Patients who began treatment before January 1, 2025 now have a new insurance plan for dates of service on or after that date. A frequent question that arises is whether a new evaluation is required when a patient switches insurance during an ongoing episode of outpatient therapy.

The good news is that in most cases, a new evaluation is not required simply because the patient changed insurance. The key exception is if the new insurance carrier specifically mandates a new evaluation. However, providers should be aware that the new insurance may require prior authorization to continue therapy services, even if a new evaluation is not necessary.

For patients who switch to original Medicare, a new evaluation is not required or appropriate. What is required, however, is a signed and dated plan of care starting from the first date of service billed to Medicare. This plan must be completed by the treating therapist and signed by the referring physician or nonphysician practitioner (NPP) responsible for overseeing the patient’s care. Also, keep in mind that this first visit under Medicare will count as visit one toward the 10-visit minimum progress report period.

If the patient transitions to a Medicare Advantage (MA) plan, a new evaluation is also not typically required, unless the MA plan has a policy stating otherwise. However, similar to private insurance carriers, prior authorization may be necessary for dates of service under the new plan. It’s crucial to confirm the requirements of the specific MA plan to ensure compliance and avoid reimbursement delays.

In summary, while changing insurance during treatment doesn’t automatically require a new evaluation, it does often involve verifying prior authorization and updating documentation to align with the new payer’s policies. Staying ahead of these administrative steps helps ensure uninterrupted patient care and proper reimbursement.

¨If you or someone you know might need physical therapy, please call us at 305-570-1633, or if you are interested in opening a Physical Therapy Franchise. Email us franchise@physicaltherapynow.com or visit our website at www.physicaltherapynow/franchise¨

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