If you’re trying to figure out what exactly direct access means for occupational therapy and whether or not you need a physician’s referral to see a patient, you’re in the right place! Let’s explore the concept of “Direct Access” in Occupational Therapy (OT) and answer the crucial question: Do you need a physician’s referral to see a patient?
Ep 31: Direct Access in OT: Do I Need a Physician’s Order?
Direct Access allows OT practitioners to evaluate and treat patients without a physician’s prescription, providing greater autonomy and accessibility to care.
In most cases, patients come to therapy with some form of physician’s order or prescription. This could also potentially come from a nurse practitioner, physician’s assistant, or the physician themselves. These clinicians are generally referred to as “prescribing clinicians”. For instance, in post-acute care facilities or hospitals, patients usually have a prescription that triggers the therapy referral.
However, the issue of needing a physician’s prescription arises more frequently in private practice or outpatient settings where patients directly request services. Here, we need to consider two separate questions:
- State Practice Issue: Does your State Practice Act grant you direct access to patients without a physician’s order?
- Reimbursement Issue: Does the insurance provider require a physician’s prescription for reimbursement?
What is direct access in occupational therapy?
Direct access is when a clinician does not require a prescription, referral, or order to see a patient and initiate care. Direct access is a scope-of-practice issue and can increase patient access to care because they do not have to get permission from their doctor or provider first. It can also reduce delays in care and support individuals who don’t have health insurance or may not have a primary care provider who is willing to issue an order.
What states have direct access to occupational therapy?
Most states have some form of direct access to OT services. However, the access may be limited in scope. To identify if you have direct access in your state, check the occupational therapy state practice act.
Looking at direct access through your state practice act is a scope-of-practice issue. This is a different discussion from whether or not it is required for reimbursement, which we’ll discuss below.
If you need help identifying if your state has direct access, start by contacting your state association. (If you aren’t a member, you should join to support them helping you out.)
Can an OT evaluate a client without a physician’s prescription?
Some states allow occupational therapists direct access to evaluate and treat the patient without involving a physician, others may only allow direct access for the evaluation. Others may limit direct access based on the diagnosis. For example, in some states, if you identify a medical condition that indicates a need for therapy, you may need to seek a physician’s prescription to continue care. Review your practice act for details on what your state requires.
Insurance and Reimbursement Considerations
Even if you have direct access in your state, there may still be requirements for a physician referral or order in order to get paid for those services. So even though your scope of practice or practice act allows you to see a patient without a referral, certain health insurance plans may require a referral or order for reimbursement.
Another consideration is when exactly you have to obtain that referral. Some insurances, like an HMO, may require the referral BEFORE you see the patient in order to get paid. Other insurance like Medicare may only require a physician to approve the plan of care after the initial eval. Some insurances may require both an order before you see the patient, and that the physician signs off on the plan of care. So make sure to review your patient’s insurance guidelines for details.
Below, I’ve explored some of the common scenarios around direct access to occupational therapy.
Scenario 1 – Direct Access with Insurance Reimbursement:
Suppose a patient wants to utilize their health insurance for occupational therapy but lacks a physician’s prescription. If your state has direct access, you can see the patient without a physician’s order. However, if insurance requires an order for reimbursement, you’ll need the physician’s prescription to initiate the plan of care.
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Scenario 2 – No Direct Access with Cash Payment:
If a patient wants to pay cash or doesn’t want to use insurance, then you’ll need to check your state practice act to determine if you need a physician’s order or referral and when you might need it. So if your state has limited direct access, you’ll still need to get the appropriate referral even if you are not utilizing insurance for payment.
Scenario 3 – Direct Access and Cash Payment:
If you have a patient who does not want to use insurance or wants to pay cash, and you have robust direct access in your state then you should be good to go! Of course, make sure you are complying with the Occupational Therapy Code of Ethics and other relevant laws. Some states may limit the number of visits you have with a patient before seeking orders others may limit direct access based on a patient’s diagnosis.
Does Medicare require a referral for occupational therapy?
Medicare technically doesn’t require a physician’s order to see a patient. However, the physician or another prescribing clinician must sign off on your plan of care in order to get paid.
To avoid losing money, most clinicians still get the physician’s order before seeing the patient to avoid risking the physician declining to sign the plan of care because they disagree with the services. Sometimes a simple phone call can be enough to confirm the physician is willing to approve the plan of care, other times, you may want to have the order in hand.
AOTA, APTA, and ASHA are advocating for this policy to be revised and that CMS should not require a physician to sign off on the plan of care if the patient already has an order or referral before initiating the care. However, this is not yet a rule change that has been proposed or adopted by the Centers for Medicare & Medicaid Services (CMS).
Summarizing Direct Access in OT
To determine if a physician’s referral is necessary, consider both your state’s regulations and the insurance provider’s policies. Of course, even if you have an order, you still need to make sure your services are medically necessary, meet coverage criteria, are within your scope or practice, and that you’re complying with the Code of Ethics.
Having a referral or a physician signing off on your plan of care does not alleviate your liability or responsibilities as a clinician.
If you have questions about direct access or want to discuss more, check out the Amplify OT Podcast episode on this topic and jump into the Amplify OT Membership, where we can discuss these topics in depth.