Tricare policy does not allow for therapy to be paid when it is provided by a physical therapist assistant (PTA) in private practice settings. A previous post on this generated a lot of comments , as well as a lot of email. The reference in that post on Tricare and private practice PTAs was the provider manual for the Tricare North Region. (Do you know which region you are in?). The 2014 Tricare Provider Manual for the North Region has recently been published online, and continues to state as part of its exclusions list (page 70): “physical therapy services performed by a physical therapy assistant”.
As a result of my previous post many providers called the other Tricare regions (South and West) to find out that the provider manual for those regions did not specifically mention exclusions related to therapy provided by physical therapists assistants (PTAs). Another provider contacted me to indicate that she uses the underlying federal regulations as a guideline, even through the prohibition against PTAs is not in her region’s manual.
Tricare and Private Practice PTA – Policy in the Code of Federal Regulations
To clarify, the exclusion of PTAs as providers, is limited to PTAs in private practice, as noted in the policy below based upon the Code of Federal Regulations at 32 CFR 199. 6(c)(2). So those providers utilizing PTAs (under appropriate supervision) in hospitals and other institutional providers such as Rehab Agencies and CORFs are not subject to the PTA exclusion. The Tricare Policy, is noted below.
Services Rendered By Employees Of Authorized Independent Professional Providers
Issue Date: April 19, 1983, Authority:32 CFR 199.6(c)(2)
Services commonly furnished by employees in physicians’ offices or clinics which are either rendered without charge or included in the physicians’ bills are referred to as services furnished incident to a physician’s professional services. This means that the services are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.
Services rendered by employees (i.e., aides, technicians, attendants, etc.) of an authorized independent individual professional provider (hereafter referred to as an authorized provider) are subject to the following criteria:
2.1 The individual must be an employee for whom the authorized provider, as employer, pays a salary, Social Security taxes, Workmen’s Compensation, etc.
2.2 The services must be performed under the authorized provider’s direct personal supervision.
2.3 The authorized provider must bill for the services rendered by the employees.
2.4 The services rendered must be otherwise covered, and not of a type usually performed only by a physician or other authorized provider.
Services performed by a physical therapy assistant who is employed by an independent provider, may not be cost-shared.
Do you provide services under Tricare (a Federal health care program)? Do you use physical therapist assistants? Do you have a facility policy in your private practice setting for therapy services provided to Tricare enrollees? Have staff been trained on this policy?