October 2012
After the
settlement of a landmark class-action lawsuit this
week, Medicare will soon begin paying more often for physical,
occupational and other therapies for large numbers of people with certain
disabilities and chronic conditions such as MS.
While the
reach of change following the ruling is still uncertain, advocates hope that
Medicare will soon pay for many forms of therapy that it did not always cover
before. For people with MS, this may mean more approval for treatments for
spasticity and gait training to prevent falls.
Pending
approval by a federal judge, the settlement would end a lawsuit that accused
Medicare of allowing the contractors that process its claims to use an
“improvement standard” over the last few decades. To the Center for Medicare
Advocacy and the many other organizations that joined the suit, that standard seemed
to call for cutting off physical, occupational and speech therapy, and some
inpatient skilled nursing for many people who had reached a plateau in their
treatment.
Medicare
is supposed to pay for reasonable treatment of an illness or injury
as long as a doctor has prescribed it. For the sort of in-home
care that this week’s settlement may affect the most, a doctor must have
certified that you are, in fact, homebound and have prescribed treatment that
only a skilled practitioner can provide. (The “skilled practitioner” rule keeps
Medicare from paying for assistance with everyday activities like bathing and
dressing.)
The
settlement agreement does not describe itself as an expansion of Medicare
coverage. But it does state that the Centers for Medicare and Medicaid Services
will revise the manuals their contractors use to make clear that coverage “does
not turn on the presence or absence of a beneficiary’s potential for
improvement from the therapy but rather on the beneficiary’s need for skilled
care.”
The
settlement also specifies that skilled care can qualify for Medicare coverage
even if it merely maintains someone’s current condition or prevents or slows
further deterioration. Certain patients who have had claims rejected will be
able to resubmit them.
It is
anticipated to take a couple of months before the judge approves the
settlement, and then a year or more until the Medicare billing contractors get
the newly clarified manuals.
Even so,
some patient advocates see no reason for people not to demand coverage that
maintains their condition or slows deterioration right now, given that Medicare
was supposed to be paying for it all along.
source:MSFyi Newsletter
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