Medicare Policy Summary

Medicare is a tightly regulated US health insurance program that provides coverage to those who are 65 years or older, certain younger individuals with disabilities and those with end staged renal disease or amyotrophic lateral sclerosis. Medicare has four parts associated with it, one of which is Part B. Part B is also known as supplementary medical insurance and provides coverage to beneficiaries for outpatient care, preventive services, ambulance services, and durable medical equipment. Outpatient physical therapy services falls into this category of coverage for Medicare Part B (Jannenga, 2014). However, there are several rules and regulations that health care providers, including physical therapists, must follow in order to receive proper

A physical therapist may do this in order to increase their productivity and treat more patients at one given time in order to bring in more revenue to the practice (Jannenga, 2014). However, Medicare guidelines specifically states that “you cannot bill for the services of an aide that is supervised by the therapist or a therapy assistant”. Medicare will only pay for “skilled, medically necessary services delivered by qualified individuals” (“11 Part B Billing Scenarios for PTs and OTs,” 2009). The correct way to be in compliance with Medicare’s rules is to have the aide set up treatment for a different patient who is not covered by Medicare so that the licensed physical therapist can work directly with the patient who is covered by Medicare. Another alternative, as mentioned above, is to block out treatment time so that care can be individually directed toward the Medicare patient in order to be in compliance with the rules and regulations to be properly reimbursed (“11 Part B Billing Scenarios for PTs and OTs,” 2009) (Jannenga,

A therapist may do this once again in order to continue to receive reimbursement from Medicare for their services in order to generate more revenue for the clinic. Prior to the Jimmo versus Sebelius case in 2013, Medicare would deny coverage to patients receiving maintenance care for their condition due to their inability to demonstrate improvement from the skilled therapy services that they received (“Jimmo v Sebelius Settlement Agreement Factsheet,” 2013). However after the Jimmo versus Sebelius case, the Centers for Medicare & Medicaid Services revised portions of the manual which now states that coverage “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” (“CMS Manual System,” 2014). The correct action for the therapist to take in order to be in compliance with the rules is to provide adequate documentation as to why the patient would need and benefit from maintenance care services in order to prevent or slow the deterioration of their condition. An alternative would be to discharge the patient if they no longer require skilled and medically necessary services (“Jimmo v Sebelius Settlement Agreement Factsheet,” 2013) (“CMS Manual System,”