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Blankmeyer 1 Jacob Blankmeyer Kade Parry ENG 1010 October 11, 2013 Medicare: Coverage and Cut Outs

In 1965, Medicare became the federal insurance policy, but what has become of it today? With the lifespan of Americans increasing and research improving medical technologies, more treatments are viewed as needed or highly recommended. Therapy has become one of the most important treatments today, especially for the elderly. However, due to past fraudulent claims and the American government falling deeper into debt, Medicare has quickly been cut back and restricted. Most would agree that Medicare does want to see the elderly in America strive all through their lives, but that cannot be done due to the lack of trust and lack of funding available. To avoid the high costs, Medicare has put caps on the amount able to pay as well as challenges for the therapist to claim what is needed for payment. The therapists try their best to complete the treatments at little cost and time for the patient and themselves. Ethically, it's hard for them to stop a treatment that is needed due to just the money aspect involved in the therapy. Today, the government has limited their maintenance programs as well as only paying certain amounts for any therapy needed for their patients. This has caused issues in many of the therapy settings; Outpatient, Inpatient, and Skilled Nursing, when it comes to trying to maintain and heal the patients. What does Medicare and Physical Therapists believe needs to be done today, regarding patients and their careers? When it comes to treatment, Medicare does allow money to flow the Therapists way. They grant all of their patients a budget to spend in Physical and Speech Therapy, and separately

Blankmeyer 2 Occupational Therapy. A $1,900 cap is placed on both of the therapies. To continue the treatments if needed, they have also created what is called the K2 modifier to be filled out by the Therapists, in order to continue the treatments as they see needed. The modifier is a very challenging file to complete, making the therapist only do this when it is absolutely necessary. Medicare has made it so challenging to complete, due to past fraudulent charges. One example of this would be Dr. Christopher Wayne, AKA, "The Rock Doc." He was a man in south Florida, who was not a licensed Therapist, but was using machines that anyone could buy and claiming to give the patients treatments. He was breaking the code of ethics with his marketing techniques, using attractive females dressed in beach ware. He was lying to the government, claiming to be giving the patients manual therapy that the was "trained" to do. Upon Medicare finding this out, they immediately pursued him in court. At the settlement, the man was forced to pay back the 3.2 million he charged insurances. After this trial, insurances started their network systems, where all of the therapy facilities must prove that they are true therapist and are giving accurate treatments. That again has caused difficulties to the therapy world. After insurances created their networks, it then left small private practices out of big insurance networks, restricting the therapist again. In the outpatient setting, therapist are seeing many Medicare patients on a daily basis, to give either maintenance therapy or post-operational. The Medicare cap has put a struggle onto the small business's when they are trying to treat them for both or if the patient has already seen therapy that year. Medicare has put different restrictions onto the patients doctors or surgical visits. If the two clash, it can often cause large problems for the two sides. Another large issue is trying to get into network with Medicare. When speaking To Dr. Chris Harper, DPT OCS, on the subject, he told his struggles of trying to join the Medicare network. Harper stated, "For the first six months of opening my practice, I continued to see my Medicare Patients. They rejected all of

Blankmeyer 3 my claims and I now just gave months of work away for free." Problems like this are common in the therapy world. Dr. Harper addressed the governments side, as well, by saying, "The Medicare has been and is a good program. Sadly, they have been used wrongly and that makes the government put restrictions out there for their own safety." Even though the government will allow therapy, the outpatient therapists want to see everyone walk out of the clinics happy. Regarding inpatient therapy, the therapists need to be able to feel comfortable with their patients being healthy to get them home. The treatment centers main patient intake consists of Medicare patients, due to the elderly being so dependant of others in this world. But, with the intensive care needed, they must keep in mind that after the treatments, they may need to go to outpatient therapy. That may not be their career responsibilities, but it is, by code of ethics, a thought to keep in mind. It is quite common that some patients won't reach the full independence needed to get home. With Medicare cutting of the funding after $1900, it puts the families in the place to cover the costs, but its common the families cannot cover the expensive costs either. When speaking with Robyn Smith COTA, an employee at Shadow Creek Medical Facility, she explained how towards the end of the therapies its common that the treatments turn into teaching the patients how to carry on the care with their own home exercise programs. That takes away from the modalities that could be used until the final stages of the treatments. The outpatient therapists often deal with the KM modifiers to try to keep the patient under care, but to keep them under their care it must be proven as needed and not just recommended. The outpatient therapists need to be granted more funding to keep their patients, before they can be transferred to outpatients care. Now, the other side of inpatient care is a skilled nursing facility. There, a patient is not fit to go home and take care of themselves. These treatments are ran under a Medicare A account

Blankmeyer 4 that associates the long term inpatient care. Along with skilled nursing facilities, it also is the accounts that cover the hospital stays and care there. These benefits have been covered a lot better; giving the patients a shared room, transportation, and other living necessities. With Medicare trying to keep the patients more comfortable at the SNF's, it justifies that the therapies are capped in other places to help fund all of the needed items for the long term care. SNF patients are treated more like the inpatient facilities, yet, they aren't trying to move the patients on. With the goal of maintenance in the picture, it gives more jobs to the nurses and physical therapist aides, just make sure to get the patients exercising and moving along with their daily needs. It cuts back on the high cost modalities used in the other facilities to make the job cheaper for the patients. Ethically, it does still hinder the Physical Therapist to not be trying to improve the quality of life for the patients. Overall, Medicare has been stolen from, by paying out false claims. The united states government has cut back their medical spending due to the high costs of treatment today. The therapist become hindered by the small amount allowed to cover costs of treatment given to the patient. Though every patient could use the heat, cold, massage, or other relaxing treatments, its unfair for a therapist to give it away for free, when other insurances have to pay, just to help improve the quality of life given to the patients. Therapists need more money to continue the treatments of patients and help them reach a higher quality of life. This is not easily done when Medicare forces the therapist to jump though so many hoops in attempt to keep the patient under treatment or even to fully claim the treatments have been done. I truly believe that, as a tax payer, I would like to see the treatment of the elderly improve along with the therapist getting paid in at a higher level, to help boost the career field and truly show its importance. With the government spending so much money, it's understandable that

Blankmeyer 5 they try to save the most amount possible. Still, that does not mean they are allowed to neglect the citizens who have paid taxes all their lives and have paid for others to get medical coverage. Studies have shown that exercise improves the quality of life and reduces pain by the way the body keeps itself healthy from the outside effects. Instead of promoting therapy that could keep them away from expensive medicine, Medicare takes away the therapy, but pays the high costs of medical doctors, who only cover the pains, instead of fixing it.

Blankmeyer 6 Works Sited: Center For Medicare Services, Revised June 27, 2013, http://www.cms.gov/Medicare/Billing/TherapyServices/index.html?redirect=/TherapyServices/ Medicare.Gov, Revised April 2013, http://www.medicare.gov/Pubs/pdf/10988.pdf Center For Medicare/Medicaid Servises, Revised April 2013 http://www.cms.gov/Medicare/Billing/TherapyServices/Downloads/ABN-NoncoverageFAQ.pdf American Physical Therapy Association, 11/20/2013 http://www.apta.org/federalissues/therapycap/ The Wall Street Journal, 12/22/2011 http://online.wsj.com/news/articles/SB10001424052748704457604576011382824069032 Dr. Harper, Christopher, DPT. Personal Interview. 11 Nov. 2013. Smith, Robyn, COTA. Personal Interview. 17 Nov. 2013.