Compliance Matters TRICARE: The US Military's Health Care Program A look at 2 issues: Are PTAs reimbursable? Also, regions will consolidate. By Kyle Levin, JD | December 2016 APTA has received many requests from its members for clarification on the role physical therapist assistants (PTAs) can play within TRICARE, the health care program of the US Department of Defense. The confusion is understandable, as neither TRICARE itself nor contractor provider manuals have been crystal clear in their communications. APTA can state without ambiguity, however, that PTAs, unfortunately, are not permitted under any circumstances to provide services for payment under TRICARE. The rationale is contained in the Code of Federal Regulations (CFR) and TRICARE's policy manual. The CFR is the codification of the general and permanent rules and regulations (sometimes called administrative law) published in the Federal Register by the executive departments and agencies of the federal government. 32 CFR Part 199 regulates the TRICARE program. Part 199.6, specifically, addresses TRICARE providers, and it does not recognize physical therapists (PTs) as "independent authorized providers." PTs are classified, rather, as "other individual paramedical providers." This means that, while PTs may provide services to TRICARE beneficiaries, the patients must have been referred by a physician, certified physician assistant, or certified nurse practitioner and physician. Also, the referring individual(s) must provide continued and ongoing oversight and supervision of the program or episode of treatment provided by the PT (or by anyone else listed as "other individual paramedical provider"). No direct mention of PTAs is made in 32 CFR Part 199.6, so they are not recognized as TRICARE-authorized providers. While TRICARE does recognize the use of employees such as aides and technicians in the physician's office, it does not pay for these services, and PTAs are not among the employees listed. Meanwhile, Chapter 11, Section 10.1 of the TRICARE policy manual, which governs services rendered by employees of authorized independent professional providers, excludes PTAs by name. The pertinent passage reads, "Services performed by a physical therapist assistant who is employed by an independent provider may not be cost-shared." Despite APTA's advocacy efforts, TRICARE officials have defended the exclusion. They maintain that under TRICARE overall care of the patient receiving physical therapist services is the responsibility of the physician or other "independent professional provider," requiring ongoing supervision by that independent provider of "other paramedical professional providers" identified under TRICARE policy. Because PTAs are not listed by TRICARE among paramedical providers, officials say, services rendered by PTAs cannot be covered. Penalties APTA believes that TRICARE has no reasonable basis for denying payment for services provided by PTAs. Regardless, providers submitting reimbursement claims to TRICARE for services provided by PTAs face significant potential penalties. The False Claims Act is a federal law meant to protect government programs from fraud. As it is illegal under that act to submit claims for payment to Medicare, Medicaid, or TRICARE that providers know or should know are false or fraudulent, the act applies to providers who submit to TRICARE reimbursement claims for services provided by PTAs. The act authorizes fines of up to 3 times the claim amount plus an additional $11,000 per claim filed. Each instance of improper billing counts as a claim under the False Claims Act. In other words, only a few instances of improper billing for PTA services could put a practice out of business. Within the civil portion of the False Claims Act, providers can be penalized if the provider is deemed to have acted in deliberate ignorance or reckless disregard of the truth. In such cases, intent to defraud by billing TRICARE for services provided by a PTA need not be shown. The False Claims Act also has a whistleblower provision that encourages people to call attention to instances of improper billing by entitling them to a portion of any money recovered. Providers also can face fines or potential imprisonment for filing false claims to TRICARE under the criminal component of the False Claims Act. While criminal prosecution for filing claims for services provided by PTAs is rare, it has happened. The bottom line is that PTs should not use PTAs when providing services to patients under TRICARE. Often TRICARE provides supplemental insurance coverage, leading to additional inconsistencies. It is prudent, therefore, to use a tracking system to flag TRICARE patients and keep them off the list of patients assigned to PTAs. APTA also recommends that you educate all members of your staff or practice on rules regarding TRICARE and billing of services provided by PTAs. APTA recognizes the burden that TRICARE's policy on PTA services places on PTs—particularly those who serve a large number of TRICARE beneficiaries. PTAs are licensed individuals who provide quality care under the supervision of PTs and are recognized as eligible for reimbursement by Medicare, Medicaid, and most private insurance companies. APTA has advocated and will continue to advocate for policy changes to allow PTAs to provide reimbursable services under TRICARE. Coming in 2017: Two Regions Another TRICARE-related matter of importance to APTA members is the agency's recent announcement that in 2017 it will consolidate its regions from 3 to 2. TRICARE currently divides the United States into a North Region consisting primarily of the Northeast, Mid-Atlantic, and Midwestern states; a South region that extends as far west as Oklahoma and most of Texas; and a West region that includes Alaska and Hawaii. The North, South, and West regions are administered by Health Net, Humana Military, and United Healthcare, respectively. Around mid-2017, a new TRICARE structure will divide the nation into East and West regions, with the boundary between the 2 being Wisconsin, Illinois, Arkansas, Oklahoma, and Texas east of that state's western panhandle. Although the selection of final contractors is being challenged, TRICARE has announced Humana and Health Net as possible administrators for the East and West regions, respectively. The effects of these changes on PTs who bill services to TRICARE are still to be determined, but some PTs have reported to APTA that health care contractors administering TRICARE have contacted them and have indicated that future contract negotiations may result in lower reimbursement rates. APTA finds this information troublesome and has initiated advocacy efforts with the Department of Defense to thwart such cuts. In the meantime, it is imperative that, before signing any documents, PTs carefully read and understand any contractual addendums from TRICARE contractors that concern payment rates. If you have received such a contact—and/or if you have any questions or concerns about the information in this column regarding nonpayment for the services of PTAs under TRICARE—please contact Kyle Levin, JD, at firstname.lastname@example.org. Kyle Levin, JD, is a regulatory affairs specialist at APTA.