Re: Re: Times May Be Changing!

[Guest guest]

I certainly agree that we should be able to be paid to decrease risk of decline

of function. We also have a responsibility to know how to identify those cases

and measure their function in a way that shows what we do, does what we say

Jim Dunleavy PT, MS

Re: Times May Be Changing!

We can have differing opinions, but my position is generally always absolutely

on the side of being a patient advocate. I was delighted to see a judge

believe, as I do, that Medicare beneficiaries should not risk a decline in

function or worse to prove they need physical therapy services.

It appears that the law doesn't have the expectation that the patient is

required to make significant progress in a reasonable period of time. It also

seems to appear the law values maintaining function over declining function.

Our thoughts have been molded and misled with the " urban legend " - we do have

skill and our services are necessary in some cases to prevent deterioration

which will have escalating financial costs.

Based on some of the dollar figures Medicare spends, I don't think there needs

to be a worry on the amount spent on physical therapy services. Our services

are generally underutilized.

The quality of physical therapy/intervention wasn't mentioned in the ruling. I

do tend to believe that aspect could be open for discussion.

Selena Horner, PT

> > Finally, some common sense and what we all know!

> >

> > " People with chronic conditions are being denied care in the mistaken

> > belief that Medicare requires improvement of a person's condition as a

> > prerequisite for coverage, " Mr. said Monday. " That's not in the

> > law. It's urban legend. "

> >

> > " Medicare terminated coverage after five weeks, saying her condition had

> > not improved and was unlikely to improve. "

> > ~Example of 'urban legend' applied.

> >

> > " In reversing the decision of Medicare officials, the court said Ms.

> > Papciak needed skilled nursing home care " to maintain her level of

> > functioning " and to prevent her condition from deteriorating. "

> >

> > " Beneficiaries are frequently told that Medicare will not cover skilled

> > services if their underlying condition will not improve, " the letter

> > said. " For example, as people with multiple sclerosis are often not

> > likely to improve, skilled services such as physical, occupational and

> > speech therapies that are necessary to slow the progression of the

> > disease, or maintain current function, are denied. As a result, these

> > individuals' conditions deteriorate — frequently leading to more

> > intense, more expensive services, hospital or nursing home care. " Right on!

> >

> > Read more:

> >

http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=2 & tc=pg

> >

<http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=2 & tc=pg\

>

> >

> > We need to watch how this plays out because it will most definitely

> > impact how Medicare will need to re-interpret 'reasonable and necessary'

> > and should impact why 'maintenance' is important.

> >

> > Selena Horner, PT

> > ton, MI

> >

> >

>

------------------------------------

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[Guest guest]

I'm not certain what " urban legend " you are referring to, and apparently

we do have differing opinions. Mr.. Carson is absolutely accurate in his

representation of Medicare's guidelines, and in his therapeutic

reasoning. Medicare has a very clearly defined expectation for medical

necessity. If you want or expect Medicare to pay for your services, then

you must abide by their guidelines. These guidelines specify that

Medicare will not pay for maintenance therapy, but they do allow for the

therapist to instruct a patient or caregiver on an appropriate HEP, and

then to periodically follow-up with the patient to adjust and modify

that program. In maintenance programs, the skills of a therapist are not

usually required in the daily performance of the exercises, but in

developing and periodically modifying the HEP to meet the patient's

on-going needs.

Sue Krieg

Rehabilitation Compliance Manager

Phone:

Fax:

" Never Miss A Good Opportunity To Shut-Up " Will

________________________________

From: PTManager [mailto:PTManager ] On

Behalf Of selenahorner

Sent: Tuesday, November 02, 2010 9:29 AM

To: PTManager

Subject: Re: Times May Be Changing!

We can have differing opinions, but my position is generally always

absolutely on the side of being a patient advocate. I was delighted to

see a judge believe, as I do, that Medicare beneficiaries should not

risk a decline in function or worse to prove they need physical therapy

services.

It appears that the law doesn't have the expectation that the patient is

required to make significant progress in a reasonable period of time. It

also seems to appear the law values maintaining function over declining

function. Our thoughts have been molded and misled with the " urban

legend " - we do have skill and our services are necessary in some cases

to prevent deterioration which will have escalating financial costs.

Based on some of the dollar figures Medicare spends, I don't think there

needs to be a worry on the amount spent on physical therapy services.

Our services are generally underutilized.

The quality of physical therapy/intervention wasn't mentioned in the

ruling. I do tend to believe that aspect could be open for discussion.

Selena Horner, PT

> > Finally, some common sense and what we all know!

> >

> > " People with chronic conditions are being denied care in the

mistaken

> > belief that Medicare requires improvement of a person's condition as

a

> > prerequisite for coverage, " Mr. said Monday. " That's not in

the

> > law. It's urban legend. "

> >

> > " Medicare terminated coverage after five weeks, saying her condition

had

> > not improved and was unlikely to improve. "

> > ~Example of 'urban legend' applied.

> >

> > " In reversing the decision of Medicare officials, the court said Ms.

> > Papciak needed skilled nursing home care " to maintain her level of

> > functioning " and to prevent her condition from deteriorating. "

> >

> > " Beneficiaries are frequently told that Medicare will not cover

skilled

> > services if their underlying condition will not improve, " the letter

> > said. " For example, as people with multiple sclerosis are often not

> > likely to improve, skilled services such as physical, occupational

and

> > speech therapies that are necessary to slow the progression of the

> > disease, or maintain current function, are denied. As a result,

these

> > individuals' conditions deteriorate - frequently leading to more

> > intense, more expensive services, hospital or nursing home care. "

Right on!

> >

> > Read more:

> >

http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=

2 & tc=pg

> >

<http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p

=2 & tc=pg>

> >

> > We need to watch how this plays out because it will most definitely

> > impact how Medicare will need to re-interpret 'reasonable and

necessary'

> > and should impact why 'maintenance' is important.

> >

> > Selena Horner, PT

> > ton, MI

> >

> >

>

[Guest guest]

I am also a patient advocate. However, given that Medicare is footing

the bill, we can not be patient advocates in a vacuum. We MUST consider

the rules and regulations of the contract we agree to work under.

I believe that Medicare RULES (i.e LAW) requires the patient have the

expectation of making significant progress. I don't see any " wiggle

room " or how this is an " urban legend " . I'm almost 100% confident this

phrase is actually written in Medicare standards.

Over utilization is wrong, regardless if it's .5%, 1% or 10% of

Medicare's overall outlay.

Ron Carson MHS, OT

> We can have differing opinions, but my position is generally always

> absolutely on the side of being a patient advocate. I was delighted to

> see a judge believe, as I do, that Medicare beneficiaries should not

> risk a decline in function or worse to prove they need physical therapy

> services.

>

> It appears that the law doesn't have the expectation that the patient is

> required to make significant progress in a reasonable period of time. It

> also seems to appear the law values maintaining function over declining

> function. Our thoughts have been molded and misled with the " urban

> legend " - we do have skill and our services are necessary in some cases

> to prevent deterioration which will have escalating financial costs.

>

> Based on some of the dollar figures Medicare spends, I don't think there

> needs to be a worry on the amount spent on physical therapy services.

> Our services are generally underutilized.

>

> The quality of physical therapy/intervention wasn't mentioned in the

> ruling. I do tend to believe that aspect could be open for discussion.

>

> Selena Horner, PT

>

>

> > > Finally, some common sense and what we all know!

> > >

> > > " People with chronic conditions are being denied care in the mistaken

> > > belief that Medicare requires improvement of a person's condition as a

> > > prerequisite for coverage, " Mr. said Monday. " That's not

> in the

> > > law. It's urban legend. "

> > >

> > > " Medicare terminated coverage after five weeks, saying her

> condition had

> > > not improved and was unlikely to improve. "

> > > ~Example of 'urban legend' applied.

> > >

> > > " In reversing the decision of Medicare officials, the court said Ms.

> > > Papciak needed skilled nursing home care " to maintain her level of

> > > functioning " and to prevent her condition from deteriorating. "

> > >

> > > " Beneficiaries are frequently told that Medicare will not cover skilled

> > > services if their underlying condition will not improve, " the letter

> > > said. " For example, as people with multiple sclerosis are often not

> > > likely to improve, skilled services such as physical, occupational and

> > > speech therapies that are necessary to slow the progression of the

> > > disease, or maintain current function, are denied. As a result, these

> > > individuals' conditions deteriorate — frequently leading to more

> > > intense, more expensive services, hospital or nursing home care. "

> Right on!

> > >

> > > Read more:

> > >

>

http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=2 & tc=pg

>

<http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=2 & tc=pg\

>

> > >

>

<http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=2 & tc=pg

>

<http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=2 & tc=pg\

>>

> > >

> > > We need to watch how this plays out because it will most definitely

> > > impact how Medicare will need to re-interpret 'reasonable and

> necessary'

> > > and should impact why 'maintenance' is important.

> > >

> > > Selena Horner, PT

> > > ton, MI

> > >

> > >

> >

>

>

[Guest guest]

I light of this ruling, how does one reconcile the 2 seemingly

contradictory regs from Medicare that on one side demand that " There must be an

expectation that the

beneficiary's condition will improve materially in a reasonable (and

generally predictable) period of time " , but on the other hand allows for

ongoing

" maintenance " services where a patient is not expected to make any

material progress?

Secondly, how does one " objectively " define and qualify a patient who is

at " risk for decline " , and thus justify an ongoing maintenance? I'm curious

as to what criteria is used to define a patient who would qualify for

ongoing maintenance therapy.

Lastly, does anyone in the group have personal experience in providing

" ongoing " maintenance PT services (I mean months & months at a time) to home

health patients? I'd like to hear from therapists who could share experience

where such cases were either denied or approved.

Finally, Thank You Selena, for sharing this important information with the

rest of us!

Corneau, MPT, GCS

Board Certified Specialist

Geriatric Physical Therapy

In a message dated 11/3/2010 6:19:15 P.M. Pacific Daylight Time,

BassHorner2@... writes:

As an addendum to this post... please remember, these rulings were specific

to skilled nursing home and home health care situations which fall under

Medicare A.

We have to always remember Medicare is a very convoluted, inconsistent

program when it comes to regulations. Medicare A is different from Medicare B.

Medicare B has inconsistencies based on practice setting.

Selena

> > > > Finally, some common sense and what we all know!

> > > >

> > > > " People with chronic conditions are being denied care in the

> > mistaken

> > > > belief that Medicare requires improvement of a person's condition

as

> > a

> > > > prerequisite for coverage, " Mr. said Monday. " That's not

in

> > the

> > > > law. It's urban legend. "

> > > >

> > > > " Medicare terminated coverage after five weeks, saying her

condition

> > had

> > > > not improved and was unlikely to improve. "

> > > > ~Example of 'urban legend' applied.

> > > >

> > > > " In reversing the decision of Medicare officials, the court said

Ms.

> > > > Papciak needed skilled nursing home care " to maintain her level of

> > > > functioning " and to prevent her condition from deteriorating. "

> > > >

> > > > " Beneficiaries are frequently told that Medicare will not cover

> > skilled

> > > > services if their underlying condition will not improve, " the

letter

> > > > said. " For example, as people with multiple sclerosis are often

not

> > > > likely to improve, skilled services such as physical, occupational

> > and

> > > > speech therapies that are necessary to slow the progression of the

> > > > disease, or maintain current function, are denied. As a result,

> > these

> > > > individuals' conditions deteriorate - frequently leading to more

> > > > intense, more expensive services, hospital or nursing home care. "

> > Right on!

> > > >

> > > > Read more:

> > > >

> >

_http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=_

(http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=)

> > 2 & tc=pg

> > > >

> >

<_http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p_

(http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p)

> > =2 & tc=pg>

> > > >

> > > > We need to watch how this plays out because it will most definitely

> > > > impact how Medicare will need to re-interpret 'reasonable and

> > necessary'

> > > > and should impact why 'maintenance' is important.

> > > >

> > > > Selena Horner, PT

> > > > ton, MI

> > > >

> > > >

> > >

> >

> >

> >

> >

> >

> >

> > [Non-text portions of this message have been removed]

> >

>

[Guest guest]

Thank you for this very important clarification.

I, for one, benefit greatly from such informative contributions to the

listserv.

I will be following these new developments re: maintenance therapy with

much interest.

Corneau, PT, GCS

In a message dated 11/5/2010 11:17:15 A.M. Pacific Standard Time,

BassHorner2@... writes:

There doesn't happen to be 2 seemingly contradictory regulations. The

language within Medicare regulations for skilled nursing facility and home

health is not as strict as Medicare experts have interpreted. The recent ruling

indicates the language of Medicare regulations DOES allow for physical

therapy intervention for people with chronic conditions who are at risk for

deterioration. The recent ruling eliminates the requirement to have progress

in a reasonable/expected amount of time.

Most definitely, there is a huge risk for misuse and for escalating costs

with this particular population. That is a separate issue though... the

issue was the actual law and the language of that law. Medicare has not been

paying appropriately and has been denying for services that are well within

the language of the law.

The intent of the law and the language of the law are apparently in

contradiction.

With regard to identifying a patient who is at risk, the current process

focusing on claims and ICD-9 codes is an inadequate process to easily

identify a patient is a risk. Those at risk are more than just a few ICD-9

codes:

_http://www.cmellc.com/geriatrictimes/g020831.html_

(http://www.cmellc.com/geriatrictimes/g020831.html)

We do have research to support who is at risk for a decline. One main

decline that costs the most money is a fall. Research indicates comfortable

walking speed is an indicator for mortality and risk of falling. Is it the 6th

vital sign?

_http://blog.myphysicaltherapyspace.com/2009/06/the-6th-vital-sign.html_

(http://blog.myphysicaltherapyspace.com/2009/06/the-6th-vital-sign.html)

Chronic pain is associated with a higher risk of falling

(Leveille, 2009). Has the patient fallen in the last 12 months?

_http://blog.myphysicaltherapyspace.com/2008/10/have-you-fallen.html_

(http://blog.myphysicaltherapyspace.com/2008/10/have-you-fallen.html) The Berg

and the Tinnetti are

performance related tools that can help capture how well a patient performs

various activities. The Activity Specific Balance Scale captures a

patient's confidence in performing various activities. Believe it or not, grip

strength has become a predictor of frailty, disability and mortality (Syddall

2003).

I tend to believe we do have evidence out there to help justify a patient

is at risk of falling or disability or frailty or mortality.

Since this ruling just came out, the only stories that will be out there

are those of denial. I'm more curious about who will use the rulings to

fight denials.

Selena Horner, PT

> > > > > Finally, some common sense and what we all know!

> > > > >

> > > > > " People with chronic nditions s are being denied care in the

> > > mistaken

> > > > > belief that Medicare requires improvement of a person's

condition

> as

> > > a

> > > > > prerequise for coverarage, " Mr. said Monday. " That's

not

> in

> > > the

> > > > > law. It's urban legend. "

> > > > >

> > > > > " Medicare terminated coverage after five weeks, saying her

> condition

> > > had

> > > > > not improved and was unlikely to improve. "

> > > > > ~Example of 'urban legend' applied.

> > > > >

> > > > > " In reversing the decision of Medicare officials, the court said

> Ms.

> > > > > Papciak needed skilled nursing home care " to maintain her level

of

> > > > > functioning " and to prevent her condition from deteriorating. "

> > > > >

> > > > > " Beneficiaries are frequently told that Medicare will not cover

> > > skilled

> > > > > services if their underlying conditn will l not improve, " the

> letter

> > > > > said. " For example, as people with multiple sclerosis are often

> not

> > > > > likely to improve, skilled services such as physical,

occupational

> > > and

> > > > > speech therapies that are necessary to slow the progression of

the

> > > > > disease, or maintain current function, are denied. As a result,

> > > these

> > > > > individuals' conditions deteriorate - frequently leading to more

> > > > > intense, more expensive services, hospital or nursing home

care. "

> > > Right on!

> > > > >

> > > > > Read more:

> > > > >

> > >

>

__http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=__'>http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=__

(http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=_)

>

(_http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=_

(http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=) )

> > > 2 & tc=pg

> > > > >

> > >

>

<__http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p__'>http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p__

(http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p_)

>

(_http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p_

(http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p)

)

> > > =2 & tc=pg>

> > > > >

> > > > > We need to watch how this plays out because it will most

definitely

> > > > > impact how Medicare will need to re-interpret 'reasonable and

> > > necessary'

> > > > > and should impact why 'maintenance' is important.

> > > > >

> > > > > Selena Horner, PT

> > > > > ton, MI

> > > > >

> > > > >

> > > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >

[Guest guest]

Where is this stated in the Medicare regs?

Thanks

Ilene Larson PT MS

Rehab Agency Administrator

GL Rehabilitation Services

ilarson@...

From: PTManager [mailto:PTManager ] On Behalf

Of selenahorner

Sent: Friday, November 05, 2010 1:43 PM

To: PTManager

Subject: Re: Times May Be Changing!

There doesn't happen to be 2 seemingly contradictory regulations. The

language within Medicare regulations for skilled nursing facility and home

health is not as strict as Medicare experts have interpreted. The recent

ruling indicates the language of Medicare regulations DOES allow for

physical therapy intervention for people with chronic conditions who are at

risk for deterioration. The recent ruling eliminates the requirement to have

progress in a reasonable/expected amount of time.

Most definitely, there is a huge risk for misuse and for escalating costs

with this particular population. That is a separate issue though... the

issue was the actual law and the language of that law. Medicare has not been

paying appropriately and has been denying for services that are well within

the language of the law.

The intent of the law and the language of the law are apparently in

contradiction.

With regard to identifying a patient who is at risk, the current process

focusing on claims and ICD-9 codes is an inadequate process to easily

identify a patient is a risk. Those at risk are more than just a few ICD-9

codes: http://www.cmellc.com/geriatrictimes/g020831.html

We do have research to support who is at risk for a decline. One main

decline that costs the most money is a fall. Research indicates comfortable

walking speed is an indicator for mortality and risk of falling. Is it the

6th vital sign?

http://blog.myphysicaltherapyspace.com/2009/06/the-6th-vital-sign.html

Chronic pain is associated with a higher risk of falling (Leveille, 2009).

Has the patient fallen in the last 12 months?

http://blog.myphysicaltherapyspace.com/2008/10/have-you-fallen.html The Berg

and the Tinnetti are performance related tools that can help capture how

well a patient performs various activities. The Activity Specific Balance

Scale captures a patient's confidence in performing various activities.

Believe it or not, grip strength has become a predictor of frailty,

disability and mortality (Syddall 2003).

I tend to believe we do have evidence out there to help justify a patient is

at risk of falling or disability or frailty or mortality.

Since this ruling just came out, the only stories that will be out there are

those of denial. I'm more curious about who will use the rulings to fight

denials.

Selena Horner, PT

> > > > > Finally, some common sense and what we all know!

> > > > >

> > > > > " People with chronic nditions s are being denied care in the

> > > mistaken

> > > > > belief that Medicare requires improvement of a person's condition

> as

> > > a

> > > > > prerequise for coverarage, " Mr. said Monday. " That's not

> in

> > > the

> > > > > law. It's urban legend. "

> > > > >

> > > > > " Medicare terminated coverage after five weeks, saying her

> condition

> > > had

> > > > > not improved and was unlikely to improve. "

> > > > > ~Example of 'urban legend' applied.

> > > > >

> > > > > " In reversing the decision of Medicare officials, the court said

> Ms.

> > > > > Papciak needed skilled nursing home care " to maintain her level of

> > > > > functioning " and to prevent her condition from deteriorating. "

> > > > >

> > > > > " Beneficiaries are frequently told that Medicare will not cover

> > > skilled

> > > > > services if their underlying conditn will l not improve, " the

> letter

> > > > > said. " For example, as people with multiple sclerosis are often

> not

> > > > > likely to improve, skilled services such as physical, occupational

> > > and

> > > > > speech therapies that are necessary to slow the progression of the

> > > > > disease, or maintain current function, are denied. As a result,

> > > these

> > > > > individuals' conditions deteriorate - frequently leading to more

> > > > > intense, more expensive services, hospital or nursing home care. "

> > > Right on!

> > > > >

> > > > > Read more:

> > > > >

> > >

> _http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=_

> (http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p=)

> > > 2 & tc=pg

> > > > >

> > >

> <_http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p_

> (http://www.heraldtribune.com/article/20101102/ZNYT02/11023019/-1/news?p)

> > > =2 & tc=pg>

> > > > >

> > > > > We need to watch how this plays out because it will most

definitely

> > > > > impact how Medicare will need to re-interpret 'reasonable and

> > > necessary'

> > > > > and should impact why 'maintenance' is important.

> > > > >

> > > > > Selena Horner, PT

> > > > > ton, MI

> > > > >

> > > > >

> > > >

> > >

> > >

> > >

> > >

> > >

> > >

> > >