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PT and the Greater Good

Maintenance Therapy

Published May 28, 2013 4:51 PM by Dean Metz

A very important ruling came out February in the Jimmo vs. Sebelius argument. It clarified that improvement of function is not a requirement for Medicare reimbursement. Rather it's the need for skilled services that determines whether a claim is reimbursable. If a skilled service is required to maintain function or prevent decline, then according to CMS it's reimbursable.

This is incredible news to those who struggle with chronic and/or progressive conditions! For those with MS, Parkinson's, ALS, and even COPD, they no longer have to suffer through a remission in order to receive services that may prevent, or slow, their deterioration. From a public health point of view, this is brilliant preventive action.

Unfortunately I've heard stories of clinics, skilled nursing facilities and home care agencies still discharging people because "they're not making progress." In some cases that may be legitimate, but I'm sure others include those who could still benefit from maintenance interventions. As professionals, we'll be charged with sorting out who needs skilled maintenance and who simply needs an aide to assist them with walking or doing a home program. Based on some of my ADVANCE colleague bloggers' tales of pressure to keep inappropriate people on caseload, I can see this becoming a bigger challenge now.

It's good to know that we're empowered to give the right care, to the right people and be confident of our ability to be paid for it.

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Toni, I wish I could say that you were wrong and that this ruling would not be abused to bolster caseloads. I can't.

This is one of the reasons though I think that PTs should be able to aspire to something greater than rehab manager of a department. So that our voices are heard on larger levels and we can ensure care is provided appropriately.

I recall one person with a chronic respiratory ailment that I saw every two weeks to reinforce the caregivers applications of chest PT and provide assessment of her lung sounds and function. Kept her out of hospital for 13 months until she passed away. Total cost under $60,000. The year previous she was on and off home care due to lack of progress and had 11 hospitalizations. Total cost over $1 million. That was an exceptional managed care case where I had the good fortune to work with an innovative care manager. Maintenance treatment can work, improve function and quality of life AND save money when applied appropriately.

Dean Metz May 29, 2013 1:02 PM

Skilled maintenance is a wonderful term.  I can't wait to see how it is misused and abused.

I agree there are many people out there who need skilled therapy to maintain their functional status. There are others who could regain lost ground with regular tune ups.  Now that I've spent time in the world of long term care I tremble with fear to think of the permutations that will be used to justify care in order to bolster caseload.  

SNFs only make money if patients receive therapy.  From a purely monetary stand point each resident is a source of reimbursement if skilled therapy can be justified.  We have now given it to them.

Toni May 28, 2013 8:37 PM

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About this Blog

    Dean Metz
    Occupation: Staff Development Specialist
    Setting: New York, NY – Newcastle Upon Tyne, Great Britain
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