Simplifying Medicare Coverage for Therapy


There is a common misconception when it comes to Medicare coverage for therapy that is adversely affecting seniors. Medicare claims processors believe that beneficiaries are eligible for physical therapy, occupational therapy, and other skilled care only if their health is improving.

The end result is that seniors are often inaccurately denied Medicare coverage for therapy once their health stops improving. Four years after Medicare already tried to deal with this issue, they are once more trying to rectify this concern. As a travel physical therapist or traveling occupational therapist, expect to see older patients more frequently if you are working for an organization that accepts Medicare.

Here are just a few things you should know and a couple tips to tell your senior patients that have been denied previously for coverage.

2013 Improvement Standard Settlement

This is still happening four years after the settlement of a class action lawsuit against the US Centers for Medicare & Medicaid Services (CMS) regarding this so-called Improvement Standard. In 2013, a U.S. District Court ruled that Medicare claims processors were wrongfully denying Medicare coverage for skilled care including skilled nursing facilities (SNF), home health (HH), and outpatient therapy (OPT).

Under this settlement, the government provided an education campaign for Medicare processors to help them clear any confusion about the Improvement Standard. They wanted claims processors to understand that as long as seniors met all the other requirements for coverage, the continual improvement of health was not required.

Medicare Coverage for Therapy: Moving Forward

Now, a federal judge has accepted a plan from Medicare to try and correct this coverage misconception and get seniors the skilled care they need. The CMS website will now implement a new website dedicated to the Improvement Standard and how claims should be processed.

Plaintiff statements said, “the Medicare program will pay for skilled nursing care and skilled rehabilitation services when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).”

Medicare will also be required to hold a second education campaign on the Improvement Standard for claims processors, appeal judges, and others. These changes must be completed by September of this year. The government does have 14 days to file an objection to the decision, but that seems unlikely.

Helping Seniors Get Medicare Coverage for Therapy

There are many plans and options that make Medicare confusing for seniors to understand, so it’s no wonder even Medicare processors don’t always get it right either. As a skilled therapist, you may have patients who were denied coverage and pay out-of-pocket. Perhaps you know patients that you had to stop treating when they were denied Medicare coverage for therapy due to no longer making health progress.

If you know a senior who was denied Medicare coverage for therapy, you can let them know the information I’ve shared with you above. If you have patients that stopped receiving treatment due to coverage denial, you should let them know that changes are being made that may make them eligible for treatment again.

You’d be surprised at the available information that patients do not know. If you empower your patients with knowledge and power, you may help them appeal Medicare claims decisions and get the care they need. Though the ruling has no bearing on those that have already been declined Medicare coverage for therapy, it certainly will provide some strong ammunition for an appeal.

Author: Allied Travel Careers

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