Medicare And Pt: Important Information

[Knitter4444]

Re: Recommendations in SF Bay area for TKR surgeons

Hi All. I thought I would post some information that may help you.

I am a health care reimbursement specialist. Nearly 70 and very young. Scheduled for BTKR and have done so much research so thought I would share.

Rehab: I started looking. The first one I went to had no one under 300 years old. There was just no joy in the place. It was quiet, semi private rooms but I did not see staff smiling. Red flag for me: How was the staff treated and how happy were they with their jobs which would affect me as a patient.

The second one was an acute rehab with low toilets. Really!! There were no metal bars on the walls for support but when I asked about this, the response was: Well, you will use a bedside commode for the two weeks that you would be here. I howled and responded. I will be in rehab so that I can set goals for my recovery. Why would anyone think that I would be doing this for two weeks. She even invited me to bring an extended seat with me. Yikes.

Ok, hold your breath because the third visit was the absolute best and it is available in many parts of the country. It is part of the Hyatt Chain..(no joke) It is called Hyatt Classic and they have a wonderful facility. All private rooms, dining rooms with table cloths and fresh flowers, wireless connections in the rooms..and the atmosphere is of community and family. They have entertainment at night, cocktail hours, a beauty shop etc.

So you think that you cannot afford this, right? Medicare pays for this..and if you have Medigap, you will have no cost except perhaps a beauty salon or a massage etc.

My specialty in the health care field is Medicare so I am telling you the accurate information. Happy to answer questions related to Medicare or anything insurance related.

Here is some more info:

PT: Medicare has always extended the cap for PT and OT each year. What that means is that if you have circumstances that you need more of these services than are allowed, you can get them with physician documentation. (this is for out patient PT) Starting in 2010 they did not extend this, so every patient on Medicare is restricted to $1860 total for the year for PT and another $1860 for OT. Amounts may change as the years go by, but there will be low limits imposed. So if you have a knee replacement, Medicare will only pay up to that figure and under no circumstances will they pay for anything else. Those of us are on Medicare will have to pay out of pocket for the services EXCEPT..and this is the trick....if you go to a facility that is part of a hospital, you can go to PT and OT and have unlimited services again with proper documentation.

Why the difference you ask? Medicare for outpatient services for PT and OT is billed to Part B Medicare. (the same as your provider bills). If the facility is part of a hospital, you are still an outpatient but they bill to Part A which is hospital billing.

So, be sure that you go to a hospital based facility for your PT so that you will not be forced to perhaps stop this very important therapy.

NOTE: This only applies to Original Medicare and not to a Part C plan or Advantage Plan.

I hope that this information helps you all.

Merry

 

[Knitter4444]

This ONLY refers to Original Medicare..not an Advantage Medicare plan or HMO

Medicare only allows $1860 a year for PT and it includes speech therapy in that amount. (Believe it..it is true)

But for this year (2010) there are exceptions and TKR's are covered as one of the exceptions. This is all handled by the PT facility and the patient does not do anything for this. It involves how the claim is billed to Medicare. BUT..be aware, that this exception rule did not come into play until sometime in March (Congress) so it takes very little to use up the $1860..perhaps just a few visits. On January 1 of each year, it starts all over again. So it starts with no exceptions. This means NONE for NO REASON. So someone who has had a stroke and needs PT and also speech therapy can only get $1860 worth of care and then NOTHING..unless Congress passes exceptions. I really wonder how many of our elected officials have ever had joint replacement surgery.

The way around this is to go to a facility affiliated with a hospital..which is billed to another part of Medicare and there is no limit. I am just posting this because this can be catastrophic for those on Medicare having their surgery in December or even now.

It is good to be prepared for this. I am crossing my fingers that the exceptions will pass again but it could take months.

I am always happy to help anyone with Medicare issues.

 

[Knitter4444]

This may need to be added to the pre op board also but this is just an update.

As of now, no patient will get more than $1870 worth of PT if you have Original Medicare for the year 2011. And this includes charges for speech therapy also.

As you know, it takes only a few visits to get to that amount. And that figure is for the approved amount, not just what Medicare pays as the other 20% is the patient's responsibility or secondary insurance.

So, if you are going to a private PT facility, we will start the new year with only that amount allowed. There are NO EXCEPTIONS at all at this time. Not a drs note, nor any amount of pleading or appealling will give you more PT at this time. It took till March of 2010 for them to approve exceptions and extend more PT to people under certain circumstances including joint replacement.

This is IMPORTANT: If you affiliate with a PT based within a hospital then this is not information for you. Another part of Medicare is billed and there are no restrictions.

YOU MUST consider this as we go through the changes in health care reform. I do not want to see anyone stuck without PT if it is necessary.

Anyone who needs help with Medicare is welcome to contact me. I train on this and happy to assist anyone here.