Referral

• Occupational therapy services begin with a referral.
• Also known as an occupational therapy order (by a doctor), consultation, or prescription.² 
• The person or organization that placed the referral is the ‘referral source’.
• Considered appropriate when there is an expectation that occupational therapy will benefit the client.
• Clients may self-refer to occupational therapy, as can physicians, other health professionals, teachers, school administrators, family members or caregivers, employers, insurance companies, industries, businesses, or state and local agencies.³  Instances include when a client is:
  • Unsafe independent performance in occupations for an expected role.
  • At risk for limitations in performance of self-care, productivity, or leisure.
  • At risk for experiencing restrictions in participation in the performance context
  • At risk for impairments in performance that can lead to difficulty with occupations.
• Upon receiving a referral or an order, the occupational therapy practitioner may conduct a screening to determine if occupational therapy services are appropriate.
• In the United States, whether the occupational therapist can act on the referral depends on state law and third-party payors.
  • For example, in California, a referral for OT is appropriate in a school-based setting when, “a child is not able to participate in the educational curriculum at the expected level of ability, when modifications and accommodations have not been effective, and when the areas of concern are in the domain of OT practice.”⁴ 
  • In a California occupational therapy board meeting held in 2018, there was a discussion about the word “referred” as defined in the scope of practice and whether this pertains to a physician’s referral. The terms referred and referral have since been removed from section 2570.2. Existing language does not specify who the referral must come from. “Heather Kitching, President of OTAC and licensed occupational therapist agreed with the Board members’ comments regarding a physician referral not being needed to deliver services and that practitioners need to be forward-thinking about the future of occupational therapy. Kristin Neville, AOTA’s State Affairs Manager stated that it was her understanding after speaking with Executive Officer Heather Martin that removing referral language doesn’t take away the fact that insurance companies commonly require a referral for reimbursement purposes. ⁵ 
  • Whereas, in New York, OTPs “can perform occupational therapy evaluations without a referral or prescription. However, to implement an OT treatment plan, under certain circumstances described below, you must have a referral or prescription from a licensed health care provider acting within his or her scope of practice.”² 
  • The referral/prescription becomes part of the record that the occupational therapist must maintain for each patient/client he or she serves.² 
• Occupational therapy practitioners can refer to their state’s OT practice website or reference the scope of practice as defined in the state’s code.
  
  • Find your state board’s occupational therapy practice website.
  • In the search box, type referral and see what comes up in official documents.
  • Consider contacting the board directly if you are unable to find any specific information.

Medicare ⁶ 

• Medicare beneficiaries may receive a referral for occupational therapy services if their doctor or other health care provider certifies that they need it.
• Medicare Part B (medical insurance) covers occupational therapy services up to 80%. The Part B deductible applies.
• Description of occupational therapy under Medicare: “Therapy to help you perform activities of daily living (like dressing or bathing). This therapy helps to maintain current capabilities or slow decline.”
• Reasonable and Necessary ⁷ 
  • Services meet accepted standards of medical practice
  • Specific and effective treatment for the condition
  • A level of complexity/sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist (or supervised PTA/OTA)
  • Patient’s clinical condition requires the skills of a therapist.

Medicaid ⁸ 

• Each state has the discretion to design its own Medicaid programs within the broader federal guidelines.
• As long as states cover certain “mandatory benefits,” they can also choose whether to provide other “optional benefits,” like occupational therapy.
• As participation is voluntary, states determine their own eligibility standards, services, payment rates, and procedures within the federally mandated guidelines.
• Medicaid policies for eligibility, services, and payment may vary considerably among states.

Stark Law and Anti-Kickback Statutes⁹ 

• Illegal referral relationships between physicians and therapists are defined as those financial arrangements between the parties that violate state or federal laws.
• It is illegal for a therapist to give kickbacks to a physician who refers patients to them.
• Two federal laws and regulations that identify which types of referral relationships are illegal are the Federal Physician Self-Referral (commonly referred to as “Stark”) law and Anti-Kickback Statute.
• However, many referral relationships between physicians and therapists are legal.
• Most legal referral relationships between these parties are specifically structured so that there is no financial relationship between the parties, or they meet a specific legal exception from the Stark Law and Anti-Kickback Statute or other state laws.

1. American Occupational Therapy Association. (2018). Telehealth in occupational therapy. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410059 10.5014/ajot.2018.72S219[↩]
2. New York State Education Department. (n.d.). When Occupational Therapy Services Require a Prescription or Referral. Retrieved from http://www.op.nysed.gov/prof/ot/otpre.htm[↩][↩][↩]
3. Moyers, P. A. (1999). The guide to occupational therapy practice. American Journal of Occupational Therapy, 53(3), 247-322.[↩]
4. California Board of Occupational Therapy. (n.d.). School Based Therapy Frequently Asked Questions. Retrieved from https://www.bot.ca.gov/forms_pubs/sbt_faqs.shtml[↩]
5. California Board of Occupational Therapy. 2018. Board Meeting Minutes. Retrieved from https://www.bot.ca.gov/board_activity/meetings/20180823_24_minutes.pdf[↩]
6. Medicare.gov (n.d.). Occupational Therapy. Retrieved from https://www.medicare.gov/coverage/occupational-therapy[↩]
7. Centers for Medicare and Medicaid Services. (2012). Physical, Occupational, and Speech Therapy Services. Retrieved from https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/downloads/therapycapslidesv10_09052012.pdf[↩]
8. American Occupational Therapy Association. (n.d.). Medicaid. Retrieved from https://www.aota.org/advocacy-policy/federal-reg-affairs/pay/medicaid.aspx[↩]
9. American Occupational Therapy Association. (n.d.). Private Pay. Retrieved from https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Pay/Private.aspx[↩]