How to negotiate therapy reimbursement rates

Owners of OT, PT and SLP practices with pediatric, adult or mixed caseloads can negotiate rates with private plans, including Medicare Advantage and Medicaid managed care plans, one contract at a time. Medicare’s fee schedule, a state’s Medicaid fee-for-service rates and TRICARE’s maximum allowable charges are set by rule. Bring your costs, each plan’s allowed amounts and Medicare’s rates.⁠^1,2,3,4

Which therapy reimbursement rates can a practice actually negotiate?

The rates in a contract you sign with a private plan are open to negotiation, though a plan may decline to change them; the rates a government program sets by rule are not. Medicare pays therapists in private practice under the Physician Fee Schedule, a state Medicaid agency pays fee-for-service claims from its own schedule as payment in full, and TRICARE allows the lower of the billed charge or the local CHAMPUS Maximum Allowable Charge (CMAC).⁠^1,2,3 A Medicare Advantage plan, a Medicaid managed care plan and a commercial plan each pay what their contract with the practice says.⁠^4,5

Why is Medicare’s fee schedule not open to negotiation?

Because CMS publishes one schedule for every enrolled practice in a locality, and changes to it come through rulemaking and legislation, not through any one practice’s request. CMS describes the Physician Fee Schedule as the primary method of payment for enrolled health care providers, used for the professional services of health care providers in private practice; when Congress passed the Consolidated Appropriations Act, 2024, it raised the 2024 conversion factor partway through the year, and Medicare’s values for the speech codes that start in 2027 are set in its 2027 final rule.⁠^1,14 CMS adjusts the amounts for differences in practice costs from area to area.⁠⁷

Therapists cannot step outside it either. On CMS’s list of who may opt out of Medicare, OTs, PTs and qualified SLPs appear under the providers who may not; a therapist who sees no Medicare patients need not enroll at all.⁠¹⁷ What a practice controls under Original Medicare is accuracy: the codes, units, modifiers and documentation behind each claim. Enrollment itself is in the credentialing guide.

Medicare Advantage is different. A provider without a contract that sets payment amounts for a plan’s enrollee must accept, as payment in full, what it could collect if the patient were in Original Medicare, so a Medicare Advantage contract is where any rate above that is agreed.⁠⁴

Who sets Medicaid and TRICARE rates for therapy services?

The state sets Medicaid fee-for-service rates and TRICARE’s regulation sets its maximums; managed care plans and TRICARE network agreements work within them. A practice enrolled in a state’s Medicaid program takes what the agency pays, with any deductible, coinsurance or copayment owed by the patient, as payment in full.⁠² Every state has had to post its full Medicaid fee-for-service rate schedule where the public can read it, starting no later than July 1, 2026, with pediatric and adult rates shown separately when they differ.⁠¹⁸

Medicaid managed care plans set their own provider rates, with a limit: as a general rule the state may not direct a plan’s spending, but it may require a plan to adopt a minimum fee schedule, for example at the state plan’s approved rates, or a maximum fee schedule for a service.⁠⁵ Ask the state agency or the plan whether a directed minimum applies to therapy services before you open a negotiation, since it changes what the plan can offer. The Medicaid enrollment guide covers joining the state program and its plans.

For TRICARE, the allowable charge is the lower of the billed charge or the local CMAC, which is adjusted for localities with the same geographic factors Medicare uses.⁠³ The regulation lets network reimbursement differ from CMAC, for example as percentage discounts off CHAMPUS allowable amounts, refers to network rates as negotiated, and requires network providers to be Medicare participating providers unless that is waived.⁠¹⁹ A non-network, nonparticipating provider may not bill a TRICARE patient above a balance billing limit set at the same percentage as Medicare’s limiting charge.⁠³ The TRICARE participation guide covers certification, the network decision and the referral rules by discipline.

What data should a therapy practice bring to a rate negotiation?

Four kinds, each from a source the plan can check: your cost per unit or visit, the plan’s own allowed amounts from your remittances, Medicare’s amount for your locality as a public reference, and access facts from your scheduling records. Leave out anything you cannot document; a single figure the plan can disprove weakens every other row.

Start with the allowed amount, the figure the whole negotiation is about. In HealthCare.gov’s glossary it is the highest amount a plan pays for a covered service, a figure that also goes by negotiated rate or payment allowance.⁠⁶ For an in-network practice it is the ceiling on what the visit brings in from the plan and the patient together, because a preferred provider may not balance bill a patient for covered services.⁠²⁰ Pull a year of remittances, list the allowed amount for each code you bill the plan, and note any code where it varies.

Then add the access facts, from the practice’s own records rather than impressions: the median days from inquiry to evaluation, evening and weekend hours, the languages sessions are offered in, the ages seen, and services few local providers offer, such as pediatric feeding therapy, vestibular rehabilitation or augmentative and alternative communication evaluations. State each with its period and source.

How do you work out your cost per visit or per unit?

Divide what a treatment hour really costs the practice by what that hour can bill. Add up a year of the costs that keep a clinician’s hour available: pay and payroll taxes, benefits, front-desk and billing staff, rent, the record system, liability insurance and supplies. Divide that total by the treatment hours actually delivered in the year, not the hours on the schedule, because cancellations and open slots are part of what an hour costs. Then divide the cost of an hour by what it bills under each plan’s rules: the 15-minute units a PT or OT hour produces, or the sessions an SLP completes in it.

Count the work no claim pays for. Documentation, benefit checks, authorization requests, appeals and reworking denied claims all take paid time, and a plan whose rules add that work costs more per visit than its rate suggests. Run the figure separately for each discipline, and for pediatric and adult services where their costs differ: a gym-based pediatric OT hour and a telehealth adult speech hour do not cost the same. The startup budget worksheet lays out the cost lines.

How can Medicare’s fee schedule serve as a reference point?

As a public, code-by-code figure the plan already knows, not as a target the plan owes you. CMS’s look-up tool shows Medicare payment amounts for each code and searches by Medicare Administrative Contractor and locality; CMS directs practices to their contractor for the official payment files.⁠⁷ Record the amount for your locality and the date you looked it up in each worksheet row. Two Medicare rules lower the amount for some therapy visits, and a plan that pays a percentage of Medicare may apply them too: a 50 percent cut to the practice expense component of each “always therapy” service after the first on a given day, and payment at 85 percent for PT and OT services that an assistant provides all or part of.⁠²¹

Where can you see what a commercial plan pays other providers?

In the plan’s own public files. Group health plans and health insurers, with exceptions that include grandfathered plans, must post an in-network rate file covering all covered items and services, with negotiated rates, underlying fee schedule rates or derived amounts, publicly available to anyone free of charge and without an account, and updated monthly.⁠⁸ The files are machine-readable, built for software rather than reading, so a billing service or a data tool may be needed to pull out your codes and county.

Public files are the right place to look. The FTC says a company may collect price or other competitive information from public sources; asking a competing practice what a plan pays it is a different matter, covered in the antitrust section below.⁠²²

How do you read the rate exhibit in a therapy payer contract?

Find how each code is priced, which codes are missing, and what makes the numbers change. A rate exhibit may pay a fixed amount per code, a percentage of a reference schedule such as Medicare’s, a flat amount per visit, or a case or episode rate. Read it with the remittances beside it and check that the amounts the plan has actually paid match the exhibit.

What does a percent-of-Medicare rate mean for therapy codes?

It pays the stated percentage of Medicare’s amount for each code, so the rate follows Medicare’s schedule, its locality adjustment and possibly its therapy-specific reductions, and it changes when Medicare’s amounts change, as they did partway through 2024.⁠^1,7 Ask three questions in writing: which year’s Medicare schedule the percentage applies to (the current year, or a year fixed at signing); which locality’s amounts it uses for each office; and whether the plan applies Medicare’s multiple procedure payment reduction and the 85 percent assistant rate.⁠²¹ A schedule locked to an earlier year does not move when Medicare’s does.

How do per-unit and per-visit rates differ for OT, PT and SLP?

They pay for time differently, and the disciplines bill time differently. CPT descriptors for several therapy modalities and procedures specify 15 minutes of direct one-on-one time, billed in 15-minute units, as with code 97530 in Medicare’s occupational therapy example, while an untimed code is billed as one unit however long the service takes, as with a speech-language evaluation.⁠²³ Where PT and OT treatment is billed on timed codes, a per-unit rate pays more for a longer session; a flat per-visit rate pays the same for any length, so compare it with the units your visits actually bill.

Speech-language pathology is changing. Code 92507 can be reported through December 31, 2026; on January 1, 2027 it is replaced by a family of ten treatment codes with a time-based structure of a base code and add-on codes, and ASHA notes that payers other than Medicare may decide if and when to add them to their fee schedules and advises verifying each payer’s implementation.⁠¹⁴ If a contract pays one rate per 92507 session, ask the plan now what it pays for each new base code and add-on, whether the rate exhibit updates automatically or needs an amendment, and from which date.

Which contract clauses matter as much as the rate itself?

The ones that decide whether a claim is paid at all, and when. A good rate with a filing deadline your billing cannot meet, or authorization rules that take an hour of staff time per patient, can pay less per visit than a lower rate without them. Check these clauses before comparing two offers:

• Timely filing and corrected claims: the days allowed after the date of service, and for a corrected claim.
• Payment timing: when the plan pays a clean claim, and which state’s prompt-payment rules apply to the product; ask the plan to name them.
• Authorization and visit limits: what needs approval, how often, and how a denial is appealed.
• Recoupment: how far back the plan can recover an overpayment, and with what notice.
• New clinicians: the date a newly credentialed clinician is paid at contract rates.
• Settings: whether telehealth and home visits are covered at the same rates.
• Termination: the notice period without cause, and the steps for patients in care.

Can therapy practices negotiate with insurers as a group?

Not by agreeing among themselves on rates or on what to demand. The FTC defines price fixing as an agreement among competitors, written, verbal or inferred from conduct, to raise, lower, maintain or stabilize prices, and says the antitrust laws generally require each company to set its prices and other competitive terms on its own.⁠⁹ Its own example is a reimbursement case: competing optometrists agreed not to join a vision care network unless it raised its reimbursement rates, and the FTC called the agreement illegal price fixing.⁠⁹

Walking out together is treated the same way. Any company may refuse on its own to deal with another firm, but the FTC has challenged groups of competing health care providers whose refusal to deal with insurers except on jointly agreed terms amounted to an illegal group boycott; it says an independent decision not to offer services at prevailing prices raises no antitrust concern.⁠¹⁰

A professional association is not a shelter. The FTC says forming a trade association does not shield joint activities from antitrust scrutiny and that using one to control or suggest members’ prices is illegal.⁠²² The same page notes that an association may represent its members before legislatures or government agencies, which is a different activity from bargaining with a plan; an association’s counsel can say where the line sits.⁠²²

What happened to the agencies’ health care antitrust guidance?

Both agencies withdrew it. The Justice Department withdrew three health care antitrust policy statements on February 3, 2023, saying they were overly permissive on subjects such as information sharing; the FTC withdrew the 1996 health care statements and its 2011 statement on accountable care organizations on July 14, 2023, and said it would evaluate conduct in health care markets case by case.⁠^11,12 On December 11, 2024, the two agencies also withdrew their 2000 Antitrust Guidelines for Collaborations Among Competitors, saying they no longer provide reliable guidance, and encouraged businesses considering a collaboration to review the statutes and case law.⁠¹³

That changes what older articles can be trusted for. Advice that describes a safety zone for sharing price or fee data rests on the 1996 health care statements, which are withdrawn, although the FTC’s own trade association page still describes that safety zone.⁠^12,22 Any joint arrangement, whether an independent practice association, a network that contracts for several practices, a messenger that carries offers between practices and plans, or a fee survey run with other practices, belongs with an antitrust lawyer before the first meeting.

How do you write a rate proposal letter to an insurance company?

Keep it to the codes, the numbers and the reasons, send it to the contact the agreement’s notice clause names, and attach the worksheet. The plan can test each figure against its own claims and directory data, so a short letter a reader can check line by line does more than a long description of the practice. Include only what the practice’s records show, and leave out any claim about outcomes.

What goes in the data worksheet behind a rate proposal?

One row per code you bill the plan, with the evidence for each number. A reader at the plan should be able to see where every figure came from, and the practice should be able to rebuild each row from its own records a year later.

Keep three more lines for the owner, not the plan: the lowest amount the practice can accept for each code (its floor), the share of the practice’s visits this plan’s members account for, and what happens to those patients if the practice leaves.

What happens after a payer receives a rate proposal?

One of four things: the plan accepts all or part of the request, counters, declines, or does not answer. Log the date the letter went out, who received it and each reply, and follow up on the date the letter asked for. If the plan answers that rates for the product or region are not open to change, ask in writing whether that covers every code and when it next reviews its fee schedule.

How do you decide whether to accept, counter or walk away?

Compare the full terms against your floor, then weigh what leaving would do to patients. A rate a little below cost for a small share of visits may be worth keeping while other contracts carry the practice; a rate above cost with clauses that eat the margin may not be. Write down the decision, the reason and the date to revisit it.

1. Accept. The full terms clear your cost floor and the clauses are workable. Record the effective date of the new rates and check the first remittances against them.
2. Counter. The gap is narrow or a clause can be fixed. Send one revised figure per code, or one change to a clause, with the reason.
3. Hold. The plan declines, but its members are a large share of your patients. Keep the contract, limit new patients from that plan only if the agreement allows it, and propose again at the next review date.
4. Leave. The full terms stay below your floor and members can be served elsewhere. Give the notice the agreement requires and plan for the patients in care.

How do you leave an insurance network without stranding patients?

Give the notice the agreement requires, in the form and to the address its notice clause names, and plan for the patients in the middle of care before the notice goes out. Read when the agreement starts the notice period and whether it lets a practice withdraw a notice, and send one only if the practice is prepared to leave on the date it sets.

What does the No Surprises Act require when a provider leaves?

For patients in a group health plan or individual insurance, the plan must tell each continuing care patient in time about the termination and the right to elect continued transitional care, and give the patient a way to tell the plan they need it; a patient who elects it keeps in-network terms for that course of treatment for up to 90 days from the notice, or until they are no longer a continuing care patient, whichever comes first.⁠¹⁵ During that time the practice accepts the plan’s payment, with the patient’s in-network cost-sharing, as payment in full, and keeps following the plan’s policies and quality standards as if the contract had not ended.⁠¹⁶

A continuing care patient is narrower than anyone with an open plan of care. The definition covers, among others, a patient undergoing a course of treatment for a serious and complex condition, which for a chronic condition means one that is congenital, degenerative, potentially disabling or life-threatening and calls for prolonged specialized medical care.⁠¹⁵ A child with a congenital condition in a long course of therapy may qualify, and so may an adult with a degenerative neurological condition; not every patient with an open plan of care does. The rule counts the expiration or nonrenewal of a contract as a termination, but not a termination for failing quality standards or for fraud.⁠¹⁵ Ask the plan how it identifies continuing care patients and how a patient asks for transitional care.

What changes when the network is a Medicaid managed care plan?

The plan has its own notice duty to your patients. A Medicaid managed care plan must make a good faith effort to give written notice of a contracted provider’s termination to each enrollee who was seen by that provider on a regular basis, by the later of 30 days before the termination takes effect or 15 days after the termination notice is received or issued.⁠²⁴ Give the plan your notice early enough for that letter to reach families before the last in-network visit, and tell families yourself as well. For children in Medicaid, the EPSDT guide covers what the program owes them and what a pediatric practice documents.

What should patients and families hear when you go out of network?

The date, what changes for them, and their options, in writing and before their next visit. Tell each patient or family the last date the practice is in network, whether they may qualify for transitional care and how to ask the plan, what an out-of-network visit would cost them if their plan has out-of-network benefits, the self-pay rate and the practice’s estimate process, and how the practice helps transfer care to an in-network provider. Self-pay fees and good faith estimates are covered in the payment explanation guide.

Then correct every place the practice says which plans it takes, on the effective date: the website, the Google Business Profile, referral sheets, and directory profiles. On DrSensory, a paid listing’s Clinic details box shows the insurance the clinic ticks in its portal, and the description, in the clinic’s own words, is the place to name plans; changes show on the profile about a minute after publishing; after a listing’s first seven days it can be republished once a week, so schedule the edit for the effective date.

How do pediatric and adult caseloads change a rate negotiation?

They change which payers matter and which codes carry the money, so prepare each track from its own numbers. Count visits by payer for children and for adults separately: a plan that dominates one track may barely appear in the other, and the negotiation that matters most follows the visits.

For a pediatric track, compare an offer with the pediatric column of the state’s Medicaid schedule, since states must list pediatric and adult fee-for-service rates separately where they differ.⁠¹⁸ For a speech track serving either age group, every contract that pays one 92507 rate needs prices for the ten codes that replace it in January 2027.⁠¹⁴ For an adult track with many patients over 65, Original Medicare’s rates are fixed, so the negotiable part of that caseload sits with Medicare Advantage and commercial plans.⁠^1,4

By discipline, PT and OT practices that use assistants should check whether a plan copies Medicare’s 85 percent rate for PT and OT services that an assistant provides all or part of.⁠²¹ Payer mix by track, and how to staff each one, are in the children-and-adults guide.

Sources

1. Centers for Medicare & Medicaid Services. Physician Fee Schedule (page last modified September 30, 2026). Checked October 24, 2026.
   Show the passageHide the passage

   “The PFS is the primary method of payment for enrolled health care providers.”; Medicare uses the PFS when paying “Professional services of physicians and other health care providers in private practice”; “On March 9, 2024, President Biden signed the Consolidated Appropriations Act, 2024, which included a 2.93 percent update to the CY 2024 Physician Fee Schedule (PFS) Conversion Factor (CF) for dates of service March 9 through December 31, 2024.”.
2. 42 CFR. §447.15, Acceptance of State payment as payment in full (Medicaid). Checked October 24, 2026.
   Show the passageHide the passage

   “A State plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual.”.
3. 32 CFR. §199.14, Provider reimbursement methods (TRICARE, formerly CHAMPUS). Checked October 24, 2026.
   Show the passageHide the passage

   (j)(1)(i)(A), (j)(1)(iv)(A) and (j)(1)(i)(C): “The allowable charge for authorized care shall be the lower of the billed charge or the local CHAMPUS Maximum Allowable Charge (CMAC).”; “The national CHAMPUS Maximum Allowable Charge level for each procedure will be adjusted for localities using the same (or similar) geographical areas and the same geographic adjustment factors as are used for determining allowable charges under Medicare.”; “Nonparticipating providers may not balance bill a beneficiary an amount which exceeds the applicable balance billing limit. The balance billing limit shall be the same percentage as the Medicare limiting charge percentage for nonparticipating physicians.”.
4. 42 CFR. §422.214, Special rules for services furnished by noncontract providers (Medicare Advantage). Checked October 24, 2026.
   Show the passageHide the passage

   (a)(1): “Any provider (other than a provider of services as defined in section 1861(u) of the Act) that does not have in effect a contract establishing payment amounts for services furnished to a beneficiary enrolled in an MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts that the provider could collect if the beneficiary were enrolled in original Medicare.”.
5. 42 CFR. §438.6, Special contract provisions related to payment (Medicaid managed care). Checked October 24, 2026.
   Show the passageHide the passage

   (c)(1), the general rule, with the exceptions that follow it, including (c)(1)(iii)(A) and (E): “the State may not in any way direct the MCO’s, PIHP’s or PAHP’s expenditures under the contract.”; “Adopt a minimum fee schedule for providers that provide a particular service under the contract using State plan approved rates.”; “Adopt a maximum fee schedule for providers that provide a particular service under the contract”.
6. HealthCare.gov. Allowed amount (glossary). “The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.””. Checked October 24, 2026.
7. Centers for Medicare & Medicaid Services. PFS Look-up Tool Overview (page last modified February 9, 2026). Checked October 24, 2026.
   Show the passageHide the passage

   “The PFS Look-Up Tool helps you find Medicare payment amounts for each code so you can calculate the patient coinsurance amount.”; “You can use a single procedure code, a range of procedure codes, or a list of procedure codes to search for national payment amounts through a specific MAC or a specific MAC locality.”; “We adjust the PFS pricing amounts to reflect the variation in practice costs from area to area.”; “For the official and definitive CMS PFS payment files, contact your MAC.”.
8. 45 CFR. §147.212, Transparency in coverage requirements (group health plans and health insurance issuers). Checked October 24, 2026.
   Show the passageHide the passage

   “An in-network rate machine-readable file that includes the required information under this paragraph (b)(1)(i) for all covered items and services”; “All applicable rates, which may include one or more of the following: Negotiated rates, underlying fee schedule rates, or derived amounts.”; “The machine-readable files must be publicly available and accessible to any person free of charge and without conditions”; “A group health plan or health insurance issuer must update the machine-readable files and information required by this paragraph (b) monthly.”; “this section does not apply to grandfathered health plans.”.
9. Federal Trade Commission. Price Fixing (Guide to Antitrust Laws, Dealings with Competitors). Checked October 24, 2026.
   Show the passageHide the passage

   “Price fixing is an agreement (written, verbal, or inferred from conduct) among competitors to raise, lower, maintain, or stabilize prices or price levels.”; “Generally, the antitrust laws require that each company establish prices and other competitive terms on its own, without agreeing with a competitor.”; “A group of competing optometrists agreed not to participate in a vision care network unless the network raised reimbursement rates for patients covered by its plan.”; “The FTC said that the optometrists’ agreement was illegal price fixing”; “Each company is free to set its own prices, and it may charge the same price as its competitors as long as the decision was not based on any agreement or coordination with a competitor.”.
10. Federal Trade Commission. Group Boycotts (Guide to Antitrust Laws, Dealings with Competitors). Checked October 24, 2026.
    Show the passageHide the passage

    “Any company may, on its own, refuse to do business with another firm, but an agreement among competitors not to do business with targeted individuals or businesses may be an illegal boycott, especially if the group of competitors working together has market power.”; “The FTC has challenged the actions of several groups of competing health care providers, such as doctors, charging that their refusal to deal with insurers or other purchasers on other than jointly-agreed upon terms amounted to an illegal group boycott.”; “An independent decision not to offer services at prevailing prices does not raise antitrust concerns”.
11. U.S. Department of Justice, Office of Public Affairs. Justice Department Withdraws Outdated Enforcement Policy Statements (press release, February 3, 2023, archived). Checked October 24, 2026.
    Show the passageHide the passage

    “The Justice Department’s Antitrust Division announced today the withdrawal of three outdated antitrust policy statements related to enforcement in healthcare markets”; “the statements are overly permissive on certain subjects, such as information sharing, and no longer serve their intended purposes of providing encompassing guidance to the public on relevant healthcare competition issues in today’s environment.”.
12. Federal Trade Commission. Federal Trade Commission Withdraws Health Care Enforcement Policy Statements (press release, July 14, 2023). Checked October 24, 2026.
    Show the passageHide the passage

    “The Federal Trade Commission announced today the withdrawal of two antitrust policy statements related to enforcement in health care markets: Statements of Antitrust Enforcement Policy in Health Care , published in August 1996, and Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program from October 2011.”; “The Commission’s withdrawal follows the Department of Justice’s decision to rescind the same statements in February 2023.”; “The Commission will continue its enforcement by evaluating on a case-by-case basis mergers and conduct in health care markets that affect consumers.”.
13. Federal Trade Commission. FTC and DOJ Withdraw Guidelines for Collaboration Among Competitors (press release, December 11, 2024). Checked October 24, 2026.
    Show the passageHide the passage

    “Today, the Federal Trade Commission and the Justice Department’s Antitrust Division (DOJ) jointly announced the withdrawal of the Antitrust Guidelines for Collaborations Among Competitors (Collaboration Guidelines).”; “The Collaboration Guidelines, issued in April 2000, no longer provide reliable guidance about how enforcers assess the legality of collaborations involving competitors”; “Businesses considering collaborating with competitors are encouraged to review the relevant statutes and caselaw to assess whether a collaboration would violate the law.”.
14. American Speech-Language-Hearing Association. Speech-Language Pathology Treatment Codes Replacing 92507 (coding guidance). Checked October 24, 2026.
    Show the passageHide the passage

    “CPT code 92507 remains in effect through December 31, 2026. The new codes take effect January 1, 2027.”; “should verify implementation requirements with each payer, as they may vary.”; “The new codes describe individual treatment by clinical service and use a time-based structure consisting of a base and add-on codes.”; “Final Medicare values will be established in the CY 2027 MPFS final rule.”; “Other payers may decide if and when to implement the new codes into their fee schedules.”.
15. United States Code. 42 U.S.C. §300gg-113, Continuity of care (U.S. Code, 2024 edition; Public Health Service Act §2799A-3, added by the No Surprises Act). Checked October 24, 2026.
    Show the passageHide the passage

    (a)(2)(A), (a)(2)(B), (a)(2)(C)(i) and (ii), (b)(1)(A), (b)(2)(B) and (b)(3): “notify each individual enrolled under such plan or coverage who is a continuing care patient with respect to a provider or facility at the time of a termination described in paragraph (1) affecting such provider or facility on a timely basis of such termination and such individual’s right to elect continued transitional care from such provider or facility under this section”; “provide such individual with an opportunity to notify the plan or issuer of the individual’s need for transitional care”; “the 90-day period beginning on such date”; “the date on which such individual is no longer a continuing care patient with respect to such provider or facility”; “is undergoing a course of treatment for a serious and complex condition from the provider or facility”; “in the case of a chronic illness or condition, a condition that is”; “is life-threatening, degenerative, potentially disabling, or congenital; and (ii) requires specialized medical care over a prolonged period of time.”; “includes, with respect to a contract, the expiration or nonrenewal of the contract, but does not include a termination of the contract for failure to meet applicable quality standards or for fraud.”.
16. United States Code. 42 U.S.C. §300gg-138, Continuity of care (U.S. Code, 2024 edition; Public Health Service Act §2799B-8, the provider’s side of the same rule). Checked October 24, 2026.
    Show the passageHide the passage

    “accept payment from such plan or such issuer (as applicable)”; “for such items and services as payment in full for such items and services; and”; “continue to adhere to all policies, procedures, and quality standards imposed by such plan or issuer with respect to such individual and such items and services in the same manner as if such termination had not occurred.”.
17. Centers for Medicare & Medicaid Services. Manage Your Enrollment (page last modified March 4, 2026). “Providers NOT Eligible to Opt Out Anesthesiology assistants Chiropractors Occupational therapists Physical therapists Qualified audiologists Qualified speech language pathologists”; “If you don’t see Medicare patients, you don’t have to enroll in or opt-out of Medicare.”. Checked October 24, 2026.
18. 42 CFR. §447.203, Documentation of access to care and service payment rates (Medicaid). Checked October 24, 2026.
    Show the passageHide the passage

    (b)(1): “The State agency is required to publish all Medicaid fee-for-service fee schedule payment rates on a website that is accessible to the general public.”; “If the rates vary, the State must separately identify the Medicaid fee-for-service payment rates by population (pediatric and adult), provider type, and geographical location, as applicable.”; “The initial publication of the Medicaid fee-for-service payment rates shall occur no later than July 1, 2026”.
19. 32 CFR. §199.17, TRICARE program (TRICARE). Checked October 24, 2026.
    Show the passageHide the passage

    (p)(6), Special reimbursement methods for network providers, and (p)(4)(iv) and (vi): “The Director, may establish, for preferred provider networks, reimbursement rates and methods different from those established pursuant to § 199.14 . Such provisions may be expressed in terms of percentage discounts off CHAMPUS allowable amounts, or in other terms.”; “All preferred network providers must be Medicare participating providers, unless this requirement is waived based on extraordinary circumstances.”; “The provider must agree to accept the same payment rates negotiated for Prime enrollees for any person whose care is reimbursable by the Department of Defense”.
20. HealthCare.gov. Balance billing (glossary). “When a provider bills you for the difference between the provider’s charge and the allowed amount.”; “A preferred provider may not balance bill you for covered services.”. Checked October 24, 2026.
21. Centers for Medicare & Medicaid Services. Therapy Services (page last modified March 10, 2026). Checked October 24, 2026.
    Show the passageHide the passage

    “Medicare applies a MPPR to the practice expense component of certain “always therapy” services. Since April 1, 2013, the MPPR rate is 50 percent for both practitioner/office and institutional settings. It applies to the second and subsequent therapy services provided to a patient on the same day.”; for physical therapy and occupational therapy services furnished in whole or in part by physical therapist assistants and occupational therapy assistants, “Payment for these services is at 85 percent of the otherwise applicable PFS payment amount/rate for the service, effective January 1, 2022.”.
22. Federal Trade Commission. Spotlight on Trade Associations (Guide to Antitrust Laws, Dealings with Competitors). Checked October 24, 2026.
    Show the passageHide the passage

    “The association also may represent its members before legislatures or government agencies, providing valuable information to inform government decisions.”; “forming a trade association does not shield joint activities from antitrust scrutiny”; “it is illegal to use a trade association to control or suggest prices of members.”; “One area for concern is exchanging price or other sensitive business data among competitors, whether within a trade or professional association or other industry group.”; “Your company may collect price or other competitive information from public sources.”; “Information about future plans should be closely guarded”; “employees should be careful when sharing information they could not otherwise share with competitors through intermediaries such as a financial analyst or even a supplier.”; “the Statements of Antitrust Enforcement Policy in Health Care set out a "safety zone" for data exchanges”.
23. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (§20.2, Reporting of Service Units With HCPCS). Checked October 24, 2026.
    Show the passageHide the passage

    “Several CPT codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes.”; “A beneficiary received a total of 60 minutes of occupational therapy, e.g., HCPCS “timed” code 97530”; “When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe (“untimed” HCPCS), the provider enters “1” in the field labeled units.”; for a speech-language pathology evaluation billed with untimed code 92521, “Regardless of the number of minutes spent providing this service only one unit of service is appropriately billed on the same day.”.
24. 42 CFR. §438.10, Information requirements (Medicaid managed care). Checked October 24, 2026.
    Show the passageHide the passage

    (f)(1): “must make a good faith effort to give written notice of termination of a contracted provider to each enrollee who received his or her primary care from, or was seen on a regular basis by, the terminated provider. Notice to the enrollee must be provided by the later of 30 calendar days prior to the effective date of the termination, or 15 calendar days after receipt or issuance of the termination notice.”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. Antitrust and contract questions belong with a lawyer, and its figures are hypothetical, not DrSensory data or benchmarks.