Page four of this newsletter provides information about health reform from the perspective of legislation and regulations that follow the enactment of laws. Since many policy guidelines also are formulated to improve health care by clarifying legislative intent, they may be considered useful aspects of health reform. As described in a manuscript published in the January 2019 issue of the journal Archives of Physical Medicine and Rehabilitation, the objective of a study was to determine if there was a change in the number of outpatient physical therapy (PT) and occupational therapy (OT) visits for Medicare beneficiaries, and in the number of beneficiaries receiving extended courses of >12 therapy visits, after the Jimmo vs Sebelius settlement.
Medicare Part-B helps to cover outpatient physician, PT, OT, speech therapy, and home health services. Policy is designed to cover rehabilitation services that require the skill of a PT or OT to restore function, or when no improvement is expected, to slow deterioration and maintain current levels of functioning. Beneficiaries are able to receive outpatient OT and PT services until a monetary threshold, or cap is reached. If the cap is met, and treatment is medically necessary to further improvement or to prevent a worsening of function, Medicare guidelines state that reimbursement of care can continue. Historically, however, this process was not always followed.
Coverage determination is delegated to Medicare administrative contractors (MACs) who make local decisions to ensure that therapy is medically necessary. Policy manuals developed to help interpret regulations became more restrictive and in some cases contradicted federal regulations. Beneficiaries were being denied access to and payment for therapy if their chronic conditions precluded improvement. Regional local coverage decision manuals for outpatient PT incorrectly noted that coverage depended on the “expectation that the patient’s condition will improve significantly in a reasonable and generally predictable period of time.” If there was no expectation that the condition would improve and there was no measurable change in function, MACs would deny coverage.
After the Jimmo settlement was reached, Part B Medicare beneficiaries were likely to receive about one additional therapy visit per year. An estimate is that at a minimum, the settlement will increase utilization by about 12 million visits per year. Patient therapies help minimize functional decline, avoidable hospitalizations and nursing home admissions, which may result in lower costs.
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