Can I Treat My Partner’s Mother and Bill Medicare?

By R.L. “Ron” Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.

The regulations on treating immediate relatives are found in the Medicare Benefits Policy Manual, Pub 100-02 in Chapter 16 (General Exclusions From Coverage) Section 130.  To better understand these regulations, you must first be familiar with the definitions of “provider and supplier” as used in all Medicare regulations.

Provider is defined at 42 CFR §400.202 and generally means a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency or hospice, that has in effect an agreement to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services; or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization services.

Supplier is also defined in 42 CFR §400.202 and means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.

In general, Medicare excludes payment for services rendered by a physician or other practitioner not only to their own immediate relatives but also to relatives of the owner or owner’s of the practice entity. (130-A.)

The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.”.

 Immediate Relative, as defined in regulations includes;

  • Husband and wife;
  • Natural or adoptive parent, child, and sibling;
  • Stepparent, stepchild, stepbrother, and stepsister;
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
  • Grandparent and grandchild; and
  • Spouse of grandparent and grandchild.

There are some minor exceptions but basically these prohibitions also survive divorce or death of the actual relative.  In a stated example within the regulations, (130 B.) we see;

“For example, if a provider treats the stepfather of the owner after the death of the owner’s natural mother or after the owner’s stepfather and natural mother are divorced, or if the provider treats the owner’s father-in-law or mother-in-law after the death of their spouse, the services are considered to have been furnished to an immediate relative, and therefore, are excluded from coverage.”

Current regulations also extend to “members of the patient’s household” who share a single family unit dwelling and includes their (live in) domestic employees.

 “These are persons sharing a common abode with the patient as a part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.”

The prohibition of payment for services rendered to the immediate relatives is quite broad and applies whether the provider or supplier is a sole proprietor or a partnership in which even “one of the partners” is related to the Medicare patient and extends to any “incident to” services that may be provided by a nurse or technician.(130 E)

What if my PA or NP treats the relative?

Under Medicare regulations, 130 F, “This exclusion applies to charges imposed by a non-physician supplier that is not incorporated, whether the supplier is owned by a sole proprietor who has an excluded relationship to the patient, or by a partnership in which even one of the partners is related.”

Under regulation 130 D, Regulations state;  “Professional corporation means a corporation that is completely owed by one or more physicians, and is operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry, or chiropractic, or is owned by other health care professionals as authorized by State law. Any physician or group of physicians which is incorporated constitutes a professional corporation.”

 The regulations provide an “exception” for the stockholders, officers or directors of a corporation (other than a professional corporation) however you should definitely check with a competent healthcare law attorney for a legal opinion on how your “particular corporation” would actually be viewed under the Medicare rules.

Summary: The Medicare regulations would appear to prohibit your billing for services rendered to your partner’s mother or any other immediate relative of any partner within your practice.  I would suggest you refer the patient to a physician that is not associated with your practice or provide the care at no cost to anyone.

 The discussion presented above is offered only as an overview of Medicare regulations and is not intended to be, or construed by the reader as being a legal opinion or legal advice.  Private carrier policies may vary in coverage on this subject.  While the author has made a good faith attempt to present the discussion accurately, the discussions presented are base on lay-interpretation of the issues and should not be viewed as an attempt to offer or render legal advice or opinion or otherwise engage in the practice of law.  The discussion presented is, at best, of a general nature and cannot be substituted for the advice of a licensed attorney at law with specialized knowledge in healthcare regulatory issues.
 The M.A.A.M.A. and the Medcorp Compliance Network always advise physicians and other practitioners to seek the advice and legal opinion of a licensed healthcare law attorney in your home State as your only authoritative interpretation of all matters of law and regulation for Federal, State and individual carrier coverage issues.


By R.L. Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.  Executive Director. 

Physical medicine and rehabilitative services are designed to improve, restore, or compensate for loss of physical functioning following disease, injury or loss of a body part which makes them an ideal ancillary inclusion for pain management and rehabilitation practices.  Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to determine the impairments, functional limitations, and disabilities of the individual patient and then address them through design and implementation of a plan of care tailored to the specific needs of the individual patient.  The services are not only beneficial for the patient but are a good source of revenue for the practice.  Therapy service income often out performs other clinical services on a consistent basis.

Unfortunately many multidisciplinary consultants are apparently uninformed on Medicare “requirements” on who can actually “perform” the therapy services and often misrepresent permissible delegation and the actual supervision requirements over unlicensed individuals in the non-facility (Doctor’s office) setting.

Practitioners are learning the rules the hard way as whistle blower, disgruntled employees and competitor reports prompt on site audits and recoveries in the hundreds of thousands of dollars.

The premise for therapy is based on patients who must have a potential for restoration or improvement of lost functions and require the services of a skilled therapist.  Rehabilitation services are typically short term, intensive and have clear goals for services employed to restore and maintain a level of function. Naturally Medicare patients are often subjected to illnesses and conditions effectively treated with physical therapy rehabilitation efforts.

Under Medicare policies, intervention with PM&R modalities and procedures is indicated when:

  • an assessment by a physician, NPP or therapist supports utilization of the intervention,
    there is documentation of objective physical and functional limitations (signs and symptoms), and
  • the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time.

Skilled therapist, for Medicare reimbursement privileges means that the covered therapy services are “personally performed ONLY by one of the following;

  • Licensed therapy professionals: licensed physical therapists and occupational therapists
  • Licensed PTA with appropriate supervision by a licensed physical therapist.
  • Licensed occupational therapy assistants (OTA) with appropriate supervision by a licensed occupational therapist.
  • Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
  • Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
  • Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
  • “Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met.Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed.

There always seems to be some “consultants” who spend more time advising their clients on possible ways to “beat the system” than educating them on how to do things properly and avoid potential conflicts with regulations.

The basic facts are that reimbursement for services performed have a calculated component based on the amount of “professional” time required to render the service to the patient.  You may have noticed this “little requirement” in the description of various “time based” therapy codes where the language clearly states “one-on-one patient contact by provider”.

In my opinion, it is completely illogical for any provider to expect a carrier to pay for professional time when the services were provided by “trained aides” who lack the comprehensive training necessary to exercise professional judgment over the therapy or procedure.  The Federal programs for example, draw fairly clear lines on who is and who is not qualified to receive reimbursement for “professional time” by reviewing Medicare regulations 230.1(C) and 230.2(C) which clearly state;

Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Services of athletic trainers, massage therapists, recreation therapists, kinesio-therapists, low vision specialists or any other profession may not be billed as therapy services.      (This includes services performed by Chiropractors since they are statutorily excluded  for payment for any service performed other than spinal manipulation by CMT.- DrR)

In short, Medicare will not pay for the services of a “qualified provider” unless the services are performed by a “qualified provider”.  Learn the difference and apply the principles.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.

  • Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law……..o    Assistants may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of a license. Qualified personnel must have been educated and trained as therapists to qualify for furnishing therapy services under direct supervision and incident to a physician or NPP.

PTAs, even if licensed, may NOT perform “incident to” a physician or NPP, since they do not meet the definition of a therapist.

Aides are “everyone other” than those described above.  Med Techs, Chiropractic Assistants, Exercise Physiologists, Athletic trainers, massage therapists, LVNs, LPNs or any individual with a certificate of anything are NOT eligible to perform PT/OT for Medicare reimbursement.

So next time, your so called consultant wants you to bill the services of a med tech under your provider number, remember;

Fraud, as defined by Federal Regulation (42CFR455.2) , is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.
Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary. (under the carrier’s published policy).

The only difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime?

In either case, the key component is that the perpetrator knew or should have known that the act was improper.  

There are many “restrictions” providing PT / OT –  Don’t hesitate to contact us with questions.

Doc examPresident Obama has been crowned the greatest gun salesman in America. People are flocking to the gun ranges to shoot their newest protection piece and concealed weapons permits are up significantly.

One “medical concern” you should be looking for is “lead contamination”.

You and/or your patients are exposed to lead every time they shoot. Lead is typically contained in the primer of each bullet or shell, so when you fire your gun all of the residue and powder from the explosion lands on your hands, face and shirt and you’re essentially covered in lead particles. In the crime shows they call the GSR (gun shot residue) This vaporized lead obviously can be inhaled, but the particles of lead sheared off as an unjacketed bullet travels down the barrel are small enough to be easily inhaled as well. Once inhaled the lead readily crosses to the bloodstream and is distributed throughout the body. It is absorbed like calcium and interferes with iron absorption and can be deposited in bone and fat and other soft tissue.

In addition, if you clean your firearm when you get home, that firearm is covered in lead dust. When you’re shoving the cleaning rod down the barrel that dust is shooting out of the barrel into your house.
If you happen to walk around and pick up your brass or shell cases after you shoot, those are covered in lead. And if you put that in your pocket or scoop it up in a hat, then you have a pocket or hat covered in lead dust as well.

Symptoms of lead poisoning are varied and may affect many parts of the body. Most of the time, lead poisoning builds up slowly following repeated exposures to small quantities of lead and is difficult to detect until symptoms progress. Most doctors do not inquire about recreational gun use and when symptoms present, lead poisoning is way down the list of differential diagnoses. Typically it is diagnosed by a blood lead levels test. CDC recognizes blood lead levels (BLLs) of >25 µg/dL in adults and >10 µg/dL in children as levels of concern.

Signs and symptoms in adults may include:
• High blood pressure
• Abdominal pain
• Constipation
• Joint pains
• Muscle pain
• Declines in mental functioning
• Pain, numbness or tingling of the extremities
• Headache
• Memory loss
• Mood disorders
• Reduced sperm count, abnormal sperm
• Miscarriage or premature birth in pregnant women

Weight lossJust in Time for Swimsuit Season:  Your Medical Weight Loss Regimen- 

Contributed by Epic Marketing [

Summer is just around the corner and that means flip flops and family barbecues. But it also means afternoons spent lounging by the pool and wearing shorts every day. If you, like the rest of us, are not at your optimal weight, it may be time to get on a medical weight loss regimen now so you’re all set for a summer of tank top wearing that you can be proud of!

 Treatment Options 

Managing your weight and staying healthy is an important part to avoiding obesity and other health-related weight concerns like joint and muscle pain, osteoarthritis, and neuropathy. As every person’s struggle with weight loss is unique, it is best that an appropriate medical weight loss regimen is designed and tailored to your individual wellness needs and goals.

Nutritional Counseling– learn more about solutions that help you maintain needed dietary changes. Additionally, nutritional counseling is a great way to discover all things food related—from the types of food to the size of the portions—that are optimal for weight loss.

 Exercise Advisement– get tips and tricks regarding your workout regimen that will help to enhance your exercise sessions, anything from the amount of weight you should be lifting to the number of repetitions that are ideal to the time that should be invested in cardiovascular activity.

 Appetite Suppressants– under the advisement of a medical practitioner, appetite suppressants help to naturally curb hunger and support better, healthier eating habits. These prescription drugs are monitored by medical professionals during the course of your weight loss program.

Natural Supplements– supplements are a fantastic way to achieve your desired weight loss goals the natural way. These dietary enhancements, in conjunction with all-around healthier eating habits, help to get (and keep) the weight off.

If you are serious about kick starting your weight loss regimen in time for real results by summertime, contact the medical weight loss professionals today to discuss your weight loss goals and treatment options.

Blog 3 Making the Right Pick 3-27-15    March Madness has begun, which means its bracket time here at Epic. When it comes to putting a bracket together, there are so many questions and things to consider. Here at the office we have a wide variety of participants, from people who have little to no idea of what March Madness is, to self-proclaimed college basketball experts. The great thing about filling out a bracket is that everyone has a chance to win at the beginning of the tournament. For most participants, picking the best bracket is pretty much a combination of guessing and team statistics.

Last year Warren Buffet offered a billion dollars to any person who could pick a perfect bracket. The odds of doing this successfully were 1 in 9.2 quintillion.  So, you might be wondering why Buffett isn’t putting up his money again? It was great publicity. What happened? As Jordan Weissmann describes, it all boils down to lawyers. There’s literally no chance of it happening and being forced to make a payout. After all, getting a perfect bracket is like running a two-minute mile or Kentucky getting a shutout in a game. Mathematicians claim it’s all about the algorithms when it comes to picking a perfect bracket. Many of these mathematicians have come close to producing a perfect bracket, consistently having brackets in the top 5% of those picked. Despite all the odds they still remain in Warren Buffet’s favor.

This idea of striving to pick the best (possibly perfect) bracket is an interesting one to us, because in our business we are also striving to produce the best results for our clients though marketing. And like picking a bracket, it’s a combination of insight and knowledge. The closer you pay attention to all of the data, the more knowledge you’ll have to make the best decision. The longer you are involved in developing this knowledge, the more heightened your instinct becomes for making the right pick and producing an effective marketing algorithm.

When it comes to marketing, everyone has a chance to kill it and explode their business on their own. However, just like picking the perfect bracket, the odds are not in your favor. Look at it this way, if you want to pick the best bracket, would you have a better chance of doing this on your own, or by having access to the algorithms that the top bracketers use? Knowing that there’s an algorithm designed by mathematicians that consistently produces top brackets, I don’t know about you, but I’m going with the best algorithm to pick my bracket. This will significantly increase the odds of winning.

You know that marketing is a key component to growing your business, and professional marketers know the algorithms necessary to produce the best results for your company. Instead of taking an approach to marketing where you’re guessing that your approach will work, first think about how many times you’ve been in the top 5% of the NCAA March Madness bracket, without any expertise or help? With that in mind, our professional team is here to help you achieve much better odds with your future marketing success.

As always, The Academy thanks the Contributing Authors at Epic Marketing for their contribution.  Visit Epic on the Web at 

Answering Your Marketing Questions  by:  Dave Ostler – Epic Marketing

Blog 3 Answering Your Marketing QuestionsWhen you think about marking your business, there are many questions that come to mind. What’s the best avenue for marketing my product or service? How much should I budget for marketing? What promotion will get me the highest return on my investment? The list goes on and on, but luckily you don’t have to do it all alone. The great thing about being a marketing firm is that we’ve answered all of these questions before and can give you all of the guidance you’ll need.

With that being said, we’re happy to help answer some of the questions we often hear. When it comes to deciding to market your business, you should think of it as an investment. You’re investing in yourself, as you should.

Where to start? You should start by looking at your business and product. Ask yourself what sets you apart from your competition and what are the benefits you’ll bring to your customers? Determine who your potential customers are and then determine the best way to reach them.

Once you know who your customers will be, you’ll be better positioned to know how to reach them. First, create your brand around your audience. Once you have your brand established it’s been proven that a combination of print and web is the best approach to market your business. If you don’t have a website, get one and then make sure the content on the site is unique, interesting, and optimized for search engines. Once you have your website, advertise and promote your business or product through the mediums that will best target your future customers.

Now all of this does cost money and as mentioned before, you should think of it as an investment in yourself. Having a marketing budget is crucial because you will want to make sure that you’re not overspending, and at the same time, not underspending. On average, for a small business (generating less than $5 million), it’s recommended to allocate 7-8% of your revenue to marketing. If you’re really looking to grow your business, you’ll want to allocate more. There’s a great blog on the U.S. Small Business Administration’s website that goes into more detail:

Bottom line, once you decide to market your business, you‘ll want the highest return on your investment. It takes a lot of market research and time to discover what marketing methods will accomplish this. Unfortunately, there’s no easy answer because it all comes down to who you’re marketing your business to. There are approaches that will work better with one group over another. Keep in mind that it never hurts to look to professionals for help. You know your business and here at Epic Marketing, we know ours.


So you’ve decided to hire an advertising agency –  Contributed by Dave Ostler

Excellent choice! Advertising agencies come in all shapes and sizes – from small, locally-Blog 2 How to Choose The Right Ad Agency 1-23-15based agencies to large, international conglomerates. With thousands of advertising agencies in the United States, how does one choose? We have provided some factors to consider in selecting an agency that is a good fit for your business needs.

Define your intent. The first step in choosing an advertising agency is to clearly define what you are hoping to gain from the partnership. Do you need help developing strategy or driving execution? Do you wish to become the leader in your local business sector? Enter a new geographical territory? Whatever your goal – clearly defined business objectives will help guide you through the process of choosing the right agency.

Conduct initial research. Compile a list of eligible agencies. Do a Google search, ask a non-competitive business owner in your industry or reach out to media outlets for recommendations. Once you have a list of contenders, further narrow the list down by considering:

What type of agency are they? Some agencies are full service, while others specialize in a specific function, such as Public Relations. Go back to your intent – what type of services do you really need?

Are they currently handling the account of your direct competitor?

Where are they located? While many businesses prefer to have face-to-face interaction with their agency, it’s not uncommon for a business to work with an agency in another city or state. If you are comfortable with the majority of your conversations being conducted by phone or email, don’t limit yourself geographically.

Choose agility over size. There is much debate about whether it’s best to work with a large or small agency, but what you really want is an agency that is fluid and can adjust to your workload. What are you going to demand of the agency in terms of time – and can they meet your deadlines? If you assigned a large project or group of projects they don’t have the capacity to handle, how would they ensure it was completed by your deadline? Do they have a network of freelancers they can reach out to if needed? It is important to partner with an agency that can adjust to meet the needs of its clients.

Don’t base your decision solely off industry experience. Many businesses think that working with an agency experienced in their industry is a requirement. While industry experience is helpful, choosing an agency that is new to your industry could yield that fresh perspective that you’ve been looking for. Isn’t differentiating yourself from competitors the goal, anyway? Sure, there might be a learning curve, but no agency will ever know as much as you do about your industry, so if you’re going to base your decision on experience, choose the experience that really matters: marketing and communications.

Consider core competencies. Let’s be honest – most agencies do not excel in every discipline. Ask an agency about their core competencies, and consider whether those strengths align with your objectives. You may discover that the agency you’re considering is particularly skilled in print advertisements, but you want to produce a video – so why not find an agency that is more closely aligned with your goals?

Is there chemistry? The key to long-term success is a good working relationship, so make sure that you like the people and their approach. Also consider professionalism. How do they conduct themselves when interacting with your business – because as your agency, they represent you. You want an agency that will conduct themselves in a professional manner when working with you or on your behalf.

What’s your budget? Agency fees can vary dramatically, and some companies cannot afford the agency that they really want to work with. Fees may be a flat rate by project, hourly, or a mix. Do they have minimum billing increments? Do they have a retainer structure? Be sure you fully understand their fee structure so there are no surprises when you get your first bill. You don’t want to choose an agency that your company can’t sustain financially in the long run.

Advertising is an investment. Finding the right agency can be a time consuming process, but the effort is worth it in the long run when you find a partner that helps your business grow to achieve, and even exceed its goals.


Does your website convert visitors into patients?

Contributed by: Dave Ostler   General Sales Manager, Epic Marketing


Your online presence is your first impression to the world. It takes less than two-tenths of a second for a visitor to form a first opinion of your business based on the quality of your website. Are your visitors sticking around, or hitting the back button?

Allow me to introduce the concept of conversion.

Conversion is the art of getting your visitors to perform an action that you have determined to be valuable to your business. This could be requesting a free consultation, “liking” you on Facebook, or subscribing to your monthly newsletter. Simply put – conversion is turning visitors into customers.

Here’s the golden rule of conversion: clarity trumps all. Figure out what users are looking for when they arrive at your site. While a unique website design may be eye-catching, if users can’t answer 1) who you are 2) what you offer and 3) why they should choose you in a matter of seconds, you can say sayonara to that lead.

  • Who are you?

When users first land on your page, they are in the orientation phase. In a matter of seconds, they decide whether that page is relevant to what they are looking for. Clutter, blocks of text, and poor graphics confuse and overwhelm users, and will seriously hurt your conversion rate. The purpose of your website should be very clear in your logo, headline, and supporting text and graphics.

  • What do you offer?

Next, use copy and design elements to guide the user toward conversion. If you specialize in treating back pain, neck pain and shoulder pain, consider highlighting these three conditions on your homepage.

  • Why should I choose you?

Finally, tell users clearly and simply why they should choose your practice instead of continuing their online pursuit. Make sure that your value proposition is clearly stated. If you offer a free consultation for new patients, this should be highlighted on your homepage and internal pages in the form of a call-to-action.

Conversion isn’t about attracting new visitors; it’s about making the most of your existing traffic. If it’s been a while since you last looked at your website, it may be time for a revamp. Take the time to identify the top three things you want users to do as a result of visiting your site. Do you want them to request a free consultation via an online form? Call your clinic? Define your goals, and then optimize your website accordingly.

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    Contact David:   (801) 505-9322