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Physical therapists must submit claims to Medicare for covered services provided to Medicare patients. That’s my story and I’m sticking to it!

Manditory Claims Sumbmissions?  Is it Really Manditory?  Here’s What You Should Know!

Last week I jointly presented a program about Medicare’s Mandatory Claims Submission requirement with Kara Gainer, JD, Director of Regulatory Affairs for the APTA.   The presentation clearly demonstrated that, physical therapists must submit claims for covered services provided to Medicare patients, with a few exceptions. By not doing so they may be subject to civil monetary penalties of up to $2,000 per claim and face exclusion from the Medicare Program for up to five years.

The Legal Opinion

A plethora of legal authorities validated the position upheld and reinforced the fact that there is no wiggle room for accepting cash in lieu of enrolling in Medicare. Physical therapists, at this time, cannot Opt-Out of Medicare like physicians and several other practitioners.

For more information on Opting-Out of Medicare please go to: Therapists are not required to accept Medicare patients but if they do they MUST enroll in the program.

References:  Powers, Pyles, Sutter & VervilleHealth Policy AlternativesMintz an AM Law 100 Firm

The Cash-Based Practice

Physical therapists who have cash-based practices and who are adept in collecting monies at the time of service would do well enrolling as a non-participating Medicare supplier.  This means they choose not to accept Medicare’s allowable fee schedule as payment in full but are subject to the’ limiting charge’ proviso:  i.e. they may not collect more than 115% of Medicare’s allowable fees and they must also comply with other conditions set forth relating to their non-participating status.

For more information on provider enrollment and on non-participating suppliers please go to: and

The Exception

There is an exception to the mandatory claim submission provision, but it isn’t a result of HIPAA’s (HITECH’s) Patient Rights as many individuals believe. It is a Medicare provider specific Patient Right which allows the beneficiary/legal representative to (of his/her free will) refuse to authorize the submission of a claim to Medicare if the provider is enrolled in the Program. The HIPAA Patient Right specific to restriction of Protected Health Information (PHI) is the option to request that a Covered Entity/healthcare provider not disclose (PHI) to a health plan. That right is preempted by the Mandatory Claims Submission requirement as noted in § 164.502(a)(2)(ii), § 164.510(a) or § 164.512, which stipulates:

“If a provider is required by State or other law  (Mandatory Claims Submission) to submit a claim to a health plan for a covered service provided to the individual, and there is no exception or procedure for individuals wishing to pay out of pocket for the service, then the disclosure is required by law and is an exception to an individual’s right to request a restriction to the health plan pursuant to 154.522(a)(1)(vi)(A) of the Rule.”


For more information on Mandatory Claims Submission please see the attached reference document as well as linking into the APTA’s FAQs on the subject:

Additional references for the relationship between cash practices and Medicare.

Business & Clinical Management Services (BCMS) is an outpatient rehab consulting firm that provides the keys to unlocking the compliance reglatory vault.  For more information about our services, contact Alicia N. Mahoney at