Earlier this week, Feb 13th, a letter was written by Jerry Mulcahy to Medicare Advantage Organizations. Jerry Mulcahy is the Director Medicare Enrollment and Appeals Group. He had penned this letter from the Centers for Medicare and Medicaid Services.
What was the purpose of the letter?
This letter was a reminder of the Jimmo settlement coverage and training policies from January 2013. The settlement established what should be covered under Medicare guidelines for skilled therapy services in hospitals, home health, and skilled nursing. It also pointed out the establishment of therapy to maintain a certain level of care when the skills of a therapist are required to safely and effectively carry out the treatment properly.
So what does this mean in the real world?
Sadly this is a direct example of what us as therapists have been fighting for years. There has been a slow and steady decline in coverage for Medicare Advantage beneficiaries by these managed care organizations. It seems like each year there has become more and more unnecessary and insignificant “rules” added by these managed care plans that slowly chips away at the covered services us therapists can not only provide, but be a huge impact on the wellbeing of those patients.
So what can we do?
“The squeaky wheel gets the grease.” I know most have heard that saying before. Unfortunately the only way to make change is to constantly fight for these covered services. Every attempt at denied coverage by a Medicare Advantage Organization must be appealled as far as possible. The only way to make it change is to make it more expensive for them to have to deal with each appeal level than it would be to just cover the service.
We also have another part to do
We as therapists and Therapy companies must stay on top of any change in the “rules” and be proactive at reasonably following their guidelines so that we have the ammunition to fight any attempt the say our service was not “medically necessary “. If we don’t do our part then we just don’t have the evidence to fight for what is right.
Why does this matter?
Ultimately the biggest effect of the degradation of coverage of therapy services if felt by our elderly who sign up for these managed care plans. Insurance is very complicated and difficult for most people to find the right coverage for themselves. When these companies don’t cover services that would significantly improve the quality of life of these elderly beneficiaries, their quality of life is directly impacted.
Advocate for your loved ones
We also need to be a loud voice for our Senators and Representatives to establish guidelines for the management of Medicare Advantage Organizations to follow the actual guidelines established by Medicare. They need to hold them accountable to follow the established rules in order to service this population. We all can make a difference.
