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| Special Advisory dK Coding & ProviderLAW | |||||
| Research Sponsored by TLC for Superteams | |||||
Delegation of Services – Can Insurance Carriers Refuse to Pay for Treatment (e.g., Massage Therapy) When the Services Are Properly Delegated by Doctors to Unlicensed Support Personnel? | |||||
A Look at Chiropractic in Pennsylvania as an Illustration. | |||||
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A copy of this Special Advisory |
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| Drafted by: dK Coding – David Klein, CPC, CHC and ProviderLAW – Keith Pendleton, JD | |||||
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The following is a synopsis only. The full text We also encourage you to check out the following links on our web site: |
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| Synopsis | |||||||||||
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This Advisory addresses the issue – must an insurance carrier reimburse for services delegated to trained-but-unlicensed support staff? Recently, a number of subscribers in Pennsylvania have indicated that certain carriers have taken the position that benefits will only be paid when the treatment is personally performed by licensed individuals. If true, the limitation would certainly discourage licensed doctors from delegating services to individuals who may be trained, but who are not licensed. Through a combination of research and analysis, the Advisory creates a new paradigm for viewing the issues in a fresh light. The Advisory raises a question whether under Pennsylvania law, health insurance carriers may have a duty to reimburse providers for properly-delegated services. The limitation raises a significant issue in Pennsylvania when it comes to massage therapy. In Pennsylvania, there is no statute providing for the licensure of massage therapy. In addition to this, the Advisory looks at various state laws including insurance laws, Professions and Occupations provisions, contract provisions and various carrier opinions. Specifically, the Advisory addresses three main questions:
While the Advisory delves into Pennsylvania law, and also looks specifically at the chiropractic profession, it does so as an illustration only. The expressed purpose of the Advisory is to begin gathering information about whether the same type of problem is occurring in various states. Its purpose is also to provide a methodology by which providers in any state, and in any profession, and with respect to any given carrier, can begin to address similar kinds of limitations imposed by that carrier. If you are experiencing this problem in your state, then this Advisory certainly applies to you. We also encourage you to contact us with any information or questions you may have. If you have become the subject of a post-payment review / recoupment request on this issue, we recommend that you contact an attorney. If for any reason your attorney needs to speak with us regarding these issues, please feel free to have your attorney give us a call. |
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Legal Notice (Rev. 05-01-07): This Legal Notice ("Agreement"), Located Online at http://www.providerlaw.com/legal_notice.php and Accessible Through Various Menu Options, Contains the Basic Terms Associated with All Resources Of, and Agreements With, ProviderLAW as Well as with Designated Resources of Ancillary Entities. You Are Responsible for Reading These Terms Carefully as a Condition of Using this Web Site, as Well as of Purchasing, Using, and Relying Upon, ProviderLAW Resources. The Terms Include Without Limit the Terms of Subscription, Business Associate Agreement (To the Extent Required by Hipaa), Licensure of Multimedia Products, Conference Participation, Web Site Use, and Privacy, as Well as General Terms Common to Agreements. The Resources of ProviderLAW and/or of Other Ancillary Entities Do Not Constitute Legal Advice, Cannot Be Relied upon as Legal Advice, and Do Not Establish a Client-attorney Relationship. Such Resources Are Provided for Educational, Awareness, and Discussion Purposes Only and as Such, Are Provided Strictly as Samples or Illustrations. While ProviderLAW and Other Ancillary Entities May Be Able to Assist You in Finding an Attorney, Unless Otherwise Stated, ProviderLAW and Other Ancillary Entities Are Not Law Firms and Do Not Offer Legal Representation to Any Third-party. If You Have Questions of a Legal Nature, You Should Contact an Attorney at Law. "ProviderLAW," "ProviderLAW Corporation," and "ProviderPRO.net" are fictitious names of the ProviderLAW Knowledgebase, Inc., a Pennsylvania corporation.... [ Click Here for Terms ] |
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