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New Jersey Occupational Therapy Billing and Fees

Unprofessional Billing Conduct

False Claims

No licensee shall submit any claim, bill or governmental assistance claim to a third-party payor for occupational therapy services rendered to any client that involves dishonesty, fraud, deception or misrepresentation.

No licensee shall submit to a third-party payor any claim, bill or governmental assistance claim, which contains any of the following:

    • Any treatment date, which does not accurately reflect the date when the services were actually provided;
    • Any description of an occupational therapy service, which does not accurately reflect the actual service provided;
    • Any statement material to the claim, which is known to be false or misleading; or
    • A charge for any service the amount of which has been advertised as free or complimentary or for an amount that exceeds the advertised charge for discounted services.

Copayments

A licensee who provides occupational therapy services to a client enrolled in any insurance plan with co-payment features and who intends to waive any part of the co-payment or all of the co-payment by the client shall, when submitting any claim or bill to the third-party payor, conspicuously disclose on the face of the claim or bill in a legible manner, or in the electronic claim submission, that the co-payment, or a portion of the co-payment, has not or will not be billed to, or collected from, the client.

Claims Accuracy

The accuracy of all information contained in written or electronic submissions to a third-party payor, including pre-determinations, claims, bills or governmental assistance claims, shall be the personal responsibility of the licensee whose name, license number or signature appears on the signature line of the claim. In the case of electronic claims the licensee identified as the provider shall be held responsible for the accuracy of the information whether or not said licensee actually completed the claim. The Council shall presume that the licensee identified on the claim reviewed its contents and approved its submission. It shall not be a defense to an allegation of a violation of this section that the claim was completed or submitted by an agent of the licensee.

All insurance records shall be maintained pursuant to the provisions of N.J.A.C. 13:44K-10.

Financial Arrangements with Clients and Third-Party Payors

Fees for occupational therapy services shall be reasonable and commensurate with the status and experience of the occupational therapist offering like services or treatment in the geographic area and shall be consistent with the provisions prohibiting excessive fees.

Prior to the initiation of occupational therapy services, the occupational therapist or his or her designee shall explain to the client in an understandable manner the financial arrangements for the services that will be provided. The information provided to the client shall include the following:

    • The fee for services or the basis for determining the fee to be charged;
    • Whether the licensee will accept installment payments or assignment of benefits from a third party payor;
    • That insurance coverage may not be available in all circumstances; and
    • The financial consequences, if any, of missed sessions.

An occupational therapist shall not require a client or a third party payor to pay:

    • A fee for preparing an insurance claim form;
    • Interest on an unpaid account unless the client has been notified of this policy, in writing, prior to the initiation of occupational therapy services;
    • A full or partial fee for unkept appointments unless the client has been notified of this policy, in writing, prior to the initiation of occupational therapy services; or
    • A fee for any occupational therapy service not documented in a client record.

An occupational therapist shall prepare and maintain a written list of current fees for standard services and, upon request, shall provide the list to clients. The list shall include the following information:

    • Whether Medicaid clients are accepted;
    • Whether Medicare clients are accepted;
    • Whether other third-party payor plans are accepted; and
    • Whether special fee categories are available, such as for senior citizens or for members of designated groups, such as preferred provider plan members.

An occupational therapist shall provide a copy of a written fee schedule to any interested person upon request.

Excessive Fees

An occupational therapist shall not charge an excessive fee for services. Factors which the Council may consider in determining whether a fee is excessive include the following:

    • The time or effort required to perform the services;
    • The skill required to properly perform the services;
    • The nature and length of the professional relationship with the client;
    • The experience, reputation and ability of the licensee performing the services;
    • The nature and circumstances under which services are provided; and
    • Whether the fee is set by a medical, health, educational or social agency.

Citations

N.J.A.C. § 13:44K-8.9

N.J.A.C. § 13:44K-9.2

N.J.A.C. § 13:44K-9.4

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