Medical Necessity

[Guest guest]

A question to the Listserve-

I work in an outpatient department of a hospital, we bill Medicare

part A. I have been working with a female for the past 6 months on a

self pay basis. This person had a TBI some time ago and has made

minimal progress althouth the family has remained adamant that

treatment continue despite my numerous attempts at discharge to a home

program.

This person has recently qualified for Medicare and now would like to

continue with us as a Medicare patient. We are not subject to the

CAP but are still compelled to document progress in order to justify

medical necessity. My question is, " Do the members of this group

feel it is appropriate that Medicare should now be charged for this

person's treatment? "

Ken Muller, PT,PhD

Port St Lucie, FL

[Guest guest]

When billing Medicare for services, it is incumbent on the provide to

ensure that treatment is medically necessary. In part, medical

necessity requires that goals are reasonable and that significant

progress will be made within a reasonable time frame. To the best of

my knowledge, " reasonable " and " significant " are nowhere defined.

However, based on your below message, I would say that in YOUR opinion

it is unlikely that the patient will make significant progress towards

their goals. As such, I recommend NOT billing Medicare for your

services.

Obviously it's a judgement call, but at some point we must say, " I can

continue seeing you, but I can not bill insurance. If you want

continued therapy, you must pay out of pocket " .

Hope this helps.

Ron

--

Ron Carson MHS, OTR/L

Hope Therapy Services, LLC

www.HopeTherapyServices.com

===============<Original Message>===============

On 4/2/2008, k_muller@... said:

k> A question to the Listserve-

k> I work in an outpatient department of a hospital, we bill Medicare

k> part A. I have been working with a female for the past 6 months on a

k> self pay basis. This person had a TBI some time ago and has made

k> minimal progress althouth the family has remained adamant that

k> treatment continue despite my numerous attempts at discharge to a home

k> program.

k> This person has recently qualified for Medicare and now would like to

k> continue with us as a Medicare patient. We are not subject to the

k> CAP but are still compelled to document progress in order to justify

k> medical necessity. My question is, " Do the members of this group

k> feel it is appropriate that Medicare should now be charged for this

k> person's treatment? "

k> Ken Muller, PT,PhD

k> Port St Lucie, FL

k> ------------------------------------

k> In ALL messages to PTManager you must identify yourself, your discipline and

your location or

k> else your message will not be approved to send to the full group.

k> PTManager encourages participation in your professional

k> association. Join APTA, AOTA or ASHA

k> and participate now!

k> Visit the NEW and IMPROVED www.InHomeRehab.com.

k>

[Guest guest]

Ken,

We to have had several issues like this where a patient has platued and we no

longer feel skilled treatment is necessary. I personally have been treatened

with legal action when I attempted to explain this to a patient's family and get

him on a home program. What we do in this case is have the patient sign and ABN

(Advanced Beneficiary Notice) prior to each days' treatment outlining our

believe that objective improvements have been maxed out and that we believe

Medicare will not cover the service. We also write out the treatment and charge

for that treatment. The patient or POA signs the ABN prior to treatment. Now,

I have never heard of Medicare or the hospital going after a patient on a bill

but at least we continually inform the patient on the possible financial

repercussions.

I have found it almost universally true with these patients that the referring

physician refuses to take responsibility for telling the patient that no further

treatment is warrented and they cont. to write scripts.

This may sound like a " cop out " on our part but this is the policy that our

hospital takes with OP Medicare.

Jeff Brown PT

Director of Rehabilitation

Decatur Memorial Hospital

Decatur, Illinois

>>> " knnth_muller " 04/02/08 4:41 PM >>>

A question to the Listserve-

I work in an outpatient department of a hospital, we bill Medicare

part A. I have been working with a female for the past 6 months on a

self pay basis. This person had a TBI some time ago and has made

minimal progress althouth the family has remained adamant that

treatment continue despite my numerous attempts at discharge to a home

program.

This person has recently qualified for Medicare and now would like to

continue with us as a Medicare patient. We are not subject to the

CAP but are still compelled to document progress in order to justify

medical necessity. My question is, " Do the members of this group

feel it is appropriate that Medicare should now be charged for this

person's treatment? "

Ken Muller, PT,PhD

Port St Lucie, FL

[Guest guest]

Hello Ken,

I am the office manager for an OP dept of a hospital (we have 6 sites).

Whether or not the patient now has Medicare doesn't take away whether or

not the services being provided constitute 'skilled PT.'

If medical necessity is not present to justify skilled PT, the patient

should sign an ABN form after being explained that there is a high

likelihood that MCR will not pay for these services as you are unable to

support medical necessity for skilled physical therapy. Through signing

the form, the patient acknowledges that they may be held financially

responsible for payment should Medicare deny payment. There is also a

modifier that you will need to attach to your claim (per line item) that

denotes that a signed ABN form is on file for these services (modifier

-GA). In addition, should the patient refuse to sign the form it will

not take away their financial responsibility as you have notified them

of this information. Just note on the form that they refused to sign

the ABN.

Hope this helps.

Kimberley R. Palma

Office Manager - ECHN Rehabilitation Services

Manchester Memorial and Rockville General Hospitals

Tel:

Fax:

_____

From: PTManager [mailto:PTManager ] On

Behalf Of knnth_muller

Sent: Wednesday, April 02, 2008 5:42 PM

To: PTManager

Subject: Medical Necessity

A question to the Listserve-

I work in an outpatient department of a hospital, we bill Medicare

part A. I have been working with a female for the past 6 months on a

self pay basis. This person had a TBI some time ago and has made

minimal progress althouth the family has remained adamant that

treatment continue despite my numerous attempts at discharge to a home

program.

This person has recently qualified for Medicare and now would like to

continue with us as a Medicare patient. We are not subject to the

CAP but are still compelled to document progress in order to justify

medical necessity. My question is, " Do the members of this group

feel it is appropriate that Medicare should now be charged for this

person's treatment? "

Ken Muller, PT,PhD

Port St Lucie, FL

" This message originates from Eastern Connecticut Health Network. The

information contained in this message may be privileged and confidential. If you

are the intended recipient, you must maintain this message in a secure and

confidential manner. If you are not the intended recipient, please notify the

sender immediately and destroy this message, Thank you. "