[Federal Register Volume 75, Number 159 (Wednesday, August 18, 2010)]
[Rules and Regulations]
[Pages 50880-50882]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-20390]
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DEPARTMENT OF DEFENSE
Office of the Secretary
32 CFR Part 199
[Docket ID: DoD-2009-HA-0098]
RIN 0720-AB36
TRICARE: Non-Physician Referrals for Physical Therapy,
Occupational Therapy, and Speech Therapy
AGENCY: Office of the Secretary, Department of Defense.
ACTION: Final rule.
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SUMMARY: The Department of Defense is publishing this final rule to
provide
[[Page 50881]]
TRICARE approval for authorizing certified physician assistants and
certified nurse practitioners (non-physicians) to engage in referrals
of beneficiaries to the Military Health System for physical therapy,
occupational therapy, and speech therapy. Upon implementation of this
provision, certified physician assistants, or certified nurse
practitioners will be allowed to issue referrals to patients for
physical therapy, occupational therapy, and speech therapy without
having the patient see a physician. This rule will align TRICARE with
Medicare's allowance of ``non-physician providers'' to provide,
certify, or supervise therapy services.
DATES: Effective Date: This rule is effective September 17, 2010.
FOR FURTHER INFORMATION CONTACT: Mr. Glenn J. Corn, TRICARE Management
Activity, Medical Benefits and Reimbursement Branch, telephone (303)
676-3566. Questions regarding payment of specific claims should be
addressed to the appropriate TRICARE contractor.
SUPPLEMENTARY INFORMATION:
I. Background
In the Federal Register of October 29, 2009, (74 FR 55794), the
Office of the Secretary of Defense published for public comment a
proposed rule that will permit services of an otherwise TRICARE-
authorized individual paramedical provider, physical therapist (PT),
occupational therapist (OT), and speech therapist (ST) to be paid on a
fee-for-service basis if based on a referral from a certified physician
assistant or certified nurse practitioner.
II. Public Comments
We provided a 60-day public comment period following publication of
the Proposed Rule in the Federal Register (74 FR 55794) on October 29,
2009. We received three comments on the proposed rule.
One commenter expressed concern that allowing referrals directly
from nurse practitioners or physician assistants will keep patients--or
at least their records--from being seen by a physician, and by doing
so, it could result in the misdiagnosis of an injury or illness
resulting in the wrong treatment action being taken. We appreciate the
comment. This rule allows referral from TRICARE-authorized certified
nurse practitioners and certified physician assistants to TRICARE-
authorized physical therapists, occupational therapists, and speech
therapists. All providers are required to practice within the scope of
their licensure and, should treatment require referral to a higher
level of professional medical provider, such referrals or consultations
are expected.
A second commenter wanted to speak against the provision that a
Doctor of Medicine and especially a Nurse Practitioner or Physician
Assistant are qualified to provide oversight to a Doctor of Physical
Therapy. The commenter further stated that physical therapists are
certified under their respective states and their educational
qualifications are equivalent to a graduate of a professional medicine
degree program and exceed the education of both the nurse practitioner
and physician assistant, who are health professionals and are qualified
to provide referral, but not oversight of a physical therapy plan of
care. We appreciate the comment and recognize the education and
training of those who obtain a Doctor of Physical Therapy degree.
However, at this time the Department is only expanding the categories
of persons who can make referral to a physical therapist and is not
contemplating a revocation of the requirement for oversight of these
providers. The Department of Defense's position on this issue is
consistent with Medicare's and its allowance of ``non-physician
providers'' to provide, certify, or supervise therapy services.
The third commenter requests that TRICARE policy also allow for the
referral of beneficiaries for licensed registered nurse services and
audiology services by non-physician practitioners. We appreciate the
comment. The proposed rule only proposed expanding referrals by
certified nurse practitioners or certified physician assistants to
TRICARE-authorized physical therapists, occupational therapists, and
speech therapists. Under current TRICARE rules, referrals for licensed
registered nurse services and audiologist services can only be made by
a physician. At this time the Department of Defense is limiting the
certified nurse practitioner and certified physician assistant referral
services to physical therapy, occupational therapy, and speech therapy
as outlined in the proposed rule. At this time the Department does not
intend to expand this rule to include a referral for registered nurse
services or audiology. At this time the Department feels the need for
these services are best assessed by a physician.
III. Regulatory Procedures
Executive Order 12866, ``Regulatory Planning and Review''
Section 801 of Title 5, United States Code (U.S.C.), and Executive
Order (E.O.) 12866 require certain regulatory assessments and
procedures for any major rule or significant regulatory action, defined
as one that would result in an annual effect of $100 million or more on
the national economy or which would have other substantial impacts. It
has been certified that this rule is not an economically significant
rule, however, it is a regulatory action which has been reviewed by the
Office of Management and Budget as required under the provisions of
E.O. 12866.
Section 202, Public Law 104-4, ``Unfunded Mandates Reform Act''
It has been certified that this rule does not contain a Federal
mandate that may result in the expenditure by State, local, and Tribal
governments, in aggregate, or by the private sector, of $100 million or
more in any 1 year.
Public Law 96-354, ``Regulatory Flexibility Act'' (5 U.S.C. 601)
The Regulatory Flexibility Act (RFA) requires each Federal agency
to prepare, and make available for public comment, a regulatory
flexibility analysis when the agency issues a regulation which would
have a significant impact on a substantial number of small entities.
This rule will not significantly affect a substantial number of small
entities for purposes of the RFA.
Public Law 96-511, ``Paperwork Reduction Act'' (44 U.S.C. Chapter 35)
This rule will not impose significant additional information
collection requirements on the public under the Paperwork Reduction Act
of 1995 (44 U.S.C. 3501-3511). Existing information collection
requirements of the TRICARE and Medicare programs will be utilized.
Executive Order 13132, ``Federalism''
This rule has been examined for its impact under E.O. 13132 and
does not contain policies that have federalism implications that would
have substantial direct effects on the States, on the relationship
between the national government and the States, or on the distribution
of power and responsibilities among the various levels of government;
therefore, consultation with State and local officials is not required.
List of Subjects in 32 CFR Part 199
Claims, Dental health, Health care, Health insurance, Individuals
with disabilities, Military personnel.
0
Accordingly, 32 CFR part 199 is amended as follows:
[[Page 50882]]
PART 199--[AMENDED]
0
1. The authority citation for Part 199 continues to read as follows:
Authority: 5 U.S.C. 301; 10 U.S.C. Chapter 55.
0
2. Section 199.4 is amended by revising paragraph (c)(3)(x)(A) to read
as follows:
Sec. 199.4 Basic program benefits.
* * * * *
(c) * * *
(3) * * *
(x) * * *
(A) The services are prescribed and monitored by a physician,
certified physician assistant or certified nurse practitioner.
* * * * *
0
3. Section 199.6 is amended by revising paragraph (c)(3)(iii)(K) to
read as follows:
Sec. 199.6 TRICARE-authorized providers.
* * * * *
(c) * * *
(3) * * *
(iii) * * *
(K) Other individual paramedical providers. (1) The services of the
following individual professional providers of care to be considered
for benefits on a fee-for-service basis may be provided only if the
beneficiary is referred by a physician for the treatment of a medically
diagnosed condition and a physician must also provide continuing and
ongoing oversight and supervision of the program or episode of
treatment provided by these individual paramedical providers.
(i) Licensed registered nurses.
(ii) Audiologists.
(2) The services of the following individual professional providers
of care to be considered for benefits on a fee-for-service basis may be
provided only if the beneficiary is referred by a physician, a
certified physician assistant or certified nurse practitioner and a
physician, a certified physician assistant, or certified nurse
practitioner must also provide continuing and ongoing oversight and
supervision of the program or episode of treatment provided by these
individual paramedical providers.
(i) Licensed registered physical therapist and occupational
therapist.
(ii) Licensed registered speech therapists (speech pathologists).
* * * * *
Dated: August 10, 2010.
Patricia L. Toppings,
OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2010-20390 Filed 8-17-10; 8:45 am]
BILLING CODE 5001-06-P