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Medicare Physical Therapy Guidelines PTs Need to Know

Considering switching to Medicare or starting a practice? Check out this all-inclusive guide that details the Medicare process, what physical therapy guidelines PTs need to know, and how to choose the proper reimbursement system.

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Medicare Physical Therapy Guidelines

The federal government doesn’t make its programs easy to understand, especially in healthcare. Medicare is no exception, but there are 62 million Americans who rely on this insurance for medical services, including physical therapy. So, what do PTs need to know about Medicare, and how can they implement Medicare at their practice? In this article, you’ll learn essential Medicare information, commonly missed definitions, and determine which type of structure works best for your practice.

Medicare and Its Four Parts

Going to a medical professional without insurance can be a costly move, especially as the scope of care increases with age. Medicare is insurance designed for people 65 and older and those with special requirements. There are different coverage areas of Medicare that all medical professionals should know. Here are the four separate parts and how they apply to physical therapy:

Medicare and Its Four Parts

Going to a medical professional without insurance can be a costly move, especially as the scope of care increases with age. Medicare is insurance designed for people 65 and older and those with special requirements. There are different coverage areas of Medicare that all medical professionals should know. Here are the four separate parts and how they apply to physical therapy:

Part A

The first section of Medicare coverage deals with hospitalization. Patients who enroll in Medicare will automatically opt-in to these benefits that include, but are not limited to, In-home care, inpatient hospital care, and skilled nursing facilities. These can include inpatient rehabilitation centers.

Part B

The bulk of Medicare includes countless services like doctor’s visits, outpatient care, and rehabilitation. Physical therapy conducted in a private practice (one that takes Medicare) will provide services under this section of Medicare coverage. Although, patients will need to pay fees and sign up to receive benefits. It’s worth noting that these parts cannot be used in tandem, and PTs will need to distinguish if patients are receiving Part A benefits beforehand.

Part C

Often referred to as “Medicare Advantage,” Part C is a service offered by private insurance companies Medicare has approved. These companies have the approval to get your payment from the federal government. Beneficiaries will use Medicare Advantage plans to search for a better deal outside Part A, B and D Medicare. These sometimes include additional costs—especially when it comes to other services that traditional Medicare doesn’t offer.

Part D

This slice of Medicare services gives patients access to prescription drugs. Private insurance companies also administer these services. If patients are on traditional Medicare, Parts A & B, they may need to meet deductibles and co-pays. Many Part C Medicare plans include these benefits in their program.

What PTs Need to Know About Medical Necessity

Even if a service physical therapists provide is covered by Medicare, challenges persist. Every PT accepting Medicare must justify the therapy provided using Medicare’s standards. Those standards state the following: “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. ”This basically means PTs need to provide reasonable and necessary treatment for the patient to get better. PTs should determine which services do and do not meet Medicare’s standards and provide patients with an advance beneficiary notice of noncoverage to ensure they make informed decisions about their treatment. This notice tells patients they may not receive Medicare coverage for the proposed treatment plan.

What PTs Need to Know About Medicare Assignment

Before taking Medicare payments, you need to be officially enrolled. Taking in Medicare patients isn’t as challenging as it seems with this step-by-step CMS guide that outlines how practices can obtain their credentials and fill out the application. Once the application is processed and confirmed, PTs can accept their first Medicare assignment. But, if you’re deciding not to receive Medicare reimbursement, practices can “opt-out.” There are three distinctions involving Medicare status PTs should consider when structuring their practice:

Participating Provider

Being a participating provider is where PTs opt-in to Medicare assignment and payment for the covered services they provide. They cannot charge patients outside of the realm of Medicare payments but receive the benefit of being accessible to many patients who search specifically for physical therapists who accept Medicare. In fact, over 18% of the U.S. population is on Medicare, and the aging population is increasing that number. Some PTs must rely on the influx of Medicare patients to keep the practice profitable. However, there are some cons to being a participating provider. Notably, Medicare doesn’t always cover the total cost of care, which can leave PTs chasing down what’s often 20% of the entire bill for reimbursement. Additionally, PTs are at the mercy of Medicare Physician Fee Schedules rules that contain fluctuating reimbursement amounts for services many PTs deem critical for patients.

Non-Participating Provider

Who knew being a “non-participant” means you do participate but at a limited capacity? Non-participating PT providers might see Medicare patients but don’t accept the reimbursement as full payment. Instead, these providers will take the Medicare reimbursement as a partial payment and expect the patient to pay up to 15% more depending on state laws. Non-participating providers can also accept assignment or full payment for specific services under Medicare’s proposed payment amounts. The provider simply designates those services and cannot charge for anything other than the Medicare deductible and coinsurance fees.

Opt-Out of Medicare

The final option for providers is to opt-out of Medicare altogether. Often referred to as cash-only clinics, these PTs gain complete control over their pricing and services offered. Medicare comes loaded with many rules, and third-party companies operating under Part C are no better. As mentioned before, many PTs don’t want their practice to fall victim to the fee schedule. Additionally, they don’t need to choose from a cookie-cutter list of interventions and administer them over a specific time. This greatly enhances the flexibility of care and can often help PTs get better outcomes in a shorter time. On the contrary, when PTs stray away from Medicare altogether, they’re essentially pinching off a large group of eligible patients. It can slow referrals drastically and make running a practice difficult. PTs who go this route may need additional marketing, sales, and communication with their patients.

The Bottom Line

PT practices need to know the ins and outs of Medicare to ensure patients get the information and treatment required by CMS. While most PTs will deal with Medicare Part B, they’ll need to ensure patients don’t receive Parts A and B concurrently. Additionally, there are Medicare requirements like showing necessity that PTs must uphold. Once physical therapists know these concepts, choosing whether you entirely, partially or skip Medicare assignment altogether is a delicate financial decision that must be weighed using several factors. Regardless of your relationship with Medicare, taking on patients takes communication, billing and administrative expertise to keep your operation running smoothly. And without the right software, practice management can take away precious time practice managers need to make big decisions. If you’re looking for an all-in-one solution for your PT practice, consider MWTherapy. We offer the best PT software solution created by physical therapists like yourself to make practice management a breeze. Try a free trial today and see what MWTherapy can do for you!

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