National Public Radio | January 30, 2017

Date: 
January 30, 2017

Legal Dispute Continues Over Medicare Coverage of Physical Therapy

Four years after Medicare officials agreed in a landmark court settlement that seniors can't be denied coverage for physical therapy and other skilled care simply because their condition isn't improving, patients are still being turned away.

As a result, federal officials and Medicare advocates have renewed their federal court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.

Several organizations report that the government's initial education campaign following the settlement has failed. Many seniors have only been able to get coverage once their condition worsened. But once it improved, treatment would stop — until the people got worse and were eligible again for coverage.

Every year thousands of Medicare patients receive physical therapy and other treatment to recover from a fall or medical procedure, as well as to help cope with disabilities or chronic conditions including multiple sclerosis, Alzheimer's or Parkinson's diseases, stroke and spinal cord or brain injuries. Although the settlement removes the necessity to show an improving health condition, it doesn't affect other criteria and limitations on Medicare coverage. [...]

The agreement, approved in 2013, settled a class-action lawsuit against the Centers for Medicare & Medicaid Services filed by Center for Medicare Advocacy and Vermont Legal Aid on behalf of five Medicare beneficiaries, including Glenda Jimmo, and six nationwide patient organizations. Coverage doesn't depend on the "potential for improvement from the therapy but rather on the beneficiary's need for skilled care," the Jimmo settlement said. [...]

Medicare's proposals include such educational efforts and a special webpage with "frequently asked questions" spelling out the proper procedures for handling claims. The government would also issue a clear statement confirming that Medicare covers physical, speech and occupational therapy along with skilled care at home, and in other settings, even if the patient has "reached a plateau" — a term seniors still hear — and isn't improving.

Attorneys for the seniors want to monitor how Medicare officials implement these new measures and have offered to write the policy statement disavowing what's known as the "improvement standard." They also want the government to repeat its 2013 conference call with providers, contractors and others involved in the process in order to correct mistakes, according to papers filed with the court Jan. 13. [...]