Physician involvement comes from the remote state's practice act and from payers. The state may require a referral, notice to a physician, or a signed plan of care under certain conditions. Payers such as Medicare generally require plan-of-care certification regardless of direct access. Check both before treating in a new state.
A physical therapist starting work in a new state usually thinks about direct access first. The related question of when a physician or other provider must be involved in the plan of care gets less attention, and it varies just as much. Under a compact privilege the remote state's practice act governs, and your home state's arrangements for referrals and signatures do not come with you.
Two separate sources of requirements
Physician involvement comes from two places that are easy to confuse. The first is the state practice act and board rules, which decide whether you may evaluate and treat without a referral and under what conditions. The second is the payer, which decides what it needs before it will pay.
Medicare is the familiar example of the second. It generally requires a plan of care certified by a physician or other qualified practitioner, with recertification at intervals, regardless of what the state practice act says about direct access. A state that allows broad treatment without referral does not remove that payment condition, and a signed certification does not expand what the state permits.
Medicaid programs and commercial plans set their own terms, which can differ from both Medicare and the practice act.
Kinds of physician involvement a state may require
Where states tie physician involvement to physical therapy care, the requirements tend to take a few forms. A referral or prescription may be required before treatment begins, or after a period of treatment without one. A physician may need to be notified that care has started, sometimes within a set number of days. The plan of care may need to be sent to, reviewed by or signed by a referring provider. Certain patients or interventions may require involvement even where direct access is otherwise broad.
States also differ on who counts as a referral source. Some accept referrals only from physicians, while others include physician assistants, nurse practitioners, dentists, podiatrists or chiropractors. Check the list in the remote state's act rather than relying on the one you know.
The form of a referral can matter as well: whether it must be written, how long it stays valid, and whether it must include a diagnosis.
Setting up in a new state without surprises
Before seeing patients, read the remote state's direct access and referral provisions and list each physician-involvement requirement in plain language. Then list the requirements of the payers your clinic bills most, starting with Medicare if it applies. Compare both lists with the clinic's intake and documentation workflow.
Look closely at timing. A certification that must be signed within a set period, or a notice that must go out after the evaluation, is met only if someone tracks it. Ask who sends plans of care for signature, who follows up on unsigned ones, and where signed copies are filed.
Keep evidence of each requirement you meet: the referral, the notice, the signed plan of care, and dated records of when each arrived. When a board or payer asks, the question is what the chart shows.
Requirements change and differ in detail from any summary. Confirm current rules with the remote state's board and each payer's own guidance, and consult a licensing attorney when the answer affects a large share of your caseload.
Common questions
- Does direct access remove the need for Medicare plan-of-care certification?
- No. Medicare generally requires a plan of care certified by a physician or other qualified practitioner as a payment condition, regardless of what a state practice act says about treatment without referral.
- Who can refer a patient to physical therapy in another state?
- It depends on the state. Some accept referrals only from physicians, while others include other practitioners. Check the list in the remote state's practice act rather than assuming your home state's.
- What should I track when a state requires physician notification?
- Track the deadline, the method the state requires, who sent the notice, and proof that it went out. A notification requirement is only met if the chart shows it.
- Is a signed plan of care enough to expand what I may do in a state?
- No. A signature can satisfy a referral or payment requirement, but it does not add anything to the scope of practice the remote state allows.
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