Treating Medicare Patients

Treating Medicare Patients

Medicare is complex, and seems to become more complex with each passing year. The system has reached a point where it's too difficult for a practice without a dedicated billing team to navigate the complexity; even large practices with such teams are struggling with ever-increasing requirements and significant penalties for honest or minor mistakes. It's therefore becoming increasingly common to see physicians "opt-out" of Medicare, instead directly charging the patient for services provided, in order to avoid the risks associated with billing Medicare.

Unlike physicians, Physical Therapists aren't allowed to opt-out of Medicare. This results in the following situation with respect to physical therapy services:

  • If you are of Medicare age, and you have a problem that would be covered by Medicare (typically, some type of new, acute issue), then it's illegal for a Physical Therapist to not bill Medicare for your treatment.
  • Therefore, for such issues, the only option available to the patient is to receive service from a practice that bills Medicare directly, as patients cannot submit bills to Medicare.
  • As a small practice, billing Medicare isn't a viable option for me, so I can't treat Medicare-eligible patients for acute issues, even those willing to pay in cash.
  • However, Medicare covers any issue only up to a point, beyond which the problem is deemed "maintenance" and thus ineligible for Medicare reimbursement. In order for therapy to be reimbursed by Medicare, a person must, after intensive and short-term intervention, show significant progress in their ability to carry out their daily activities; slow progress over a long period of time is not reimbursed by Medicare.

If your treatment under Medicare has reached a point where further treatment would be termed "maintenance" by Medicare, but you have not yet reached a level of decreased pain or increased function that is acceptable to you, I can then treat you as a fee for service patient, not reimbursable by Medicare. Prior to treatment, you will need to sign a Medicare Advanced Beneficiary Notice ("ABN") form. This form is a written notice that a therapist gives to a Medicare beneficiary, prior to provision of service, when the therapist believes that Medicare will not pay for some or all of the treatment.

The above may seem puzzling or confusing; it certainly is to me. I encourage you to contact me if you are interested, or need further explanation.



When I moved back to California from Vermont in 2004, and began to look for a Physical Therapy job, I was surprised by how little time potential employers expected me to spend with patients. Often they allowed no more than 15 minutes with a patient.

When considering the paperwork involved with each patient, that would have been something like working in a mill. Basically, check in with the patient, then do whatever would be minimally necessary to hand them off to an aide.

Fortunately, I was able to find a clinic that held to a strong philosophy of effective patient care, and thus was able to avoid mill work.

Therapists treating many patients per hour are typically "in-network providers". That is, they've negotiated a billing rate with one or more insurance companies, and as a result must sustain a high patient turnover rate in order to remain afloat. This is burdensome for both the therapist and the patient, and the effectiveness of such treatment seems questionable.

One way for a practice to avoid a mill situation is to bill the patient's insurance as an "out of network provider"; any amount not paid by insurance is expected to be paid by the patient, including any charge added to cover the cost of the billing specialists. However, there is often significant lag time prior to being reimbursed with this model, and insurance companies often employ delaying tactics to deny reimbursement to the therapist for as long as possible; it's obviously difficult for anyone to not be paid for an indefinite period of time.

As a sole practitioner interested in providing the best possible care to my patients, neither of these approaches seems to be viable. I've elected to go with a third, simpler approach.

I treat patients one-on-one for a full hour, without the use of an aide; this level of care, in my experience, allows patients to get better faster with fewer visits, thus improving their quality of life more rapidly.

I accept payment from the patient at the time of service, and provide a written statement. The statement, along with any necessary additional documentation, can then be submitted by the patient to their insurance for reimbursement.

In this way, I can focus on what is most important: caring for my patients, and providing a customized treatment approach that addresses individual patient needs and goals.