Receipts for your Cash Pay Patients

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After my last post, I had some follow up questions about the specifics of the self-claim receipts I provide my patients. Given that my treatments are all one hour long with the majority of the time dedicated to Manual Therapy and always at least a review of the HEP, here’s what my receipts include (along with the obvious business and patient identifying info):



  • Business Tax ID/EIN #
  • ICD9 diagnosis codes
  • CPT codes
    • 3 x Manual Therapy (15 minutes each) at $30 each
    • 1 x Therex (15 minutes) at $30
  • My credentials, Texas License number, National Provider ID #, and signature

Author Note – Jan 2013: in addition to the above info, please also include:

  • Location of Services: Outpatient Clinic (stand alone), code = 11
  • A note at the bottom (in bold large font) that the patient has already paid in full for the services, and that any payment should be sent directly to the patient

Here is a template you can work from:

Cash-Based PT Receipt example template

Please note that the receipts your patients need for a successful self-claim may be very different from what I’ve outlined above. You know those insurance companies … they’ll do whatever they can to deny a claim. With that said, the above format has been accepted by most insurance companies when my patients send in self-claims. There are of course times when a company will say info is missing, and after 20 minutes on the phone, they admit that everything needed is actually all there. If time on the phone becomes a common issue with a particular patient and his insurance company, I inform the patient that this is one of the reasons I don’t deal with insurance; and that more of my time on the phone will need to be paid for. It’s tough to say these things but you have to protect your time. After all, you didn’t move to a private-pay business model to continue spending time on the phone with insurance companies.

Over the past year, I’ve spent less than three hours dealing with insurance companies or insurance-related issues. Take a moment to imagine how nice that is … no research or meetings to figure out how to comply with the latest Medicare reimbursement changes, no (re)negotiations of low-paying contracts with insurance companies, no more reports from your salaried billing staff (or outsourced billing company) on why you only received 45% of the enormous bill for Mrs. Jones. It’s awesome.

 

 

 

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{ 37 comments… read them below or add one }

Christine Vlahos July 21, 2011 at 1:43 am

Thank you, Jarod! You’re the best! Great inspiration!

Christine

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Dr Jarod Carter July 21, 2011 at 2:19 am

Thanks Christine. Great looking site and so exciting to see you already have a cash practice going! I recently received an inquiry through the Private Practice Section from someone interested in creating a Women’s Health program. Could I refer him to you for some input?

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Darryl July 21, 2011 at 1:45 am

This is so helpful I had no idea about how to manage all of the receipts correctly!

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Greensboro Physical Therapist July 21, 2011 at 6:19 pm

Jarod,
great post on receipts for cash pay patients.
A long time ago, when I was actually only a massage therapist, one insurance company wanted me to identify the ‘place of service’. I mean really? did they not know it was at my business? After calling and finally talking to someone, I asked her what this was, she told me, but also said she could not give me the information (the exact code) as it was not her job.
Anyway, the place of service code is: Office Code 11 which is for a stand alone outpatient facility, so I include that on all my receipts as well.
I also include a Bold Red line stating that “the patient has paid for the service provided in full and LeBauer Physical Therapy is NOT an insurance provider for this claim. Please provide payment directly to the patient.”

Also, in your experience how do you handle it when an insurance company sends you a check made out to your business, when they should have sent the check directly to the patient? that might be another good blog post topic. This has happened infrequently but I just had a cluster of checks about 3 months ago.

If a company (insurance, law firm, etc) requests patient records, I ask for a $50 administrative fee up front. I learned the hard way by sending out notes before payment to a law firm, that offered to pay for the notes, which took 3 months and 6 phone calls, to recoup. also by asking for this ‘reasonable’ amount to be paid, 3 times and asking for the manager, one insurance company decided to reprocess the claim for my patient.
Aaron LeBauer
LeBauer Physical Therapy

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Dr Jarod Carter July 21, 2011 at 9:30 pm

Thanks for the great info Aaron!

I’ve never heard of the “place of service” issue, but it’s good to know the code if it ever comes up.

I also haven’t had any insurance companies send me checks directly, but that occasionally happened at the Cash practice where I previously worked. Like you, I would call the company and inform them to send the payment directly to the patient; then I’d go have a nice steak dinner with the check (Ha!). Since I hadn’t had to deal with this since starting my practice I forgot about adding the “this patient has paid in full… pay them directly” statement. But I just added it to my receipt template. Thanks!

For those who have not already read it, you can find my interview of Cash practice owner, Aaron LeBauer, here

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Dr Jarod Carter July 29, 2011 at 10:51 pm

Had to throw this in here…
Had a call from a patient today saying that United Health Care told her they not only needed my Employer Identification Number (EIN) listed on the receipt, but they also needed my Tax ID Number before they could process her self-claim. I had my accountant email her the explanation that these are two terms for the the exact same thing, so she could forward that to the geniuses at UHC. Like I said above… they’ll do anything to keep from paying.

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Suzanne May 12, 2012 at 5:34 pm

Hi Jarod,
Want to say all your information has been extremely helpful. I recently have started a cash based private practice and one question I have is do I need to contact the insurance companies to become a “provider” in order for the treatment to be covered even as an out of network provider?
Thanks for you input.
Suzanne

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Dr Jarod Carter May 28, 2012 at 4:08 pm

Hi Suzanne,

I’ve never heard of having to contact an insurance company to become an “out-of-network” provider. I’m pretty sure you are either in-network with them or not. However, I should say that I’ve not looked deeply into this idea and haven’t called any 3rd Party payors to see if they have a list of out-of-network providers that I could be on (to get my patients better reimbursements). It may be worth it to call a few of the most-used payors in your area and ask them directly. If you do, please let us know what they tell you.

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Josh Borgmeyer, DPT, MTC August 2, 2012 at 3:58 am

Jarod,

Thanks for all the great info. on cash-based service. Insurance companies aren’t going to increase reimbursement rates until we, as a profession, offer a little push-back.

I am currently working for an employer 2 days per week offering insurance-based PT service. I am self-employed 3 days per week offering cash-based PT and renting a space at a high-end Fitness Facility. It’s a great arrangement for me and I’ve been fortunate to stay completely booked. I am looking to expand and do things completely solo. I am torn about going completely cash-based as I still want to provide services to those who can’t afford the cash yet have decent insurance. I’m just curious: have you ever heard of anyone operating 2 businesses at one physical location? I am thinking about starting up a second company for the purpose of accepting insurance contracts on limited basis. My established company, Balanced Body Rehab, would continue to offer out-of-network/cash options for wellness PT and option of greater one on one care. Is this legal? I don’t see why it wouldn’t be but I guess it depends on the language in the contracts. Your thoughts? Thank you.

Josh

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Dr Jarod Carter August 6, 2012 at 2:36 am

Josh,

First of all, congratulations on your booked cash-based schedule. Sounds like you won’t have a problem expanding to full time. As for your question … you’ll have to be very careful about the contracts you sign with any insurance companies because they can have clauses that mandate you bill them directly for covered services provided to anyone who carries that specific insurance. For example, let’s say you sign a contract with BCBS that has such a clause, and you have people who want to see you on a self-pay basis (to get longer one-on-one treatments) but are insured by BCBS; though they want to be self-pay, you could be in violation of your contract by Not directly billing BCBS for those services.

The take home point is that if you want to have both cash-based and insurance-based patients, you should have a health care lawyer look over any contracts with insurance companies before you sign them. You also need to keep in mind that there could be clauses in contracts that dictate what you are required to charge your cash-pay patients. One example is a “most favored nation” clause that essentially mandates you charge the insurance company no more than you charge others. So you have to make sure the definition of ‘others’ does not include cash-pay patients … otherwise you could be forced to charge them as much as you charge the insurance company (which could be prohibitively expensive for many of your patients).

There are probably more legal components to the question you asked, so definitely consult with a lawyer before making any moves. The idea of having two completely separate and different legal entities may provide a solution, but I really can’t say for sure.

Thanks for the great question. Best of luck!

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Josh Borgmeyer, DPT, MTC August 7, 2012 at 2:19 am

Thanks Jarod! I appreciate the time you took on your response. It’s refreshing to see PT’s working together rather than in perpetual competition with one another. I will definitely seek the advice of a health care lawyer before signing the contracts. Once I get my hybrid model of business established, I’ll try to share any helpful insight to the post. Keep up the great work!

your fellow t-DPT USA grad,

Josh

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Mindy Forman September 4, 2012 at 5:37 pm

Jarod,
Thank you for the comprehensive information you have been providing.
If you would be kind enough to provide to the best of your knowledge clarification on the following:

1. I’m a cash based PT having nothing to do with Medicare. I am now seeing those patients who come under the heading of wellness, maintenance, general fitness.
With that being said, how should my receipts be formatted? Should I be including specific CPT codes rather than something more general?

2. It has been my understanding from some other PTs that if a Medicare patient falls under the above-mentioned categories, there is no need & it is actually better not to give an ABN. Your thoughts?

3. How & where do I go to find out if patients have capped out so I can treat them as well? I don’t have administrative staff; will I be spending an inordinate time on the phone trying to get accurate info?

Thank you again for your excellent work.

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Dr Jarod Carter September 10, 2012 at 11:31 pm

Hi Mindy. Thanks for the great questions.

1. The first is one of those questions where the first part of my answer has to be that you should ask an attorney to be sure. There may be rules that CMS has on this and there may also be components of your state’s PT Practice Act that mandate the use of CPT codes even with non-covered services. I honestly don’t know. I personally make sure to list the term “fitness,” “maintenance,” etc depending on what I’m providing. I think it is important to have those non-covered services specifically listed on the receipts you provide, just in case your client tries to send a self-claim to Medicare.

2. If the patient is continuing care on a “maintenance” basis, then it is necessary to provide an ABN (which would only apply to your situation if they had met their therapy cap at a different clinic and then wanted to continue care with you on a self-pay basis). If you are seeing a Medicare beneficiary for fitness/wellness/prevention (“Statutory” reason), then you are not mandated to provided an ABN. However, I’m simply repeating the advice I received from the APTA that it is “best practice” to provide an ABN anytime you’ll be providing any service that will/may not be covered. As I understand it, the ABN is a way to make sure your MC-aged clients are completely clear on what they will have to pay out-of-pocket. I can’t see why a practitioner wouldn’t want to do this, so I’m curious if the PTs who told you the above information also told you why they thought it was better to not provide an ABN?

3. That’s a good question … perhaps other PTs who have had to do so could also chime in here and give us some guidance? I see very few MC beneficiaries, and I haven’t had a situation in which they may have capped elsewhere and wanted to continue maintenance care with me.

When it comes to my patients and any type of insurance reimbursement questions, I leave it in their hands to figure things out with their insurance company. I know of out-of-network PTs who do have staff to help people find out what their reimbursement would be with self-claims. However, this is obviously different with the Medicare population because you really don’t want them sending in any claims trying to get reimbursement. If I were you, I would just call CMS and start asking around. It may take some time, but perhaps there is in fact a person/office you could call and quickly confirm if a cap has or has not been met.

Can any other readers out there help us on this one??

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Austin Woods December 5, 2012 at 5:28 pm

Thanks for the post Jarod.

Quick question. What software/program do you use for the itemized receipt? I’ve heard quickbooks isn’t HIPAA complaint, so wouldn’t want to use patient names to create receipts/invoices through that system. Are you just using a template for this? Any help would be appreciated.

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Dr Jarod Carter December 5, 2012 at 10:08 pm

I go the cheap simple route and use a template I created on MS Word.

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Aron January 11, 2013 at 11:11 pm

Hi Dr. Carter,

I have a small private PT/personal training business that is an LLC that has an address listed out of my house, but I rent a space at a different office for treating patients. Since the LLC and the EIN are associated with my home address, is that going to be a problem for patient’s to receive reimbursement since the address is residential and not the location where I am treating?

Thanks so much for this website, it is really helpful for starting up a cash based business.

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Dr Jarod Carter January 12, 2013 at 12:13 am

Hi Aron, I think you should be okay because I’ve done the same thing…. PLLC at my home address but all billing/receipts have my office address, and there hasn’t been any issues so far. Let me know if this proves different for you.

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Tracy Sher February 7, 2013 at 1:23 am

Hi Jarod,
Thanks for a great post!

I’m sorry if I missed this earlier in comments. I have a new cash practice and my patients are just starting to submit for out-of-network benefits.

1. I have a set flat fee for my evals and treatments, but I don’t mark each charge as a set fee (i.e. $30 per 15 min manual). Does this need to be delineated? I use WebPT and just put “4 manual” and then charge the patient the set fee and provide a receipt. Is this enough for patients to get reimbursed?

2. I’m in a direct-access state, so patients are finding me and coming in without scripts. However, I’m concerned that they won’t get out-of-network benefits if they don’t have an RX from day one. What has been your experience? (I realize that this will vary for each insurance company). I try to alert patients about this, but they still come in without an RX and then want to try seeking reimbursement.

I hope this makes sense.
Thanks!
Tracy

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Dr Jarod Carter February 7, 2013 at 2:32 am

Thanks for the questions, Tracy. And congratulations on starting a new cash practice!!
To answer your questions…
1. Delineating the charges per unit (15 minutes) is necessary for your patients to get reimbursement, so you are correct there. AND the receipts you provide your patients still need to utilize CPT codes and all other information needed to process a claim (ICD9 codes, Tax ID number, NPI number, location of service, etc).

Here is something it sounds like you need to consider: your State Practice Act may dictate that you charge specifically for the procedures you perform. For Example, if you are doing 15 minutes Evaluation, 30 minutes Manual, and 15 minutes Therex, but then giving everyone a bill that says “4 units Manual Therapy,” you might be breaking the rules of your practice act, so this is something you need to look in to.

Many private-pay practices charge Flat Rates per treatment session. That can work, but like I said above, billing must still be split into CPT codes and the different procedures performed, and your pricing per CPT code and total units performed obviously need to add up to that flat rate. So flat rates can cause problems if your treatment times and procedures are somewhat varied from one patient to the next.

If you want to go the route of having a flat rate per visit, then it’s easiest if the time spent in each session and the CPT codes used stay fairly consistent.. which doesn’t have to be that hard actually.

For example, before I raised my rates in January 2013, I collected $120 for each one-hour treatment, which I showed on the patient’s bill as 3 units of Manual Therapy and 1 unit of Therex at $30 each unit. If my treatment veers from these procedures, then I change it accordingly, but I charged $30 per unit of any procedure to keep things simple and consistent. Now that my rates are higher, my fee schedule is slightly different, but still adds up to the total flat fee and is properly delineated on the patient’s receipt.

2. Must be nice to have Direct Access!!! Our legislative session just began, so we will again be fighting hard for Direct Access in Texas. Since my patients don’t have direct access to my services, I don’t have experience in this realm. However, my input would be that if you let patients know ahead of time that they may need a referral in order to successfully submit self-claims, then the ball is in their court to find out from their insurance company and get the referral if needed.

We have been expected to take the time (and substantial cost) of getting paid/reimbursed for our services, pretty much forever. So those of us moving into the cash-based realm have patients who are now taking on that responsibility and taking the time to get reimbursement. If they run into problems (which insurance companies will often create), I try to help however I can, within reason. But when the insurance company doesn’t relent and finds new reasons to deny, I explain to the patient that “this is exactly why I got out of the insurance racket.” “Can you imagine fighting like this to get paid for the majority of the work you do?”

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Tracy Sher February 7, 2013 at 2:47 am

I really do appreciate your reply. However, admittedly this has opened up another can of question worms…ha.

1. I do charge differently for each patient. So, I could set each charge at the same amount to make it easy. But, where do I show that each charge is, for example $30? How do you have this set up to show that? My receipt just shows the pay amount and my WebPT super bill just shows the amount of charges i.e. 3 manual, 1 ther ex. What do you use to show the charge? Can I have a separate pre-made form for that?

2. Regarding the following- (ICD9 codes, Tax ID number, NPI number, location of service, etc). NPI number? How would I get that if I have only done cash-based? Did I miss getting that? Do I have it and not know it? Yikes.

The rest I have covered, but didn’t realize the tax ID has to be on my bill…Thanks for that!

Tracy

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Dr Jarod Carter February 10, 2013 at 6:09 pm

1) I would hope that WebPT allows you to place the “charge per unit” next to where you list the units of manual/therex/etc. These do need to be delineated on the bill to improve your patients’ chances of reimbursement (and decrease the time you’ll have to deal with insurance companies wanting more info from you. My receipts are simply created from a Word doc template… so it has 3 units Manual Therapy (CPT code) $30ea , total $90; and 1 unit Therex (CPT code) $30ea. TOTAL $120

2) You can get an NPI number here for free: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

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AK February 25, 2013 at 11:47 pm

Hi,

Why did you decide to a PLLC? My accountant suggested that I didn’t need it to open a cash based practice. Also do you need to have an NPI if you are not planning on taking Medicare? Are there any recommendations that you have if you are paying per patient inside of a pilates studio?

Thank you for any input!

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Dr Jarod Carter February 26, 2013 at 11:53 pm

I converted from an LLC to a PLLC because according to my attorney (who did not charge me or make money off of the conversion) said it offers better protection for companies offering “professionally licensed” services. I had also heard/read the same thing in my own research. This may not be the case in your state.

In order for your patients to file self-claims with their insurance, you will need an NPI (regardless of whether or not you’re a Medicare provider).

A Pilates studio sounds like a great spot for a cash PT practice! If I were you, I would offer monthly free seminars to the Pilates Studio trainers and clients on topics of interest to them (ex: Injury Prevention in Pilates, Burning Calories throughout the Day, Improving Joint Mobility and Health to Optimize your Pilates Sessions, etc). The clients (and instructors) will often approach you afterward to ask about different pains or limitations they’re dealing with and you can give them good advice or get them in for treatment as needed.

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AK March 7, 2013 at 9:26 pm

Thank you! Will get you some updated information on my practice next month when it “officially” launches.

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D Smith April 8, 2013 at 1:27 am

What documentation do you use for cash based clients? Does this change because they are cash based? Did you raise rates based on your rent expenses? Thank you, the information provided here is priceless!

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Dr Jarod Carter June 3, 2013 at 2:50 am

At the time of this writing, I’m extremely low tech and still use paper/pen for documentation. Documentation in a cash practice still of course must fulfill the requirements of your State Practice Act, and cover you legally if your documentation is ever needed in that arena, but you don’t have to be as detailed about many of the documentation components that can lead to insurance reimbursement denials (med necessity, ridiculously detailed goals, loads of objective measurements, etc).

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Amisha Klawonn April 25, 2013 at 8:44 pm

Hi Jarod,
My new cash based practice has officially “launched”! I haven’t seen any patients yet but am working on the receipts and paperwork that will be given to patients. Would love any input you may have on the site: http://www.onenesspt.com

Do you use any dictation software or a program to maintain patient records? I’m considering a software program that you can dictate into your iphone and have the records mailed back to you (hipaa compliant).

Thanks,
Amisha

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Dr Jarod Carter June 3, 2013 at 3:13 am

Huge Congrats on your cash based practice!! At the time of this writing, I’m still really low tech and just use pen/paper for documentation. I do have Dragon Dictate voice recognition on my computer but generally don’t have to use it much for dictation since my notes are on paper (I use it for progress notes). With that said, I’m certainly going to be on the hunt for a cash-based-specific EMR in the future (or develop one myself).

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Justin Feldman July 4, 2014 at 7:49 pm

Hey guys thought this would be the best forum to share this info, I recently have had 2 patients be told by their insurance that they will not reimburse for CPT codes that do not contain modifiers. These were not Medicare people (for obvious reasons) one was Blue Cross, the other was Aetna. Just something for everyone to keep a lookout for.

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Dr Jarod Carter July 8, 2014 at 6:16 pm

Thanks so much Justin! Like I said in the Linked In forum, once you hear back from them and figure out what’s going on, please let us know here as well with a follow-up comment

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Joey Salgado July 18, 2014 at 7:21 pm

Hi Jarod,

First and foremost, I want to thank you for being such a great resource as a I begin this journey to having my own cash-pay clinic. I opened my business bank account using my SSN, however I was wondering if it would be advisable to open one using my EIN instead? Re: superbill receipt, do I include my EIN number regardless of whether or not my SSN or EIN is associated with my account? Thanks Jarod.

Regards,

Joey Salgado

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Dr Jarod Carter July 23, 2014 at 2:00 am

Hi Joey,
I would definitely recommend utilizing your EIN for your bank acct (keep everything personal completely separate from that acct). And as far as I’ve seen, insurance companies often will not reimburse for receipts that do not have your EIN
Jarod

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Joey Salgado July 23, 2014 at 6:43 am

Thank you for the response Jarod. I will speak with you soon and hope all is well! Hope to converse with you soon re: your book, as I hope to purchase it within the next day. Have a great night!

Regards,

Joey Salgado

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Annette Broderick September 29, 2014 at 3:19 pm

Hi Jarod!
I am just starting a cash based solo practice and first of all want to thank you for sharing your wealth of knowledge. I just finalized my LLC (I understand there is no PLLC in Indiana). I want to make sure that my billing templates have all necessary information for the client to submit for reimbursement to their insurance company. I do have a few questions:
NPI – I am currently employed at an OP clinic and I have an NPI number associated with that location . Do I need to obtain a new one for my new practice or does the same number follow me regardless of where I work? Is it ok to use the same number in 2 different places?
Location code – my business address is my home address and I will be providing services in client homes. What would I use for location code?

I would like to keep things as simple as possible while at the same time supporting a client’s desire for insurance reimbursement if possible. I appreciate your feedback.

Thank you,
Annette

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Dr Jarod Carter October 8, 2014 at 11:16 pm

I believe the NPI number follows you, but I’m not sure if there would be an issue of billing via two different businesses at the same time. For that reason, I would definitely call them at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do to make sure this is not an issue.

Not sure what the home-based location code is, but I’m guessing would only take a phone call to a couple local third-party payers and they could tell you.

And … CONGRATULATIONS on starting your cash practice!!!!

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annakate moore October 8, 2014 at 11:03 pm

Thank you so much for this information. I just graduated from PT school and have a 10 year background in massage therapy. My plan is to work part time for a orthopedic clinic, and build my own practice.

Thank you,
AnnaKate Moore, PT
LMT, Certified Rolfer

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Dr Jarod Carter October 8, 2014 at 11:13 pm

You are most welcome! Be careful if building a practice on the side that would compete with your current employment.

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