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One Challenge after Another for Therapy Providers

Published on 

Tuesday, October 1, 2013

 | AL Medicaid 
 | Outpatient Services 

For continuing to provide quality patient care while dealing with Medicare’s ever-increasing requirements, MMP applauds the providers of all types of rehabilitative therapy services, with a special recognition of physical therapy providers during October, Physical Therapy Month. We hope our articles on therapy issues help therapists to understand and better implement Medicare’s rules. With that in mind, I would like to address the requirements for the use of the Advance Beneficiary Notice (ABN) for outpatient therapy services.

Prior to January 2013, therapy services provided to a patient that exceeded the therapy cap and were not medically necessary were denied as a benefit category denial. That meant the patient was liable for payment and although encouraged, a notification of liability did not have be given to the patient. The American Tax Relief Act changed denials above the therapy cap amount to be provider liable unless the patient is issued an ABN. Since therapy services below the cap have always required an ABN for patient liability, this change provides more consistency. Now, all therapy services that are not medically necessary, above or below the therapy cap amount, require that an ABN be issued to the patient so that the patient can choose whether to obtain the services and accept financial responsibility for them.

So practically, when would a therapist provide medically unnecessary services? The scenario that requires an ABN be given that I have seen most often is when patients have been receiving therapy services for a condition for a while. The patient’s progress plateaus or reaches its maximum potential for that patient in the therapist’s opinion. Sometimes such patients do not want to discontinue therapy services but the therapy is no longer “medically necessary” according to Medicare requirements. This is an appropriate time to issue an ABN to the patient. The challenge here is explaining the situation to the patient so that he or she understands the Medicare regulations and their impending liability. Just another one of the challenges therapists face beyond their clinical duties!

See the last two pages of MLN Matters Article MM8404 for more information on outpatient therapy services use of an ABN.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.