Medicare And You - Part 2

Last month I wrote an article about Medicare legislation and its recent changes. This month’s article will explain how Medicare benefits apply to you. Everyone is eligible for Medicare benefits once reaching the young age of 65. Medicare is also available to people younger than 65 if they have disability and go through the process of necessary paperwork.
Currently there is a monetary cap of $1,810 per calendar year for physical therapy. There are a number of medical conditions that are exempted from the therapy cap. Examples are strokes, multiple sclerosis, arthritis, neurological deficiencies, Parkinson’s, and difficulty walking, etc. But, even with these conditions, there must be significant progress made within every two weeks, and once the treatment goals are reached, or the progress has leveled, the treatments end. Many times when the goals are not reached, the relatives will demand the continuation of physical therapy, not understanding that the patient cannot physically reach those goals. In the case of stroke, the relatives often seek from the therapists that the patient achieves independent status, as he or she was before the stroke, which in many cases is not physically possible.
All physical therapists are board certified to treat musculoskeletal and neurological deficiencies. There are physical therapists that specialize at certain disciplines and have added certifications. Common examples are the hand specialists, pulmonary specialists, cardiac specialists, newborn specialists, and geriatric specialists. In order to receive medical benefits from physical therapy you need to see your doctor who will determine if your condition fulfills the requirement of medical necessity. This means that, to correct your condition, it requires intervention by a registered physical therapist. The doctor will then give the patient a prescription for physical therapy that will state the diagnosis, frequency of visits (two or three times per week for four weeks), and may include specific instructions or limitations. Sometimes the prescription will indicate a treatment period for 12 weeks.
The period requested by the prescription is not a guarantee for treatment if significant progress is not achieved. This means that when you start treatment with the physical therapist he makes an initial evaluation of your condition. This establishes a base line from which progress can be measured. If your visit frequency is three times per week, in a two week period you will be treated six times. At this end of two weeks your progress will be considered. It is required that the progress is significant. If it is not, then in spite of the fact that your prescription calls for four weeks or more of physical therapy treatment, your visits must terminate according to Medicare, or for that matter, any other medical insurance guidelines.
Your medical benefits are based on your improvement as physical therapy treatments are rendered. As long as you are making improvement at two week intervals your treatments will continue. Well, not indefinitely. When the therapist sees you for the first time he already has an idea how long your therapy will last. He will set a reasonable goal for your physical ability and will work towards that goal. You should be continuously informed of your progress and instructed in home exercise programs to speed up your recovery.
Most of the patients are doing the required work while in the physical therapy office but are not as regimented when it comes to doing the homework. It is important for the patient to understand that one hour of therapy in the office is a small part of time when compared to the whole day. In a case of “frozen shoulder,” the patient is given specific exercises which, when done at home, will greatly improve progress and reduce the cost of therapy. It is therefore very important to do the homework.
Medicare will not pay for “maintenance.” This means that your condition improves a bit during the therapy but by the next scheduled visit returns back to its previous state. Some patients expect the whole treatment time to be spent on stretching or massage. While these treatments are part of the physical therapy management they need to be used in short periods as regulated by treatment manuals, and not for the duration of the whole therapy session. Once instructed, most of the stretches can be done independently at home.
The ultimate goal is for the patient to get to be independent in all exercises as soon as possible. The function of the therapist is not only to treat the patient but also to educate. When the patient understands the cause of his problem and is instructed how to conduct them in the home environment, he will improve faster and attain his goals quicker. It is important for the patient to understand that the responsibility to improve his condition is his. The therapist is really an advisor.
Remember what is important when in need for physical therapy. You need to see the doctor and get the prescription for physical therapy, you need to make significant progress every two weeks, and you need to do the required work. Our job as physical therapists is to get you “good enough” as quickly as possible so that you can independently continue to work and treat yourself at home.