This year was the fourth time that Texas Physical Therapists had a proposed bill in the Texas legislature that would grant what we consider Direct Access. Before a bill can even be voted on by the House and Senate, it has to be given a “Hearing” within a committee (the “Public Health Committee” in our case). If it receives a majority vote by the committee members, it can then be brought to the floor for a vote. I usually fell asleep in my government classes, so I may be off on a point or two; but I believe that’s generally how it goes in Texas.
In preceding years, our Direct Access bills never even made it into a committee hearing, but things changed yesterday! We finally received a hearing! Keep your fingers crossed for us, because it’s obviously a long process before anything becomes law.
How Direct Access affects private physical therapy practices
I’m actually not writing to explain the Texas legislative process or to describe the events at the Texas Capitol yesterday. I’m writing to explain how the Direct Access issue affects me as a Cash-based Physical Therapist who rarely gets referrals directly from Physicians. The majority of my patients come from word-of-mouth referrals or finding my practice online (either Google search or review sites like Yelp). When I discuss my practice with other Physical Therapists, I often get the question, “If your referrals are mostly word-of-mouth and rarely from Physicians, how do you deal with the Direct Access issue?” Here is what generally happens when a new patient calls to schedule an appointment …
Getting a referral for physical therapy
Sometimes the patient was told by her Physician that she needs Physical Therapy and already has a referral. (I’m going to avoid the awkward he/she stuff and just use the feminine). If she doesn’t have a referral, it then becomes a question of whether or not she can avoid a trip to a Physician (or Chiropractor, Nurse Practitioner, Podiatrist, Dentist, etc). To see if this is possible, I go through the following questions:
- “Have you seen any other Health Care professionals for this injury/pain?” If so, the prospective patient may be able to call that office and ask them to fax one without having to go in for another appointment.
- If the answer to the above question is “No,” I ask her if she has a relationship with any Medical Doctors or Chiropractors anywhere. Would any of them be willing to fax a script without the patient needing to come in to see them? Does she have any Doctors in the family, even in another state, who would be willing to write a referral?
- If the answers are all still “No,” but she does have an established relationship with a Physician in the area, I ask her to see if she can get in for a visit soon. If she can’t get an appointment soon enough, I then suggest a local urgent care center.
- If that’s not an option either, I suggest she find a Primary Care Physician in the area who does not have a long wait. If it’s not a rural area, there is usually someone who can squeeze them in for a short visit within a day or two.
- If she doesn’t see any of the above as good options and wants to see her busy orthopedist, then she may just have to wait a while. At that point, I explain the difference between the treatment given at a POPTS and the treatment I give, and that it is always her choice where she receives PT. It is not uncommon for some orthopedists who own a PT clinic to steer the patient that way.
I have lost prospective patients due to the direct access issue and to Orthopedists convincing them to use their own PT. It’s a bummer, but as you can see from the list of questions and options above, most people who are adamant about coming to your clinic will be able to get a referral fairly quickly. If it is an emergency (ex: a newly sprained ankle, but needs to be ready for competition in a few days), I explain that their best bet is to go to the urgent care center to get an x-ray and a referral. Then I can see them that evening.
Every State has different laws so if you are not in a Direct Access state, don’t assume that the methods above are fully applicable to you too. Check with your State Board to get the needed details. If you’re adding cash-pay services to your current or future practice, you’ll have to market directly to the public, so you’ll also have to know how to handle those calling without a referral. The above info should provide some guidance.
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Hello Dr. Carter. Excuse my naivete but according to the APTA (http://www.apta.org/StateIssues/DirectAccess/Overview/ …there’s a Direct Access map linked at the bottom of the page), Texas has been a Direct Access state since 1991. … So I don’t fully understand your post here. What am I missing? Thanks!
No need to apologize. Yes, Texas is included in the list of “Direct Access” states because patients can come to us without a referral for Evaluation. However, we cannot provide any treatment without the medical referral. So I personally do not consider that “Direct Access,” because it’s certainly not Direct Access to PT Treatment. And just about every PT I know in Texas feels the same way. Thanks for the question … this was a good thing to clarify.
Dr Jarod Carter – thanks for all the information. I recently started my own practice in NYC with a combination of cash based and OON reimbursement. In NY the direct access law for physical therapy allows for 10 visits or 30 days without a physician referral. I am having a great problem that my current patients would like to stay on as cash-based physical therapy patients after their course of treatment has plateaued or ended in stead of continuing (for the most part) with their current massage therapists or personal trainers. I know that I have read about a differentiation with “maintenance” in particular with regards to medicare, but are you aware of any of the same differences that may assist me in my position with regards to direct access physical therapy treatment. It would be great if I didn’t have to keep on getting MD scripts, but I will if I have to. Another area I am unfamiliar with is what the maximum duration of a treatment plan on a physical therapy script or if the time is not specified (which may negate the script completely, but I have absolutely come across) how long it is valid for?
Let me know what you think
Steve Horney
stevehorneypt.com
homeptnyc.com
Presenter on theptproject.com
Hi Steve,
First of all, congratulations on starting your practice and going the route of cash pay and out-of-network. I’ll quickly answer your second question first: How long a PT script is valid should be covered in your State Practice Act. In Texas, referrals are valid for a year, though there are other caveats that can affect that time-frame. So I would check with your State Board because I’m sure it can vary from state to state, but they should have an answer for you.
If I’m reading your first question correctly, I think I would again have to defer you to your State Board. If you are continuing PT care after the 10visit/30day period (cash-based or not), I don’t think it matters whether or not it would be considered “maintenance” … My guess is that you would need a referral either way.
With that said, if you had “separate” fitness or wellness programs set up and had personal trainers on staff, you may be able to avoid the referral issue. However, if you (as a Licensed PT) are overseeing those programs, you could still run into direct access issues. I wish I could give more definitive answers but to be completely sure and safe, these are questions for the State Board and possible a good Healthcare Lawyer.
Hi, we have a practice in Texas…I was under the impression that the referral was only good for 30 days if unused. If the patient has begun treatment then the frequency approved by the doctor dictates the referral. Since we have to re-evaluate every 30 days, we normally send a referral with the re-eval. Regarding the 1 year, I thought that was related to whether a patient returns after “leaving”….such that they come back after discharge or absence of 35 days, you can use the same referral as before if the condition is the same, the PT has been licensed a year and you notify the doctor within 5 days. Lisa
Hi Lisa,
Thanks for your comment. I’m glad you posted because it compelled me to review our Practice Act and call the PT Board for clarification. You are correct in basically everything you wrote; and what I wrote was in reference to prior referrals (like you mentioned above). However, I was told something slightly different from your statement above that “the referral was only good for 30 days if unused.” If the referral does not give a time limit or set number of treatments, there is no end-date. It is left up to the “professional judgement” of the PT as to the need of a new or renewed referral in this situation. Also, in looking closely at the Practice Act, we are required to re-eval every 30 days but it does not mandate this re-eval be sent to the referring Physician (though it seems like best practices to do so anyway). I believe this action is something many practices do with All patients though it is only mandated for Medicare patients. Let me know if you find anything different. I appreciate your time and input on this.
Hi Jarod,
Thanks for your great info/content. I’m cash-based in Texas also. My understanding is that we need referral/RX per Texas act/rules, but the requirement to have a signed plan of care is for insurance rather than state act/rules…right? So for instance, if I have a patient who gets an referral/Rx for PT, but then when I write up the eval and send it the physician doesn’t want to sign it (because it’s “not their area of expertise” for instance), its ok ’cause I have that initial referral that covers us (the example I’m currently working with the referral is very general – “body aches”). I have double checked act/rules and don’t find anything contradicting this, but wanted to see if you understood it that way or had heard something different.
That’s how I understand it too. I don’t think we area required to have a signed POC
From what I understand, we have similar direct access legislation in California in that we are unable to treat a patient without a diagnosis from a diagnostician. We do not actually need a prescription though, just evidence of an exam/diagnosis. My question is, how do you verify this information so that it is considered acceptable from a legal standpoint? Also, in CA we can treat patients without a Dx for the purpose of improving health and wellness. Is this also the case in Tx?
It sounds similar, but there are definitely some differences… we definitely need a script to initiate treatment. However, like in CA, our practice act does not allow us to give medical diagnosis. So legally, we have to have a script from an approved healthcare provider, which includes the necessary medical diagnosis… in other words, we don’t have the same issue you’re asking about (can treat without referral but need diagnosis… which doesn’t really sound like direct access to me because people still have to see a “diagnostician” before seeing the PT). And yes, as far as I understand it, we can see clients on a fitness/wellness basis without referral but it really can in no way be considered skilled PT or you can get into trouble.
Dr. Carter,
I work PRN in a private practice and have a MCR provider number in Pennsylvania. I am new to the private pay arena. If I am to take on a few private patients outside of this office, if I understand correctly, I am still a participating provider and therefore cannot accept cash from private MCR patients? (I also have my direct access license). Thank you for clarifying.
Hi Lisa, thanks for your question. If you have a MC provider number, then I believe that would apply to you in any practice. So make sure you also read this post, because there are instances when you can take cash payments for non-covered services.
Dr Carter,
I am just moving to TX right now and through some contacts where I previously lived (Boston, MA), I have a few people who would like to see me for treatment as a self pay/out of pocket and essentially “home care” but not through insurance.
Am I allowed to do this with my PT license? I am licensed in MA and TX.
Do you have a recommendation of what to call it and paperwork to complete? I’ve done this before in MA but with patients I was familiar with and we were able to call it more of a personal training visit or a home assistant. This will be different because I’ll be doing more manual treatment. Any ideas? Thanks!
Hi Jessica. Sorry for the delayed reply.
If you are licensed in Texas, then you can see patients for treatment in their homes and provide skilled PT services. You’ll need to check with the Texas State Board on whether or not you have to register a business with them first, but I know that if you are seeing patients in their homes you do not have to register each home as a PT facility, or anything like that. Whether you take cash payments or bill insurance has no effect on the direct access law, if that’s also what your asking about? Every one of our patients here in Texas, at the time of this writing, must have a PT referral before we begin treatment (though you can evaluate the patient before obtaining a referral).
As far as calling the visits “personal training” or something other than PT, I would be very careful here because personal trainers are not supposed to be doing manual therapy, and what we do as Manual PTs still goes way beyond what massage therapist are licensed to do (although many massage therapists and personal trainers step way beyond their scope of practice on a daily basis, that doesn’t mean it’s okay for us to break the rules 🙁 ).
I wish you all the best of luck, and would say you’re off to a great start given you have cash-based patients waiting for you before you’ve even moved here! Well done!
Hello, just a question. Where is the process of direct access for PTs in Texas? when is the next vote?
Hi,
Dr Carter is currently out of the country for the holidays and will get back to you when he returns!
Kate Serra
Assistant to Jarod Carter PT, DPT, MTC
In the last legislative session (2013) we made it one step further towards changing the law than we had in previous sessions, but the direct access bill was still very very far from actually passing. In Texas, the legislature meets only once every other year so we will not have another chance to change the law until 2015.
Hi,
I am a PT practicing in PA, and I was wondering how you would deal with a situation where services are no longer covered by insurance because coverage has expired or been used up. Can patients continue on a self-pay basis with a Dr’s prescription? When patients are receiving services on a self-pay basis, are we still required to document? Must you still adhere to practice guidelines as established in the practice act and or the Guide to Physical Therapist practice (specifically regarding treatment length, etc)? Or, can you treat patients on a maintenance basis? Basically, if a patient is electing to attend PT treatment for maintenance purposes and pay out of pocket for supervised care and manual intervention and modalities, is it okay if they do not show or we cannot document progress? That is a lot of questions, thanks for your insight.
Megan
Yes, of course you can continue care on a cash pay basis if the patient’s insurance benefits have been depleted (Note: this is not necessarily the case with Medicare).
As for documentation, being cash-based doesn’t mean you don’t have to document your treatments thoroughly. You still must make sure your documentation falls within the guidelines and requirements of your State Practice Act, and that they would be sufficient in a court of law if there were ever any legal issues arising from your treatments. Luckily, in many cases, documenting in this way is still less tedious than what you have to do to ensure Insurance and Medicare reimbursement.
So if you were state practice act, which outlines the standards and details of how you must document, does not require you to document progress with each patient, then you do not have to do so.
Again, seeing patients on a cash pay basis or simply having a cash-based practice does not change how you must document. That is all determined by your state practice act.
Hello,
I am seeking to open cash base practice some point next year. I live in stat of Georgia where evaluation is the only form of direct access. would cash base practice work in this environment where we always required MD referrals? I have some ideas to accept medicare patients, but not familiar with laws.
Hey Michael,
Like I said above, I’m in the same situation here in Texas that you are in Georgia… No treatment can begin without referral. So the answer to your question is yes, I end a number of other cash-based practices are alive and very well in Texas.
As for the Medicare stuff, see this post and keep an eye out for the Medicare e-book I’ll be releasing in 2014
hi. i see there was activity in May 2015 to get direct access under consideration again. can you comment on if texas is any further along in this process? thanks!
No, the bill was once again killed by the Texas Medical Association. We’ll have to wait another two years for our next try
I know that this is an old thread, is our profession dealing with the same issue in Texas? Thinking of moving there and being cash based but this direct access thing has me second guessing.
Hey Darryl,
Unfortunately, Texas doesn’t have direct access. Jarod just recently did a video blog on this exact topic and how you can get PT scripts in non-direct access states. You can check it out here to see if you think these strategies could work for you: https://drjarodcarter.com/pt-scripts-direct-access-patients-in-non-direct-access-state/.