When a therapist—whether a full-time employee or a traveling clinician—leaves a practice, it’s not uncommon to discover unfinished documentation, such as a missing discharge report. One of the most frequently asked questions in this scenario is whether another therapist who never treated the patient can write the discharge report based solely on the existing notes in the medical record. Technically, the answer is yes—another licensed therapist could write the discharge summary. However, the real question is: should they?

Any therapist who signs their name and credentials on a discharge report becomes part of that patient’s case, regardless of whether they ever interacted with the patient directly. This can present several concerns. If an insurance company requests the records, or if the patient has an active workers’ compensation claim, pending lawsuit, or any other legal matter related to their care, the therapist who authored and signed that report could be pulled into the case. Without firsthand knowledge of the patient’s condition, progress, and outcomes, the substitute therapist may be at a disadvantage in justifying the clinical decisions or summarizing the treatment provided. While it’s permissible for a different therapist to write the discharge report based on existing documentation, it’s important to weigh the potential risks. Ideally, the therapist who evaluated and treated the patient should complete the discharge report. If that’s not possible, practices should implement a clear policy and ensure thorough internal documentation to protect both clinicians and the integrity of patient care.

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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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