National Council for Therapeutic Recreation Certification (NCTRC) Practice Exam

What is often required by insurance companies for reimbursement of services?

1. Assessment tools sanctioned by JCAHO

2. Source-oriented medical records

3. Physician's orders

4. Risk management plan for activities

The correct answer is: Physician's orders

The requirement of a physician's order for the reimbursement of services by insurance companies is grounded in the need for established medical necessity. Insurance companies typically want to ensure that the services provided are necessary and appropriate for the patient's condition. A physician's order serves as an official directive that confirms this necessity, indicating that a licensed healthcare provider has evaluated the patient's situation and recommends specific interventions or therapies. This is particularly critical in healthcare settings where various types of treatments and services may be offered. By requiring physician's orders, insurance companies protect against the delivery of unnecessary services and ensure that treatments align with established medical standards. Such orders also play a vital role in the documentation process and in securing ongoing or additional treatments as they can provide a clear reference for the rationale behind the services rendered. In contrast, while assessment tools and risk management plans are important for quality of care and safety, they do not specifically establish the medical necessity of services in the same way that a physician’s order does. Source-oriented medical records may be helpful for documentation but do not directly relate to reimbursement requirements. Thus, the presence of a physician's order directly correlates with the criteria used by insurance companies to determine if and how services will be reimbursed.