I’m starting to sound like a broken record (vinyl is coming back; the kids know what I mean), but I recently heard a therapist say the patient’s progress plateaued, so we have to stop therapy. Again.
I’m tired of it. You’re tired of it. We keep doing it.
“We have to stop therapy because she’s reached a plateau, and insurance won’t let us keep going.”
“His progress has plateaued, so it’s unethical for therapy to continue.”
The worst: “I don’t want to risk my license by continuing therapy for her when she’s not making progress. She has plateaued.”
The last one was a response from one of my staff when our Medicare client wanted to continue skilled therapy at a maintenance level. Years of misinformation and widespread therapy mythology led her to believe that her professional license dictated that her clients make progress.
Half of my professional life has been explaining and educating my staff and the wider skilled nursing community that progress is not required for therapy to continue. In the actual Medicare Manual, it is stated that Medical Appropriateness does not turn on whether the patient will significantly improve. I have underlined some key phrases:
“Coverage of nursing care and/or therapy to perform a maintenance program does not turn on the presence or absence of an individual’s potential for improvement from the nursing care and/or therapy, but rather on the beneficiary’s need for skilled care.”
One would think that this issue would have been resolved in 2013 with the Jimmo v. Sebelius decision:
“…the plaintiffs alleged that Medicare contractors were inappropriately applying an ‘Improvement Standard’ in making claims determinations for Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits).”
The settlement noted that “…nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage. The settlement agreement is intended to clarify that when skilled services are required in order to provide care that is reasonable and necessary to prevent or slow further deterioration, coverage cannot be denied based on the absence of potential for improvement or restoration. As such, any actions undertaken in connection with this settlement do not represent an expansion of coverage, but rather, serve to clarify existing policy so that Medicare claims will be adjudicated consistently and appropriately.”
Essentially, this clarifies that Jimmo v. Sebelius didn’t change the requirement for skilled care. Medicare has ALWAYS allowed for maintenance programming for therapy, and our stubborn insistence on perpetuating the misinformation does us and our clients a disservice.
Disclaimer: If the client is a Medicare Advantage beneficiary, all laws, setlements and common sense are void. MA makes its own rules, with the interests of the client ignored. Let’s talk about that another time.
Your Medicare client is entitled to every service they can get. They’ve spent their lives paying into the government system, and they pay the premiums that accord them the right to the best we can offer. We offer the best services, and a slowing of progress doesn’t mean we should stop.
As long as they still need skilled services and we document those services accordingly, the false and misleading concepts of “progress” and “plateaued” shouldn’t be part of our discussion. Skilled services are skilled, no matter how the patient is responding. Let’s give them our best, and work together to end the myths that hurt them.
Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD, is the regional director of therapy operations at Diversified Health Partners in Ohio.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
Have a column idea? See our submission guidelines here.
