Can an Enrolled Therapist Sign Off on Treatment Provided to a Medicare Patient by a Non-Enrolled Therapist?
Therapist Enrollment and Medicare Sign-Offs Explained
As outpatient therapy clinics expand to meet growing patient demand, hiring additional therapists is often necessary to maintain high-quality care and uphold the clinic’s reputation. However, the credentialing and enrollment process for new therapists can be complex and time-consuming, often delaying their ability to treat and bill for services with major payers, including Medicare. This delay can create operational challenges for both the clinic and the new therapist, who are eager to begin serving patients.
A common question we receive at BCMS, is whether a non-enrolled therapist can treat Medicare patients under the supervision of an enrolled therapist, with the enrolled therapist signing off on the treatment notes. In this scenario, the clinic would bill for services under the enrolled therapist’s National Provider Identifier (NPI), even though the enrolled therapist did not perform those services. While some payers may permit this practice under specific conditions (read your policy manuals), it is not allowed under Medicare regulations and can pose significant compliance risks.
Risks of Non-Compliance: The False Claims Act and Whistleblower Actions
Misrepresenting the rendering provider by billing under an enrolled therapist’s NPI for services performed by a non-enrolled therapist violates Medicare’s billing requirements. Such actions may also constitute a violation of the False Claims Act, which prohibits submitting false or fraudulent claims to the government.
A notable example is the 2019 case involving Fusion Physical Therapy. A whistleblower reported that the clinic submitted false claims to Medicare for physical therapy services performed by non-enrolled or, in some instances, non-licensed individuals, billed under the NPI of an enrolled therapist. Both the clinic and its founder were found liable for violating the False Claims Act. This case underscores the serious consequences of non-compliance, including financial penalties and reputational damage, often triggered by reports from clients, current employees, or former staff.
Medicare Enrollment Requirements
The Medicare Program Integrity Manual (Chapter 10, Section 10.1.2) clearly states: “No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.” This requirement, effective March 12, 2021, and implemented March 22, 2021, mandates that providers and suppliers [Part B: BCMS] enroll with the appropriate Medicare Administrative Contractor (MAC) to bill for services.
Additionally, the Medicare Benefits Policy Manual (Chapter 15, Sections 230.2 A., 230.2 B, and 230.4) specifies that therapists, defined as qualified physical therapists, occupational therapists, and speech-language pathologists, must be enrolled to bill Medicare directly as private practitioners. The MBPM further clarifies that therapy services must be provided by or under the direct supervision of an enrolled therapist in private practice (TPP). However, even if a non-enrolled therapist provides services under the supervision of an enrolled therapist, these services cannot be billed to Medicare, as the manual does not permit billing for services performed by non-enrolled providers.
Enrollment Process and Retrospective Billing
The Medicare Program Integrity Manual (Chapter 10, Section 10.6.2) provides guidance on the effective date of billing privileges for newly enrolled providers. The effective date is the later of:
- The date the MAC receives a complete, signed CMS-855I enrollment application that can be processed for approval, or
- The date the provider first began furnishing Medicare-covered services at the practice location.
Once approved, providers may retrospectively bill Medicare for covered services provided up to 30 calendar days prior to the effective date, provided the claims are submitted within the 1-year timely filing deadline. Since the Medicare enrollment process typically takes 60–90 days, therapists can begin treating Medicare patients during this period and hold claims until enrollment is finalized.
Example: A therapist submits their enrollment application on May 1, 2025, but begins treating patients on April 1, 2025. The effective date of billing privileges would be May 1, 2025 (the later of the two dates). The therapist can bill for services provided on or after April 1, 2025 (within the 30-day retrospective period) once enrollment is approved, as long as the claims meet the timely filing requirement.
Conclusion
To ensure compliance with Medicare regulations, outpatient therapy clinics must avoid billing for services performed by non-enrolled therapists, even under the supervision of an enrolled therapist. While the enrollment process can be lengthy, therapists can treat Medicare patients during this period and hold claims for submission once enrollment is complete, leveraging the 30-day retrospective billing allowance. Clinics should prioritize timely enrollment and maintain strict adherence to Medicare’s billing and enrollment guidelines to avoid costly violations and protect their reputation.
About BCMS
BCMS is a trusted leader in healthcare compliance, delivering enrollment, credentialing, audit, and appeals services, as well as other regulatory solutions, for outpatient therapy providers. BCMS specializes in empowering healthcare providers through our comprehensive Compliance Program, which includes tailored policies and procedures and integrates Federal guidance with robust annual training. Stay informed with our latest insights at bcmscomp.com/blog.
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Disclaimer: This blog is for informational purposes only and does not constitute legal advice. Consult an attorney for legal matters or a compliance professional for specific guidance.