And other places!!

Very frequently I hear OTs say, “I met a person who needs OT, BUT.... they don’t have a referral...." And that seems to be the end of the road for the person who needs help! Which is a bummer.

There are two ways a therapist could respond to this scenario.

Option One: “Why don’t you go see your doctor and then come to me for therapy?”

How likely do you think it is that that person in the midst of their busy daily life will actually take the time to do this multi-step process? It's more likely the person will give up and continue suffering than to follow through that maze to get to OT.

There are at least 7 steps in that process: Figure out which doctor, find a phone number or figure out online contact, get an appointment, go to the appointment, pay their deductible or co-pay for that visit, negotiate with the doctor about whether the referral is needed, and FINALLY schedule an appointment for therapy. Think of all the questions that have to be answered and potential barriers to be overcome!!

Option Two: Wouldn't it be better to go directly to OT?

An OT SEES and TALKS TO the person for an evaluation, educates them on their situation and options available, gives them hope and basic advice, and lets them know what next steps are?

This is far more likely to lead to the person making a decision to deal with the issue and get relief, which leads to getting their life back, instead of continuing to tolerate the problem. YES!!!! But....

Can OTs evaluate a client/patient without a referral?

The short answer, in Washington state, is “yes”. Other states vary.

There are three considerations (what is legal, what is required by the payer, and what is required by your facility or clinic). And some caveats.

For the remainder of the states, the short answer is “maybe”. The same considerations apply, and state laws vary. AOTA maintains a summary chart of the status in each state (one example of the profoundly useful advocacy tools provided by our professional organization!). Oregon is very similar to Washington. Recently, California has removed the referral requirement entirely, and now has full direct access.

Consideration #1: State practice acts and what is legally allowed.

The ability to evaluate and treat patients for occupational therapy services is dictated by the state law governing occupational therapy practice, commonly referred to as “the practice act”. States vary in whether or not OTs may evaluate or treat a patient without a referral, with more than 30 states having no specific requirements for a referral. Each state practice act has some variation of the following options:

- Direct access – OTs may evaluate and treat a patient without a referral.

- Limited direct access – OTs may evaluate any patient, but have a “duty to refer” to another medical professional to refer for occupational therapy treatment.

- Referral required – OTs must have a referral for evaluation AND treatment of the patient.

What does this look like in clinical practice? In our hand therapy practice, when we are contacted by a potential client who does not have a referral for OT, we ask them to come in for the evaluation. During the evaluation, we identify the person’s functional limitations and impairments, and what can be done through OT to improve them. We provide this information to the person and discuss options for next steps.

Assuming they have a "medical issue" and not just functional limitations, we talk with them about the need for a referral if they wish to be treated in OT and ask if they have seen a physician recently, or if they have a relationship with a primary care physician or other medical provider with whom they can communicate about the issue.

What does "medical issue" mean?  The link provided above gives some guidance via a decision tree from the OT Board in Washington State.  It is quite clear, though certainly there are some grey areas that remain and it does not address every situation.

My takeaway interpretation (non-legal opinion!) from that is:  in a situation where the patient has as a stable condition with functional limitations, and we are treating within our scope of practice, a referral is not required at all.  I'm imagining someone with osteoarthritis who has pain and trouble pinching/gripping.... 

If they have a provider that has either seen them for the presenting problem or with whom they have an established relationship, we ask the patient to contact them to let them know that they want to come to OT. We also fax the evaluation to the provider and request a signature on the plan of care. This document can serve as the "referral" for OT.  We almost never have trouble getting this back.

Consideration #2: Whether or not a referral is required by the payor.

Some payers require a referral for OT services in order to pay for evaluation or treatment by an OT. We went to great effort in the early years of my private practice to confirm this for each payer, and found very, very few that actually DO require a referral to pay, even for the evaluation. Most do not. Some notable exceptions are Medicare and some federal payers. Labor and Industries (WA Worker's Comp) and Medicare requires a signed plan of care in order to pay for the evaluation.

Consideration #3: Whether or not a referral is required by your facility or practice policy.

Some facilities take a very aggressive stance and do not require a referral for OT/hand therapy treatment.  Some facilities have elected to take the most conservative position, and require a referral prior to an OT evaluation. In this case, unless you can change your facility's policy, you are obligated to follow it.

Don't forget... even if required...

Referrals can come from many different providers, not just medical doctors. In Washington state, referrals for OT can come from: “a physician, osteopathic physician, podiatric physician and surgeon, naturopath, chiropractor, physician assistant, psychologist, optometrist, or advanced registered nurse practitioner licensed to practice in this state.” Other states vary, but it is unlikely that it is medical doctors only. We have great relationships with chiros, nurse practitioners, and others.

In a state with direct or limited direct access, I personally believe that a requirement for the patient to get a referral for OT before talking to an OT and understanding what is wrong and what can be done is an unnecessary roadblock to helping them resolve the problem that caused them to seek help.

In summary, whether or not a patient can be seen without a referral may be dictated by the state practice act, payer requirements, or facility/clinic policy. Unless the referral is required by one of these three considerations, patients can be seen for evaluation and treatment without a referral.