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.