Cooper & Bush Physical Therapy will be happy to file a claim with Medicare Part B (Trailblazer Health) and the patient's secondary health insurance carrier.

Medicare Part B does not pay for outpatient physical therapy services at an independent clinic if the patient has a home health agency coming to their home. This includes home health services for nursing, labs, and rehabilitation care.

It is the patient's responsibility to make sure all home health services have been discharged.  Cooper & Bush Physical Therapy staff will ask the patient to provide a copy of the home health agency discharge paperwork to the facility. 

Medicare coverage is provided for services determined to be “medically reasonable and necessary,” as outlined by Section 1862(a)(1) of the Medicare Law.  These services must be furnished under a plan of care established by a licensed physical therapist or licensed occupational therapist and reviewed by the attending physician every 30 days.
 

Reimbursement for outpatient therapy services performed by an independently practicing therapist is based on the reasonable charge allowance minus the coinsurance and any deductible due from the patient.
 

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, which extends the exceptions process for outpatient therapy caps (see Section 3101).  The legislation leaves one therapy cap for physical therapy and speech language pathology combined, and a separate cap for occupational therapy.  Services provided by a hospital outpatient department will continue to be exempt from the therapy caps. 

The therapy cap limit includes both the amount Medicare pays and the beneficiary copay.

 
COOPER & BUSH PHYSCIAL THERAPY is a participating provider with the Medicare program.  With the help of COOPER & BUSH PHYSICAL THERAPY staff, the patient will be kept updated on the charges incurred throughout the course of physical therapy treatment.  Patients will be informed as they approach the cap limit established by Medicare.

 
Medicare has outlined exceptions to the therapy cap in CMS Publication 100-04 Transmittal.  Medicare will not pay for further physical therapy or occupational therapy services performed beyond the cap limit at an outpatient clinic unless the patient qualifies for a cap exception.
 

Each Medicare patient will be asked to sign an Advance Beneficiary Notice as they approach the therapy cap limit. The Advanced Beneficiary Notice will help you make an informed decision about your care once the therapy limit has been met.

After a review of the medical records, Medicare will make a determination as to the medical necessity for continued care.  
 

Medicare will also review services performed and that if Medicare determines that a particular service is ‘not reasonable and necessary ‘under Medicare program standards. Medicare will deny payment for that service. 
 
Medicare will make an official decision on payment, and will send a Medicare Summary Notice to the patient. 

The patient will be billed for services if Medicare denies services based on reasonable and necessary guidelines.