Medicare Benefit Policy Manual Updated to Permit Payment for Physical Therapy, Nursing Care and Other Services

In January 2014, the Center for Medicare & Medicaid Services (CMS) updated its Medicare Benefit Policy Manual (“Policy Manual”) to reflect a change whereby Medicare will now compensate Medicare beneficiaries for certain skilled care, including physical therapy, nursing care, and other such services, without taking into account the patient’s likelihood of improvement or prognosis of a chronic disease. The clarification in policy will affect care provided by skilled care professionals providing services to Medicare and Medicare Advantage plan beneficiaries for physical, occupational or speech therapy, and home health and nursing home care.

For years, it has been standard practice for skilled care to be discontinued once it was determined that a patient was ‘not improving’; Beneficiaries with chronic diseases such as multiple sclerosis, Parkinson’s or Alzheimer’s disease were not able to maintain their condition and prevent further deterioration. The Policy Manual has been revised to clarify that coverage of skilled nursing and skilled therapy services in the skilled nursing facility, home health and outpatient therapy settings “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”

Eligibility criteria for the reimbursement of such skilled care services include, most notably:

  • Physical and speech therapy – Therapy provided in a nursing home or an outpatient facility is subject this year to a $1,920 therapy cap, with an automatic exception for medically necessary treatments up to $3,700
  • Home health coverage – Patient must obtain a doctor’s order for intermittent care on, at least, a weekly basis
  • Nursing home coverage – Patient must have spent three consecutive nights in the hospital as an admitted patient, and must obtain a doctor’s order prescribing skilled nursing home care

The change is expected to have a tremendous effect on beneficiaries, allowing for patients with chronic diseases to seek and obtain skilled care for a longer period of time and from their own homes without seeking institutional care. Medicare has not, however, announced the significant update to its beneficiaries; in fact, Medicare officials were required only to inform health care providers, bill processors, auditors, Medicare Advantage plans, the Medicare information line, and appeals judges.

Beneficiaries and skilled care providers alike should be aware of the update and the potential implications in terms of increased care to patients, and reimbursements available for such services. Finally, beneficiaries should note that a special “re-review” procedure was also established for claims that have been denied in the past three (3) years due to a lack of patient “improvement” or if the care was intended to “maintain” a patient’s condition. Medicare has posted a form beneficiaries may use to request reimbursement if they have paid for such a claim out-of-pocket. Any request for reimbursement for claims dating between 2011 and 2013 must be submitted by July 23, 2014. Contact Frier Levitt to speak to an attorney

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