The Medicare Maintenance Care Myth

There’s been quite a bit of confusion over the years about maintenance care in the rehab therapy space. In fact, some providers still believe that maintenance care doesn’t meet Medicare’s definition of medical necessity. However, Medicare’s coverage of outpatient physical, occupational, and speech therapy services doesn’t depend on a patient’s potential for improvement from therapy, but rather on the beneficiary’s need for skilled care. Read on to learn the myth-busting truth about Medicare maintenance care:

The Definition of Medical Necessity

CMS has yet to make its medical necessity guidelines easy to understand—or apply—which is why the APTA stepped in to help provide some clarification around medical necessity as it relates to therapy services. In 2011, the APTA adopted the Defining Medically Necessary Physical Therapy Services position, which states that “physical therapy is considered medically necessary as determined by the licensed physical therapist based on the results of a physical therapy evaluation” and when “provided for the purpose of preventing, minimizing, or eliminating impairments, activity limitations, and/or participation restrictions.” Furthermore, therapy treatment is considered medically necessary “if the type, amount, and duration of services outlined in the plan of care increase the likelihood of meeting one or more of these stated goals: to improve function, minimize loss of function, or decrease risk of injury and disease.”

While this definition doesn’t align with every definition of medical necessity in the healthcare community, it does offer some much-needed guidance for rehab therapists. It also seems to line up with Medicare’s reimbursement requirements—especially considering the recent court decision that nixed patient improvement as a condition of payment.

The Medicare Maintenance Fix

As Brooke Andrus wrote in this post, “For years, both providers and Medicare beneficiaries have operated under the incorrect assumption that Medicare will only pay for rehab therapy or other skilled care if a patient shows improvement as a result of that care.” Many individuals “believed that no progress meant no coverage—unless the patient’s condition deteriorated, in which case therapy could resume,” Andrus said. “Thus, even in cases where therapy would maintain a patient’s level of function by preventing a problem from worsening, therapists had to cease treatment until the problem actually got worse.” Ridiculous, right? Actually, it was more than that; for those patients who couldn’t take advantage of therapy services as a result of this stipulation, it was potentially harmful.

It’s no surprise, then, that this issue found its way to a federal courtroom as a result of a class action lawsuit filed by plaintiffs alleging that MACs were making approval or denial decisions based on an incorrect standard. According to Andrus, on January 24, 2013, the US District Court for the District of Vermont approved a settlement agreement in which CMS was required to “clarify relevant portions of the existing Medicare Benefit Policy Manual—which actually do not require improvement as a condition of coverage—and roll out new educational materials aimed at correcting long-standing, widespread misconceptions about the Improvement Standard.” (As compliance expert Tom Ambury and WebPT president Heidi Jannenga explained in this month’s Medicare-focused webinar, the same group that filed the original suit in 2013 recently filed another complaint alleging that CMS didn’t comply with the portion of the settlement agreement that required it to train its stakeholders. We’ll keep you posted as we learn more.)

During the webinar, Ambury also pointed out that “Medicare will not pay for any services—including those as part of a maintenance program—that a care provider with a lower level of experience and/or education (e.g., a technician, caregiver, fitness instructor, or massage therapist) can provide.” In other words, Medicare only covers services provided by a licensed therapist or therapist assistant under the direct supervision of a licensed physical therapist.

Want to read the settlement agreement for yourself? You can find it in full here; or, check out the two-page fact sheet that CMS compiled here. As an additional resource, the Center for Medicare Advocacy offers self-help packets for outpatient therapy patients who wish to appeal a coverage denial. These packets could come in handy if you believe CMS has incorrectly denied coverage for maintenance care.