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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Medicare and Private Insurance: They’ve Got Issues

Published February 11, 2009 10:31 AM by Lisa Lombardo

LAS VEGAS--It was a lot of ground to cover in just an hour and 45 minutes. Gayle Lee, JD, Roshunda Drummond-Dye, Esq., and Carmen Elliott, MS, presented "Emerging Issues in Medicare, Medicaid and Private Insurance on Tuesday at CSM 2009 in Las Vegas.

Lee first addressed the pending changes to the Centers for Medicare and Medicaid Services, which are somewhat on hold due to leadership issues. "Activities at CMS and HHS are obviously suspended because we still do not have a Secretary of Health chosen," Lee said, referring to the recent withdrawal of former Senator Tom Dashle from consideration for the position.
"It has been determined that the current payment system for health care is just not sustainable," she said. "According to new projections Medicare will now become insolvent by the year 2016, not 2019 as previously predicted. So it is clear CMS is looking at payment systems with an eye for change."

Lee noted that of the $4.07 billion paid out in outpatient therapy services in CY 2006, PT services accounted for 75 percent of that amount. In fact, after a low of outpatient PT expenditures in 1999 following the institution of the cap on outpatient therapy, PT payouts rebounded with gains each year up until 2006, she pointed out.

"CY 2000 also saw a major growth in PTs in private practice according to payments," Lee said. "That is why it is important for us to explain our importance to policy makers in this area."

One thing that has helped is a marked decrease in paid claims in error rates to Medicare. The reduction is largely due to more education on the matter, she said. The biggest problem was insufficient documentation on timed codes and missing certifications when PTs billed Medicare. The drop in errors has helped keep costs down and successful claims going up.

Lee also touched on the status of the fee schedule, and feels Congressional action will take place to keep the physician fee schedule from enduring more cuts. "We can't imagine such a drastic amount would be allowed to take effect," she said. At the current rate, by 2015 Medicare would see a 40 percent drop in payments if action is not taken on the Sustainable Growth Rate formula used to calculate the fee schedule.

On the therapy cap, Lee noted that APTA is involved with two studies, one short-term and one long-term, on how CMS can identify alternatives to the Medicare cap on outpatient therapy. Data has yet to be gathered on either study but Lee said that depending on the results, "we could see something radically different from what we have now." Currently the cap is set at $1,840 for OT services and $1,840 for PT and speech therapy combined.

For more information on where the cap stands, the physician fee schedule and what APTA is doing to lobby Congress on both issues check our coverage of the current political topics forum during our CSM conference coverage.

Medicaid is facing its own challenges to implement changes, Drummond-Dye said. She touched on some actions that would improve PT coverage and reimbursement under Medicaid, including establishing PT as a mandated health benefit under the Medicaid and State Children's health Insurance Program (s-CHIP); creating minimum documentation requirements for PT services; mandating federal definitions of "qualified providers of PT services;" and ensuring proper reimbursement rates for PT services in each state.




posted by Lisa Lombardo


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