Medicare and In-Home Therapy: What Individuals Must Know


8 - CopyOne question many individuals have when it comes to in-home therapy involves which services are covered and under what conditions. Many seniors wish to remain in their home as long as possible, and service such as these allow them to do so. The key is to obtain the needed care without putting the patient in debt. What do you need to know concerning in-home therapy and Medicare?

First and foremost, as with all in-home services, the patient must be seeing a doctor, he or she must determine the services are needed for the health and well being of the patient and the plan of care established by the doctor must be reviewed regularly. This doctor must certify the in-home therapy services, and a Medicare-certified home health agency has to be used. Only those who are homebound and have a doctor declare this is the case may obtain the therapy at home. These conditions apply to all in-home services to be paid for by Medicare.

In order to qualify for payment by Medicare, continued occupational, physical and speech-language pathology therapies must also meet additional specifications. First and foremost, the therapy needs to be safe, specific and effective for the condition to be treated. Patients cannot choose to use experimental treatments under these guidelines, as they don’t meet these conditions.

Furthermore, the frequency, amount and duration of the services must be reasonable, and the services are those which are either complex or those which only qualified therapists can handle safely and effectively. Where this becomes a problem for many is Medicare states the services need to be provided with the expectation that the patient will improve significantly with time. In the event Medicare determines the patient isn’t improving in a timely manner or that he or she won’t benefit from the therapy, payment may be denied. Patients, caregivers and family members need to understand this and work with the primary care doctor to ensure the services are covered. The therapist also works with patients and their caregivers to ensure the necessary care is received.

Finally, Medicare places limits on the amount of care a patient may receive in a given year. For 2016, this agency covers speech and physical therapy up to $1,960 for both services combined, and an additional $1,960 for occupational therapy. In the event more services are needed, the doctor or therapist needs to inform Medicare of the added services and their necessity. In certain situations, Medicare will approve the additional care. Furthermore, for those claims that are denied, the appeal process may be used. It’s always best to get approval before services are provided, however, so there are no surprises or high medical bills that become the patient’s responsibility.

Keep the above in mind when requesting services. Patients, caregivers and family members need to understand what Medicare does and does not pay for and the limits on this care. With this information, developing a care plan that truly works for the patient becomes easier. You remain in control of your care or that of a loved one, so make sure you act as an advocate to ensure they receive the treatment they need. For many, the treatment will be in-home therapy services of this type.

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May 16, 2018 |

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