I discussed the Medicare payment system, including their definition of medically necessary care. I urged people in this essay to not base health care decisions solely on whether private insurance or Medicare will pay. The full blog post can be read here:
So, now, three years later, the issue has surfaced again in a very real way. Unbeknownst to many Medicare beneficiaries, and just recently announced to providers, CMS/Medicare has instituted a new ruling which includes an annual cap of $3700 ( combined PT, OT and Speech Therapy ) per beneficiary, per calendar year. Beginning October 1, 2012, for my speech therapy practice for example, I will need to contact Medicare prior to commencing treatment with any patient. If a patient has already used their $3700 for prior treatment ( any therapy ), I must request additional treatment visits, and continue to request payment for visits from visit 13 onward.
If treatment is begun, without checking what funds are available, and care denied, Medicare will notify the patient of this denial, and the patient will become responsible for paying any charges accrued. Of course, secondary insurances typically follow suit, so, if Medicare has denied a claim, likely so will the other providers.
Patients are often requested to sign an Advanced Beneficiary Notice prior to treatment, which will now include a statement that if Medicare denies payment, the patient will be responsible for all charges. I am guessing, based on my 23 years of providing services primarily to Medicare aged patients, that not many will be eager to sign.
I can't help wonder about people like my own mother, who suffered a stroke this year following a lengthy illness. It was only after several weeks of inpatient treatment ( treatment which I am sure was well over $3700), that she was even eligible for out-patient speech-language therapy, which remained her greatest need. Fortunately for her, I was the one to provide that therapy, four months of daily treatment that no likely contributed to her remarkable improvement, but a frequency that could never have been afforded were she to have to pay out of pocket.
I have worked in health care for over 30 years now, in a variety of settings, and I have witnessed inappropriate use of resources on the part of providers and patients. So, I would be the first to acknowledge that reform of the payment and delivery system must occur. But changes like those described above will likely result in a minor reduction in overall healthcare spendings, and will result in many people being deprived of services that might result in improved overall health and safety. Another scenario will be higher inpatient charges when patients are admitted post falls or with aspiration pneumonia because of un-treated physical and swallowing problems.
So, what are you willing to pay for? Think about services you may have received in the past, whether PT, OT or Speech/Swallowing Therapy. Did you get your money's worth? Would you pay for it again if YOU had to?
Come writers and critics
Who prophesize with your pen
And keep your eyes wide
The chance won't come again
And don't speak too soon
For the wheel's still in spin
And there's no tellin' who
That it's namin'
For the loser now
Will be later to win
For the times they are a-changin'.
lyrics by Bob Dylan