Occupational therapy is not consistently defined and paid for across plans or within specific companies. Health care insurance plans, whether publicly or privately funded, consist of contracts that specify the rules or conditions under which they will cover an array of services.
The payer also may impose limitations or restrictions on covered services and payment. A therapist must be able to ascertain the following information about clients' plans to provide the optimal covered care and to assist them in making decisions about continuing care that their insurance may not cover.
- What is the plan's definition of occupational therapy?
- Are there limitations in number of visits, sites at which services may be received, or yearly costs incurred for occupational therapy services?
- Is there a network of providers that an occupational therapist must join to bill? Can a patient "opt out" of the network, and if so, what financial disincentives exist?
- Does the plan offer case management services for some conditions?
- Does the plan pay a fee for service or is payment for occupational therapy "bundled" into a group of services (e.g., a set amount for all rehabilitation services)?
- Does the payer require specific credentials for occupational therapists?
- Does the payer require that the therapist or health care facility or clinic join a provider network?
- Is the client responsible for co-payments, deductibles, or other out-of-pocket expenses? Under what circumstances?
To remain solvent, therapy departments and practices must develop not only good clinical skills, but also expertise in multiple payer requirements for such issues as network enrollment, coding, billing, and appeals.
Health care practitioners today, more than ever before, must expect to balance what they determine as the needs and goals of the patient with state practice regulations, employer priorities, and payer requirements, all within a framework of the ethical standards of their profession.