practices from providing therapy, an interpretation (as concluded by Tricare North)during an audit will rely on the hierarchy of laws and rules. An unfavorable audit decision may lead to an extrapolation of error rate, and while appealable, could put a small therapy practice out of business while appealing based upon Provider Manual statements.

    To be clear, from a practice act standpoint, as well as Medicare comparison, PTAs should be able to provide billable services, and the Tricare logic (as expressed in the North Manual)may not make sense. As a compliance professional I tend to be more risk adverse based upon my experience in audits.

  9. Joan says:

    Only got back to it now, but thank you for the update Nancy!

  10. Marsha says:

    So does Tricare as a secondary or tertiary insurance exclude PTA treatment as well?

  11. HI Marsha, Thank you for your comment/question. When Tricare is a payor, Tricare rules apply. So to be specific, if a private practice bills Tricare (regardless of payor position) and expects to be paid, the payor rules apply. Since Tricare prohibits payment for services by a PTA in a private practice, a PTA should not be utilized if Tricare will be billed.

  12. christina says:

    Nancy,

    Are we certain that this only applies to private practice? If I’m working in a hospital based outpatient facility would I be able treat tricare patients as a PTA?

  13. Hi Christina – I answered this question in another post about Tricare and PTAs. In that post I provide the regulatory citations. It is best practice for clinics to have policies and procedures regarding billing, coding and documentation, and policies should be based upon regulatory requirements that you are able to cite.

  14. christina says:

    Thank you. I just wanted to make sure. As I do not want to put my license at risk.

  15. Nancy Krolikowski says:

    Is there specific language excluding services provided by a certified occupational therapy assistant (COTA) in a private practice setting? Thank you for your assistance.

  16. Hello Nancy, Thank you for your comment. If you are treating Tricare patients, my first recommendation is to ensure that you have the provider handbook for your region, and that you understand the underlying Tricare policies and statutory requirements. even if the handbook is silent on “assistants” in private practice. To my knowledge, there is no specific reference to OTAs, but as “best practice” the guidance issues for PTAs does provide a reference point for your own internal policies. Providers that have called their Tricare regional contractor have reported that the answer regarding the use of assistants in private practice is not always consistent, that is why it is important to understand the Tricare policies.

  17. Triahnna says:

    Hello Nancy,

    I have always been told that Speech Language Pathology Assistants are also unable to provide services to be reimbursed by Tricare as well. Yet I have been unable to find any documentation to support this. Am I missing something?

  18. Hi Triahnna, Thank you for your question. When you say you have “always been told” – what is the source of that information? Just curious. Tracer policy on physical therapists assistants is found in Tricare policy (not the Tricare provider manuals published by the 3 Tricare contractors. The Tricare policy is “silent” on occupational therapy assistants also. A good rule of thumb is to not allow (in private practice) an SLP assistant to treat/bill a Tricare patient. While some Medicare programs may allow for the provision of services by SLP Assistants, they do not have standing with Medicare, and I would extend that to Tricare on a “best practice” scenario.

  19. Larry says:

    Hello Nancy,
    Do you know if Tricare plans to change this Law. I live in a military town and work in an out patient clinic where we have a high tricare case load. I get very frustrated because most of our Medicare patients have Tricare as a secondary and this is severely affecting my case load. We have been compliant with PTA’s no treatment Tricare patients but this year has been very frustrating as I noticed my case load becoming even smaller. I’m afraid my employer might let me go do to the low number of patients I can see.

  20. Amy says:

    Nancy,
    Does this apply to pediatric outpatient therapy as well? I believe it does but am unsure. We are in the tricare north region. The owner of the facility said she contacted the administrators and said it’s allowed but the manual says no in regards to PTAs.
    Thank you

  21. Matt S says:

    Can a PTA see a Tricare patient if we were to bill as a facility?

  22. Larry – thank you for your comment and question. This policy is based upon the Tricare regulations as noted in my post. If I had to venture a guess this is not on the radar for change with the military. However I encourage you to have your voice heard either through your elected officials in Congress, as well as making your position know to the APTA.

  23. Amy – thank you for your comment. The underlying federal authority prevails with respect to the application of this policy excluding payment for PTAs in the private practice setting. If the pediatric outpatient clinic is a private practice and billing the Tricare program this policy applies. If the pediatric program is enrolled in Medicare as a Rehab Agency (ORF) or CORF, then this regulation does not apply.

  24. Matt, thank you for your comment. The exclusion of PTAs for Tricare is limited to private practice. Therapy providers enrolled as CORFs or Rehab Agencies are not subject to this prohibition. Additionally outpatient physical therapy provided in hospitals and nursing facilities may be provided by PTAs.

  25. Gary says:

    Nancy,
    Thank you for the clarification regarding how the PTA treatment exclusion is applied for Private Practices vs. CORFs and Rehab Agencies. Where can I find that language?

  26. Gary = Thank you for your question. The reference is contained in the Tricare manual as noted in the second post on the Tricare topic. The underlying authority is the Defense CFR which is noted in the Tricare policy manual with an effective date back to 1983.Let me know if you would like to discuss this issue further.

  27. Charlene says:

    Nancy,

    What if we have a PTA and a PT that are co-owners of our private physical therapy practice. Can the co-owner/PTA treat then I wonder?

  28. Hi Charlene. Thank you for your question. Unfortunately, the Tricare rules of prohibition of “cost sharing” for PTAs is not tied to ownership. The existing Tricare policy prevails. I encourage you to express your opinions to the APTA so that concern over PTA restrictions in private practice is addressed formally.

  29. MELISSA NELSON says:

    Is a COTA allowed to see Tricare patients?

  30. Michele says:

    When I called TriCare about this rule of no cost sharing for PTA services I was informed that this represented the portion that the patient was responsible to pay for. Therefore PTA could provide the service however we could not bill the patient for copay or coinsirance if they had one. Please clarify.

  31. Hello Michelle, thank you for your comments. We have heard the same comment regarding PTAs and “copays” from other outpatient therapy providers. Which Tricare region are you in? Who is the Tricare process provided this statement? – Please contact me: nancyATnancybeckleyDOTcom

  32. Tony says:

    COTAs are not the same as PTAs. COTAs are assistants to the profession, not to the therapists. Hence, occupational therapY assistant, not occupational therapIST assistant. Just wanted to clarify because, as a private practice owner and licensed COTA/L, this is a comparison I often see. Thank you! 🙂

    As for billing purposes, my clinic does not offer PT so I have no input to the PTA debate, but TriCare has never given me any issues as far as reimbursement as a COTA/L.

  33. jon aramendi says:

    Any updates in regards to rule of no cost sharing for PTA services and PTA’s providing the service however not billing the patient for copay or coinsurance. Im refering to Northern region.
    Jon Aramendi, PTA

  34. Hello Jon, and thank you for your comment. Cost sharing does not mean “not billing the patient for copay or insurance” it means that Tricare will not pay for services provided by a PTA. Although the Tricare North region specifically identifies this as an exclusion in their “Provider Manual”, the rule is applicable to all Tricare regions, as it is in the Tricare policy manual.

  35. Tony – thank you for your post. My following comment is for all payment, irrespective of the source of the funds or the payor: In general a third party payor has no way of knowing that a services was rendered by an PTA or a COTA, as the claim (CMS 1500 form) is submitted by the enrolled or credentialed provider which is a PT or an OT. The payment of claim should in no way indicate approval of the therapy, documentation, coding or billing. This information is found upon claim and/or medical record review on a pre-payment or post-payment basis. Post-payment review, audits and investigations by payors are generally what lead to a provider having claims retroactively denied, money recouped and/or potential problems under the payor rules/contract.

  36. Mark Lanton says:

    I would like to know if a PTA is employed in a private practice and is supervised by a DPT as they follow the plan of care to private treatment. If the PTA completes the note and the DPT reviews/verify the note and finalize/sign the note would that be a violation? The Practice Act should cover in these matters what do you know?

    Thanks

  37. Gary says:

    Hi Nancy,
    A recent article by the APTA regulatory affairs specialist (PT in Motion magazine) says “The APTA can state without ambiguity, however, that PTA’s, unfortunately, are not permitted under any circumstances to provide services for payment under Tricare.” I was curious if you were aware of any recent developments surrounding this issue and are you still of the opinion that this CFR applies only to individual providers (not institutional providers – Rehab Agencies)?

  38. Tricare policy prohibits cost sharing in the scenario that you describe for private practice. The Tricare policy dictates conditions for payment, regardless of guidance provided in a Practice Act. Tricare in private practice pays for the services of a PT, and not a PTA, regardless of supervision.

  39. Hi Gary, Thank you for your comments. While the APTA article suggests unambiguity (as you state), unfortunately, when practitioners (in any setting) call a Tricare regional network (North, South, West) they are getting very different answers, and report that often the answers vary from call to call. I anticipate that further review of Tricare policy will be undertaken by our therapy constituency groups in Washington DC and that providers will have clarity from Tricare on therapy policy.

  40. Michelle says:

    Good Morning Nancy! I am a PTA in Ohio and work in an outpt setting for a hospital network, with having an every 4 week in patient rotation within one of our hospitals, we were told at a staff meeting they do not think PTAs are allowed to treat Tricare pts’s due to mom reimbursement. I have been following you article and see you have noted it is more for private practice and not a hospital based facility, is this true and if so is there any documentation tat I can present to support this? Out outpt facility is very close to an Active Base so this will affect our schedules dynamically if PTAs are not able to treat our military personnel. Thank you!

  41. Elizabeth Tenzer says:

    Maybe I missed this but does anyone know WHY Tricare doesn’t allow reimbursement for treatment by PTA’s?

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