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Continuing from last week’s post explaining a possible increase in cash-based practitioners’ ability to see private-pay Medicare beneficiaries, I’ll now cover a 2013 change that takes away one avenue through which we could see these patients.

Many of you probably heard about the federal court case which ruled that Medicare beneficiaries should no longer be denied coverage for skilled “maintenance care.” The case is called Jimmo v. Sebelius and this is a great overview fact sheet:

Taking info from the above fact sheet and some legal consultation, this is my take on it:

Medicare contractors who, for years, have been denying coverage for Medicare beneficiaries if they were no longer showing improvement, were actually going against established Medicare Policies (at least in the SNF settings):

For example, in the regulations at 42 CFR 409.32(c), the level of care criteria for SNF coverage specify that the “. . . restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”

The plaintiffs of Jimmo v. Sebelius just finally called them out on this practice.

Here are what I found to be the most important statements of the fact sheet:

A beneficiary’s lack of restoration potential cannot, in itself, serve as the basis for denying coverage, without regard to an individualized assessment of the beneficiary’s medical condition and the reasonableness and necessity of the treatment, care, or services in question. Conversely, coverage in this context would not be available in a situation where the beneficiary’s care needs can be addressed safely and effectively through the use of nonskilled personnel.

Thus, such coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves.

So as I understand it (and received legal confirmation of), if physical therapy treatment/service is preventing or slowing a patient’s deterioration, and this service could NOT be provided/reproduced by non-skilled personnel (like a spouse, caregiver, personal trainer, etc), then those services would be considered “covered services” (unless they fall into other non-covered categories like “prevention, fitness, wellness,” etc), and you could Not accept self-payment from the beneficiary to provide them. If you are familiar with this post, you know that there are very few instances in which you can accept self-payment for a “covered service.”

This is great news for Medicare Beneficiaries who only want to see Medicare Providers, but not such great news for those who want to see practitioners like me who don’t have a relationship with Medicare and, until now, have been able to see them on a self-pay basis for maintenance care.

Let me know what you think about the above change and if it affects your practice in any way.

If you want every last detail on this topic, click this book to see the list of all that is covered and all the questions that are answered inside it:

© 2011 Dr. Jarod Carter | Home | About Dr. Carter | E-Book | Contact Us | E-Book Newsletter

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