With all of the changes going on in healthcare as a result of COVID-19, many physical, occupational and speech therapists are looking for opportunities to provide care in their patients’ homes. One avenue to deliver services at home is by setting up a rehabilitation agency to bill the services. There are a lot of advantages to becoming a rehabilitation agency, but as with most business ventures, there are some disadvantages as well as pitfalls to avoid when taking this route.
Here are some suggestions to consider:
Do Your Homework
A provider often chooses to become a rehabilitation agency because the goal is to deliver rehabilitation services through a multidisciplinary team that includes physical, occupational, and speech therapy services. To be considered a rehabilitation agency under the Medicare program1, the agency must at a minimum:
- Provide an integrated interdisciplinary rehabilitation program designed to upgrade the physical functioning of handicapped, disabled individuals by bringing specialized rehabilitation staff together to perform as a team; and
- Provide at least physical therapy or speech-language pathology.
States can also create their own definitions and/or requirements for a rehabilitation agency. Some states require a multidisciplinary practice to get licensed as a rehab agency and therefore if you set up as a group practice instead, it would be illegal according to the state but not according to the CMS.
Some states may have a certificate of need (CON) program that regulates any new institutional facility. A CON program provides a set of regulations set up by states to control establishing and/or expanding health care facilities and services in a given area.2
The rehabilitation agency is also unique in that it is considered an institutional setting by Medicare. This means it is subject to Conditions for Coverage (CfCs) and Conditions of Participation ( CoPs).3 A provider must demonstrate that it meets the CfCs and CoPs before it can bill for services as a rehabilitation agency. This is accomplished by a survey conducted by the state department of health or a deeming authority.
It is also prudent to check the availability of payer networks in your area. Do they understand what “outpatient therapy in the home” is? More importantly, do they understand what a rehabilitation agency is? Don’t assume all payers are familiar with the term or familiar with the constellation of services provided. You may have to do some education with them before attempting to bill for services.
After setting up your business entity, the next step to becoming a rehabilitation agency is to enroll in Medicare. Start by obtaining a Type 2 National Provider Identifier (NPI). The next step is completing a CMS-855a form. Many providers make the mistake of completing the CMS-855B form for outpatient providers because they will be delivering ‘outpatient’ services. However, since an agency is considered an institutional entity by Medicare, the CMS-855a is required.
Prepare for Your Survey
Every agency must be surveyed prior to being able to bill for services.4 Unlike private practices or group practices, this site visit will be more than just a check to ensure you are operational. As mentioned previously, rehabilitation agencies must comply with a set of CfCs and CoPs. This requires planning, preparation, and investment of resources. Providers must have an actual ”space” to be surveyed with a minimum amount of equipment. If you plan to be primarily a mobile agency, delivering services in the home, consider this in your preparations. Providers must develop policies and procedures, patient care policies and an emergency preparedness plan.5
Practice Administration Considerations
Credentialing: One benefit of being a rehabilitation agency, rather than a group practice, is that you only have to enroll once. In other words, every therapist working for you does not have to be separately enrolled. However, Medicare-managed care payers, state Medicaid programs, and other commercial payers may still require each therapist to be credentialed.
Staffing: Services delivered by therapist assistants require general supervision.6 This is often seen as one of the primary benefits to setting up a rehab agency since in a group practice, therapist assistants require direct, onsite supervision. However, when delivering services in a rehab agency clinic, there must always be two people in the clinic.6
Billing: Rehab agencies bill on the CMS-1450 form, also referred to as the UB-04 or CMS 837I. A rehabilitation agency, as an institutional provider, bills only once a month, and therefore the UB-04 reflects up to 30 days of services. The CPT®7 codes are used to define the skilled services.7 Claims are paid using the Medicare physician fee schedule for skilled services delivered.
When it comes to providing rehabilitation services in the home or ALF, there are important decisions to make to decide what kind of entity is best for you and your clients.
How-to Guide for Part B in the ALF/Home
Advice for Rehab Consultants Seeking to Expand Their Service Options
1Electronic Code of Federal Regulations. Title 42: Public Health. Chapter IV; Subchapter G; Part 485-Conditions of Participation: Specialized Providers; Subpart H. Retrieved from: https://www.ecfr.gov/cgi-bin/text-idx?node=sp42.5.485.h&rgn=div6.
2Investopedia. Certificate of Need (CON). Retrieved from: https://www.investopedia.com/terms/c/certificate-of-need.asp.
3Centers for Medicare and Medicaid Services. Conditions for Coverage (CfC) & Conditions of Participation (CoPs). Retrieved from: https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs.
4Centers for Medicare and Medicaid Services. Quality, Safety & Oversight – Certification & Compliance. Outpatient Rehabilitation Providers. Retrieved from: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/OutpatientRehab.
542 CFR 484.4. Centers for Medicare and Medicaid Services, Internet Only Manual, Benefits Policy Manual. Chapter 15 – Covered Medical and Other Health Services. Section 230.1.C
6Electronic Code of Federal Regulations. Title 42: Public Health. Chapter IV; Subchapter G; Part 485-Conditions of Participation: Specialized Providers; Subpart H. §485.723(a)(6) Physical Environment. Retrieved from: https://www.ecfr.gov/cgi-bin/text-idx?node=sp42.5.485.h&rgn=div6.
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