Tricare does not reimburse for therapy provided by therapy assistants, and in fact excludes from reimbursement outpatient physical therapy that is performed 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?