Achieving Medicare-Certified Rehabilitation Agency Status

This brief describes the steps necessary to establish a Medicare-Certified Rehabilitation Agency and includes a sample of Medicare billing form UB 92 Medicare Uniform Institutional Provider Bill. However, please note that effective July 1, 2009, speech-language pathologists in private practice may directly bill the Medicare program and no longer need to establish a Medicare-Certified Rehabilitation agency to do so. For more information go to Medicare & Speech-Language Pathologists in Private Practice.

Medicare defines a "rehabilitation agency" as "[a]n agency that provides...an integrated multidisciplinary rehabilitation program designed to upgrade the physical function of handicapped, disabled individuals by bringing specialized rehabilitation staff together to perform as a team." At a minimum, a rehabilitation agency must provide physical therapy or speech pathology services and a social or vocational adjustment services, Code of Federal Regulations, Title 42, § 485.703. As a rehabilitation agency, you pay for the latter services and they are not reimbursable.

The following steps are a guide for SLPs in establishing a rehabilitation agency. Please note, however, that this is not a comprehensive list of requirements. For more information, please contact Mark Kander, Director, Health Care Regulatory Analysis at 800-498-2071, ext. 4139 or mkander@asha.org.

1. Determine if Medicare rehabilitation agency status is the best approach for serving Medicare beneficiaries.

   You should analyze your projected caseload and predict as best as you can the proportion of Medicare patients you expect to see. The process of becoming and remaining a rehabilitation agency takes time and resources. If only a small percentage of patients will be Medicare beneficiaries, you may want to reconsider your strategy. If you plan to see a high proportion of Medicare beneficiaries, you can proceed and review the requirements of establishing provider status.

2. Obtain an application for establishing a rehabilitation agency from your state certification agency.

   SLPs should familiarize themselves with any federal or state guidelines regarding the set-up and practice of a rehabilitation agency. The federal regulations and interpretive guidelines are usually included with the application. Note the requirement that a psychologist, social worker, or vocational counselor must periodically review case records to determine the need for intervention.

3. Complete a provider enrollment application and request a survey of the facility.

   Before a survey is undertaken, the rehabilitation agency must submit a provider enrollment form (HCFA Form 855) to the state. States vary in the length of time they take to review the application and subsequently submit it to the Medicare fiscal intermediary. The intermediary should complete its review in 60 days and return it to the state certification agency. (Note that in the next year or so, providers, including rehabilitation agencies, will submit the form directly to the intermediary.) Once the intermediary approves the enrollment, the state will contact the state survey agency to begin the survey. (If the intermediary finds only minor deficiencies in the application, the rehabilitation agency's Medicare enrollment status will be effective the date it submits a plan of correction.)

   The surveyor will want to examine the policy and procedure manual, contract with the social service provider, license of the medical director, and compliance with all state regulations. These include fire, safety, disaster escape route, hand washing facility within the office, means for disposal of contaminated waste (red bag), staff contracts and health records, and ability to document patient care appropriately.

   The state certification agency will forward your application to the Medicare regional office for assignment of a Medicare provider number for the rehabilitation agency after the survey procedure is completed and the surveyor has affirmed that the program complies with the regulations. Development of written specific policies and procedures identified in the regulations must be documented, and the office/treatment area must pass fire code and disability accessibility surveys. The surveyor writes his/her report, assuming no deficiencies, and sends it to the state. The state forwards the paperwork to HCFA. A civil rights compliance set of documents is then sent out. The assigned fiscal intermediary will send out another set of paperwork to assure that the provider is capable of maintaining proper records.

Medicare payments for all services billed by a rehabilitation agency are in accord with the Medicare Fee Schedule. Examples of national rates for 2009 are $147.15 for speech-language evaluations and $61.31 for speech-language treatment sessions. Please remember that these figures are federal rates and that geographic adjustments apply. Refer to the complete fee schedule. The rate of payment for contractual services at any other health care facility is fully negotiable, as with any other contractor. In many states, the amount received will be below the quoted fee and Medicare only will pay 80% of that amount. The remaining 20% must come from the secondary insurer or the patient.