Whether an OT needs a referral from a physician to start seeing a patient depends on state practice acts and insurance requirements. Let’s dig into each consideration.
State Practice Acts
The most important factor is the state's practice act for occupational therapy, as requirements vary by state:
- Some states explicitly require a physician's referral, while others do not.
- Some states may allow an OT to begin with an evaluation but require a signed plan of care from a physician.
- In states where the practice act doesn't explicitly require a referral, it may be interpreted that a referral isn't needed.
Either way, it's important to check the specific wording of your state practice act, which you can check out in this resource! 👇🏼👇🏼
State-referral-requirements.pdfInsurance Requirements
Even if a state doesn't require a referral, a patient's insurance may.
- If a patient plans to seek reimbursement from their insurance using out-of-network benefits, the insurance company may require a physician's referral.
- It's important to make clients aware of this possibility, especially if you're providing a super bill (an itemized receipt) for insurance reimbursement.
- When dealing with Medicare Part B, a physician's referral isn't required to start treatment, but the physician must sign off on the plan of care within 30 days. It's considered best practice to obtain a physician's referral in these cases, to ensure the plan of care can be approved.
Professional Judgement
Even if not legally required, it may be wise to get a physician's referral in some cases. For example, if you plan to use modalities or there are precautions, you may want to ensure the doctor is aware and approves. This can be an additional safety and risk management measure and also facilitates better coordinated care.