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Understanding Medicare

As our population continues to grow, and people are living longer, a large portion of patient census consists of people who have Medicare as their primary healthcare insurance. We are frequently asked questions regarding how the Medicare process works, and how many visits a patient is allowed per calendar year. This can be very confusing for some patients, especially if they have never had physical therapy before. The purpose of this article is to help the reader understand some of the Medicare basics for outpatient therapy services by answering three of the most commonly asked questions:

  1. l) How many physical therapy visits are allowed for a patient with a calendar year?

Physical therapy services under Medicare are not limited to a specific number, rather a dollar amount referred to as a Cap. For the year 2015, the Cap values are $1,940 for physical therapy (PT) and speech therapy (SLP) combined; and then a separate $1,940 for occupational therapy (OT). How many visits this equates to will depend on what services are rendered and can vary somewhat among patients.

2) What if I need more physical therapy service that what is allowed?

A patient may qualify as an exception to the therapy Cap, and Medicare may continue to pay its share for physical therapy services beyond the Cap limits if it is deemed medically necessary by its standards. This will be determined by the physicians’ and physical therapists’ medical discretion as well as required documentation demonstrating the medical necessity. If you receive outpatient therapy above the Cap threshold, a Medicare contractor may review your records to check medical necessity. The threshold amounts for 2015 are $3,700 for PT and SLP combined, and $3,700 for OT. Because Medicare doesn’t pay for therapy services that aren’t reasonable and necessary, your therapist may give you a written notice called an “Advance Beneficiary Notice of Non-coverage”(ABN), before providing services that may not be deemed medically necessary upon Medicare review. The ABN lets you choose whether or not you want to continue therapy, and ultimately be liable to pay for services rendered that Medicare does not consider necessary.

3)How do you know if you will exceed the Medicare Cap?

They will have the most up to date information in regard to your current status. You can also visit MyMedicare.gov to track your claims for therapy services and access your personal Medicare information. Last, you can check your “Medicare Summary Notice” (MSN) sent to you via mail about every three months. That lists the services you had, and the amount you may be billed.

Peter Geloso DPT received his doctorate degree in physical therapy from Elon University in North Carolina. He is a clinician at Amity Physical Therapy in Woodbridge founded by Michael Dow MSPT and CEO/Director. The practice maintains three offices in the Greater New Haven area: Woodbridge, Hamden and Branford. For more information, call 203-389-4593 or visit www.amitypt.com.

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