• When you submit a claim for services, you are attesting that you have earned the payment requested and that you are in compliance with all the billing requirements. Therefore, it is important to know the coverage and payment policies of Medicare, Medicaid, workers compensation, automobile liability, and commercial insurers.

    Ignorance is not a defense.  

    If you knew or should have known that a claim you submitted was false, then attempting to obtain this money from the government or a private payer constitutes a violation of the law.

    Types of claims that would be considered improper include:

    • Billing for services that you did not provide
    • Billing for services that are not medically necessary
      (Review 'Defining Medically Necessary Physical Therapy Services')
    • Billing for physical therapy services provided by aides
    • Billing for services provided by physical therapist assistants that were not properly supervised by a physical therapist
    • Billing for excessive duration and frequency of services
    • Billing codes that pay a greater amount than the service provided (eg, upcoding)
    • Billing for direct 1-on-1 services when they were provided to multiple patients at the same time with no direct 1-on-1 contact

    Guidance from APTA

    The federal government and other payers rely on physical therapists to use their clinical judgment to provide patients with appropriate services and to submit proper claims for payment with accurate information. When you submit a claim for services for a Medicare or Medicaid beneficiary, you are attesting that you have earned the payment requested and that you are in compliance with all the billing requirements.

    APTA provides coding guidelines at APTA.org:

  • Last Updated: 9/11/2014
    Contact: advocacy@apta.org