NAVIGATING THE MEDICARE MAZE OF REHABILITATIVE SERVICES

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1 NAVIGATING THE MEDICARE MAZE OF REHABILITATIVE SERVICES

2 NAVIGATING THE COMPLEXITY OF INSURANCE COVERAGE. Fox Rehabilitation is a private practice of physical, occupational, and speech therapists who specialize in providing rehabilitative services to the geriatric population. Most importantly, Fox delivers these exceptional services in a setting where people feel most comfortable in their own home, whether their home is a house, apartment, assisted living residence, or medical adult day care. As clinicians specializing in geriatrics, we work hard to create positive changes in our patients functional abilities. It is the mission of Fox to provide the highest quality rehabilitation to the geriatric community with compassion and respect, while promoting optimal function and meaningful lives. One issue that continues to perplex our patients, their families, and our referral sources is the complexity of insurance coverage. Fox is proud to present this thorough and informative brochure to guide you through the maze of Medicare Part A and Medicare Part B coverage. We have compiled the most frequently asked questions regarding therapy services and corresponding Medicare coverage. Q: WHAT TYPES OF THERAPY PROVIDERS BILL UNDER MEDICARE? Private home-therapy practices, such as Fox, bill for PT and OT services under Medicare Part B. Licensed Home Health Agencies bill for physical therapy (PT) and occupational therapy (OT) services under Medicare PHYSICAL, Part A. OCCUPATIONAL, & SPEECH THERAPY. Acute hospital therapies bill under Medicare T Part A. I W foxrehab.org Continuing Care Retirement Communities can bill under both Medicare Part A & B. Outpatient clinics PHYSICAL, bill under Medicare OCCUPATIONAL, Part B. & SPEECH THERAPY. FOX REHABILITATES LIVE

3 Q: CAN I RECEIVE THERAPY IN MY OWN HOUSE, AND WILL MEDICARE PAY FOR THIS? Yes, you can receive physical therapy and occupational therapy in your own home under Medicare Part A and Medicare Part B. Q: UNDER WHAT CONDITIONS WILL MEDICARE PART A AND MEDICARE PART B COVER REHABILITATIVE SERVICES IN MY OWN HOME? Medicare Part A will cover PT and OT services in your home under the following conditions: You must require skilled care You must be recovering from an acute medical episode You must be recently discharged from a hospital or rehabilitation facility You must be diagnosed with an acute medical condition You must be diagnosed with acute functional decline You must be considered homebound You must be unable to leave your home due to physical / functional impairments Your therapy services must be medically reasonable and necessary Medicare Part B will cover PT and OT services in your home under the following conditions: You have functional impairments in your daily environment You do not require skilled nursing care Your acute illness or the medical management of your chronic condition is resolved or improved; however, your functional decline is not being managed You do not need to be classified as homebound You received Part A therapy in the home, but you still want to achieve a higher or optimal level of functioning T I W foxrehab.org You completed Part A therapy in the home, but still have not reached your pre-morbid or prior level of functional independence Any flare-up of a chronic condition such as Arthritis that significantly affects FOX REHABILITATES LIVE function and requires the skill of a therapist to treat Any progressive degenerative condition such as MS or Parkinson s may require intermittent therapy services to determine the need for assistive equipment and / or establish a program PHYSICAL, to maximize OCCUPATIONAL, function & SPEECH THERAPY.

4 Q: HOW IS IT POSSIBLE FOR A PRIVATE THERAPY PRACTICE TO BILL MEDICARE PART B FOR SERVICES IN A PATIENT S HOME WHO IS NOT CLASSIFIED AS HOMEBOUND? Under the Medicare Part B guidelines, a private practice such as Fox Rehabilitation has a choice to treat patients in an office or in the patient s home. Because Fox specializes in geriatric therapy, the most logical place to treat is in the patient s home where he or she is most comfortable. It makes perfect sense to have a professional therapy expert in the home to make observations necessary to create an appropriate plan of care, and goals specific to the patients and their individual home environments. Q: WHAT MEDICAL CONDITIONS WOULD TYPICALLY INITIATE A NEED FOR THERAPY SERVICES? In order to receive therapy under Medicare Part A, the patient may require skilled therapy and / or nursing care. Patients are often medically compromised with acute exacerbations of diagnoses such as: COPD CHF CVA Pneumonia Recent total joint replacement Recent hospitalization Medicare Part B will cover therapy services PHYSICAL, for the OCCUPATIONAL, medically compromised & SPEECH patient THERAPY. as well, but in addition, Medicare Part FOX B will REHABILITATES cover conditions LIVES. and diagnoses such as: musculoskeletal impairment, reduced endurance, balance deficits, pain, falls, T I W foxrehab.org gait dysfunction, spasms / tightness, poorly fitting equipment, decreased ADLs, and wheelchair assessment and fitting. Chronic conditions such as arthritis and spinal stenosis, and progressive degenerative conditions such as Parkinson s and Alzheimer s disease, PHYSICAL, when coupled OCCUPATIONAL, with functional decline & SPEECH that require THERAPY. the skill FOX of REHABILITATES LIVE a therapist, all fall under the description of Part B rehabilitative therapy.

5 Q: HOW MANY VISITS FROM A THERAPIST SHOULD I EXPECT UNDER THE MEDICARE COVERAGE? The goal of therapy services under Medicare Part A is to get the patient safe and functional in their home and then allow the patient to progress to Outpatient Rehabilitation. Therapy services must be medically necessary and the patient must continue to meet the criteria to qualify for Part A home therapy services. Typically, the amount of visits you would receive in the first 8 weeks is visits. The goal of therapy services under Medicare Part B is to optimize function and safety in the patient s home environment. Therapy will continue as long as it is deemed medically necessary. The amount of visits from therapists that you would receive in the first 8 weeks is visits. (Combined PT and OT visits) Q: WHAT IS THE COST COVERED BY MEDICARE FOR THE THERAPY SERVICES? Therapy services billed under Medicare Part A are completely paid for. The average cost of 10 visits under Medicare Part A is $3,000. The average cost of 10 visits billed under Medicare Part B is only $850. Medicare pays 80%, and typically the other 20% is paid through the patient s secondary insurance coverage. The 80%-20% billing ratio mirrors how the patient currently pays for his or her physician visits, lab work, FOX specialists, REHABILITATES etc. under the LIVES. Medicare program. T I W foxrehab.org FOX REHABILITATES LIVE

6 Q: IS IT TRUE THAT I CAN GET MORE THERAPY OVERALL IF I UTILIZE COVERAGE UNDER BOTH MEDICARE PART A AND PART B? Not necessarily. Services under Medicare Part B can certainly be utilized as a beneficial extension to the Medicare Part A services being provided by a hospital or Home Health Agency. Medicare Part B coverage can continue to be implemented in a patient s home when he or she is no longer able to meet the stringent requirements to remain on Medicare Part A, and therefore must be discharged to Medicare Part B services. It is also noteworthy to mention that Part B services can be initiated before or in place of Part A services, provided there are no skilled nursing needs. For instance, if someone falls, the most critical time to intervene with therapy services is within the first 30 days. Part B physical and occupational therapy services can be initiated immediately up to 3 times per week each. Part A only has the ability to do half or less of those visits, which opens the door for patients to fall through the cracks, decline or not respond in a timely fashion to therapy interventions. In this circumstance, Medicare Part B is superior to providing more therapy at the right time for the patient. Q: WHAT IS THE OVERALL PHILOSOPHY OF THE THERAPIES PROVIDED UNDER MEDICARE PART A AND PART B? Therapy services under Medicare Part A are considered to be reactive. They often are not initiated unless there is an acute medical episode or condition, or an acute functional decline. Therapy treatments are limited, and the goal is to get the patient safe and functional. Therapy services under Medicare Part T B, like Fox 407 Rehabilitation, 3422 I W foxrehab.org are considered to be proactive. There is no need to wait for an acute illness or medical event to initiate therapy services. Clinical research supports that by identifying patients with potential safety risks that could receive therapy services would improve a patient s balance, strength, and stamina, PHYSICAL, and significantly OCCUPATIONAL, reduce the risk & SPEECH for falls. THERAPY. The goal is to FOX REHABILITATES LIVE optimize a patient s function in his or her home environment and keep them there for as long as possible.

7 Q: HOW DO I START THERAPY? IF YOU OR SOMEONE YOU CARE ABOUT IS A POTENTIAL PATIENT: 1. Talk with your physician, or simply call Fox Rehabilitation and we ll help coordinate services with your doctor. You ll need a referral from him / her for a physical or occupational therapy evaluation. 2. Call our referral line and leave your name and phone number. You will be contacted immediately. Q: who can i contact if i am a referral source? Complete and fax our convenient referral form, along with a demographic sheet with patient insurance information. If you do not have referral forms, please call and we will supply them to you. OR Fax a prescription / referral and demographic sheet to (i.e., PT / OT evaluation and treatment, with diagnosis). If you prefer, call our referral line to speak directly with our intake department. Fox is a Medicare provider, so if you have coverage, you should qualify for treatment. If after you read this brochure, you have any questions or need further information or clarification, please contact our Intake Department through our toll free phone number: proud to partner with Fox Rehabilitation and the Fox Rehabilitation logo are registered trademarks. Use without expressed permission is prohibited. Tim Fox: Lic. # 40QA

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