Tuesday, December 17, 2013

Stop The Medicare Therapy Cap

Some folks may not realize there is serious, harmful, bias against certain disabilities. Nowhere is this bias more devastating that within Medicare. Can you imagine Medicare capping Chemo at $1900 yearly? Or capping Dialysis, or treatment of Diabetes? Yet medicare continues to cap Physical Therapy needed for pain due to serious disabilities such as degenerative disk disease, Rhumatoid Arthritis, Lupis, Osteoarthritis, Fibro Parkinsons, Cerable Palsy. etc, etc etc. Back in Jan 2011, a courageous disabled senior living in VT, Glenda Jimmo brought a lawsuit against the Obama Administration's sibilies, for allowing Medicare to deny Physical Therapy to those who needed is based on Medicar's outrageous "failure to improve standard." The lawsuit was won, as a class action, but few people know about it, and providers have not yet been informed by Medicare (gee, are they dragging their feet?) even tho folks who had to pay for denied medicare coverage can file claimes back to January 2011 for reinimbursement. http://www.washingtonpost.com/national/health-science/medicares-improvement-standard-for-physical-therapy-has-changed/2013/06/24/102f073a-c8c8-11e2-9245-773c0123c027_story.html http://www.massnurses.org/news-and-events/p/openItem/8169 The outcome means that patients with disabilities and chronic conditions like Alzheimer’s disease, multiple sclerosis and Parkinson’s disease, who in the past were unable to get access to care, should benefit. The changes will apply to the traditional Medicare program and to private Medicare Advantage plans. They apply to people 65 and older, as well as to people under 65 who qualify for Medicare because of disabilities. .............................................................. Plaintiffs argued that Medicare has allowed the contractors that process its claims to use a so-called “improvement” standard over the last few decades. To the Center for Medicare Advocacy and the many other organizations, like the Parkinson’s Foundation, that joined the lawsuit, that standard allowed for cutting off physical, occupational and speech therapy and some inpatient skilled nursing services for patients who had plateaued. Medicare is supposed to pay for reasonable treatment prescribed by a physician for any illness or injury. For the home care patients that this settlement is thought to affect the most, a doctor must have certified that a patient is homebound and must have prescribed treatment that only a skilled practitioner can provide. (The “skilled practitioner” rule keeps Medicare from paying for assistance with everyday activities like bathing and dressing.) Providers will still have to document that the services provided are “reasonable and necessary” for the diagnosis or treatment of a medical condition. They will also have to justify why skilled care is required. But it appears that the focus on the skills needed to provide care rather than the need for improvement will expand the number of Medicare beneficiaries eligible for post-acute care services. The Parkinson’s Action Network was instrumental in arguing that for patients with degenerative diseases, holding steady or degenerating more slowly than one might otherwise is often the definition of success. Others argued that payment practices led to physicians changing their practice patterns, as doctors decided prescribing treatment that would not be covered would be pointless. The settlement specifies that skilled care can qualify for Medicare coverage even if it merely serves to maintain someone’s current condition or prevents or slows further deterioration. Certain patients who have had claims rejected will be able to resubmit them. Various patient advocacy groups have expressed hope that Medicare will soon pay for many forms of therapy that it has not covered previously. One example cited is cerebral palsy patients, for whom physical therapy to maintain muscle mass is one possibility. For multiple sclerosis patients, there may be more approval for treatments for spasticity and gait training to prevent falls. ................................................. Problems and question remain Two big remaining questions that patient advocates are still asking are how many people may benefit from the clarification of the regulations, and how quickly. A separate issue is that Medicare does have individual annual limits in certain areas; this settlement will not affect those benefit limits. YEP, Medicare plans to deny PT based on its hard cap of $1900 for 2014! Call your elected Congressmen and women and ask for a full repeal of the PT CAP. Elizabeth Warren: 1 202 224 4543; Markey: 1 202 224 2742

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