Preventing Falls adds to length and quality of life.

“Help! I’ve fallen, and I can’t get up!”

It’s not funny when it happens to you or a loved one.

Especially among the elderly, falls are no laughing matter. Each year, one in three Americans 65 and older falls, and about 30 percent of those falls require medical treatment.
 
The Centers for Disease Control reports that more than $19 billion annually is spent on treating the elderly for the adverse effects of falls: $12 billion for hospitalization, $4 billion for emergency department visits, and $3 billion for outpatient care. Most of these expenses are paid for by the Centers for Medicare and Medicaid Services through Medicare. It is projected that direct treatment costs from elder falls will escalate to $43.8 billion annually by 2020.

That’s why The Falls Free™ Coalition, a group of national organizations and state coalitions working to reduce the growing number of falls and fall-related injuries among older adults, became the driving force to push the adoption of the federal Safety of Seniors Act in 2008.

The American Physical Therapy Association (APTA) was among the coalition of health and consumer groups that undertook to educate members of Congress and their staffs about the importance of falls prevention.  In an appearance in Washington, D.C., shortly after the enactment of the Safety of Seniors Act, APTA member and Falls Free Coalition representative Bonita Lynn Beattie, PT, MPT, MHA, told legislators that "falls and falls-related injuries are not normal consequences of growing old. There are evidence-based interventions that can help reduce older adults' risk of falling and can affect the rate of falls and falls-related injuries and death."

Beattie, who also represents the National Council on Aging (NCOA), urged Congress to fund efforts to increase the falls risk assessment and intervention skills of health care providers and promote collaboration with the aging services network.


“Physical therapists are taking an active role in educating consumers about how to safely prevent falls as well as treat those who have fallen and suffered injuries as a result, added then-APTA President R Scott Ward, PT, PhD. “This education will ultimately improve the health and quality of life of our nation's seniors."


The Safety of Seniors Act authorizes the secretary of Health and Human Services to oversee a national education campaign focusing on reducing falls among older adults and preventing repeat falls.  It awards grants, contracts, or cooperative agreements to design and carry out local education campaigns.


Meanwhile, a British study indicates that prevention exercises can help the elderly avoid falls, and may also reduce injuries when a fall occurs.


In a 2013 study published in the British Medical Journal, researchers reviewed results of 17 trials involving aged patients who received falls prevention exercises with those who did not, and included data on subsequent falls and the extent of injury sustained. Authors of the analysis then grouped the injuries according to standardized classifications and reviewed seriousness of injuries across the studies.


The research revealed that in addition to lessening the rate of falls, prevention exercises also reduced the severity of injury when falls do occur, with estimated reductions of 37% for all injurious falls, 43% for severe injurious falls, and 61% for falls that produced fractures.


Authors of the study wrote that "it is…thought that exercise prevents injurious falls not only by improving balance and decreasing the risk of falling, but also by improving cognitive functioning, and the speed and effectiveness of protective reflexes (such as quickly extending an arm or grabbing nearby objects) or the energy absorbing capacity of soft tissues (such as muscles), thereby diminishing the force of impact on the body."


The Centers for Disease Control and Prevention's (CDC) new STEADI Tool Kit gives health care providers information and tools to assess and address their older patients' falls risk. The STEADI (Stopping Elderly Accidents, Deaths and Injuries) Tool Kit is based on a simple algorithm adapted from the American and British Geriatric Societies' Clinical Practice Guideline. It includes basic information about falls, case studies, conversation starters, and standardized gait and balance assessment tests (with instructional videos). In addition, there are educational handouts about falls prevention specifically designed for patients and their friends and family.


APTA members who are experts in falls prevention assisted CDC with the development of the toolkit, specifically with the evidence-based community falls prevention programs. A link to the toolkit also is available on APTA's Balance and Falls webpage under "Related Resources."
The American Physical Therapy Association (www.apta.org) is a national organization representing physical therapists, physical therapist assistants, and students nationwide. Its goal is to foster advancements in physical therapist education, practice, and research. Consumers can visit www.findapt.us to find a physical therapist in their area, as well as www.apta.org/consumer for physical therapy news and information.

Resources:
The American Physical Therapy Association

Centers for Disease Control and Prevention

 

Wellness during the “Golden Years”

Statistics tell us that one-third of our life is still ahead if we retire at around age 60.  “The Golden Years,” all the ads gush.             

But the glitter can come off quickly when retirement is also accompanied by other factors of aging: the loss of a companion, diagnosis of a serious disease, a weakening body.

If ever there is a time when we must take active control over our own destiny, this is it. By remaining active and healthy – by continuing or beginning to participate in recreation, in community life, in volunteerism, in a new career direction – we can recognize and enjoy the blessings of advanced years.

Plans and goals play a large part in remaining healthy, both physically and mentally. Rejecting a lifestyle of sedentary sameness for one of anticipation and “busy-ness” affects the appetite, sleep patterns, and health in general. Slackened muscles gain tone; mealtimes get put on a regular basis; medications and physician appointments are attended to promptly.

This doesn’t mean one has to go into training for the Boston Marathon. But studies show that gentle exercise has an amazing effect not only on physical fitness but on our mental alertness and our emotional health. It’s why most assisted-living facilities and skilled nursing centers provide some form of physical activity.

Sometimes, in the case of injury or illness, regular physical exercise is uncomfortable or painful.  That’s when the skills of a physical therapist are at their finest: the therapeutic manipulation of limbs, spine and muscles prevents atrophy and “keeps you on your toes” to resume an active lifestyle.

A physical therapist will assess a client’s joint pain, answer questions about exercise and activity, and if needed, recommend further medical or surgical consultation.

Take on the problems one by one and they won’t seem so enormous. Resolve to remain a person of value to yourself and others ... spiritually, physically and intellectually. In the process of helping others, you’ll help yourself to a healthier, stronger life.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky must disclaim any liability for the decisions you make based on this information.

Resources:

University of Southern California

On-line video,

“Wellness in the Elderly: Optimizing Function and Health in Senior Years”

by John P. Kugler, MD, MPH

http://www.slideserve.com/dingbang/wellness-in-the-elderly-optimizing-function-and-health-in-the-senior-years

Reading:

Health in the Later Years, by Armeda and Rebecca Ferrini, helps individuals make better-informed health choices to increase the quality of their later life.

 

Hate shots? This one’s to love!

Yes, it does seem like summer’s just arrived!  But it’s already time to be thinking about that dreaded bugaboo of winter: the flu.

Although influenza affects persons of all ages, the Centers for Disease Control and Prevention has identified residents of nursing homes and other long-term care facilities as being among those who are at increased risk for complications. During influenza epidemics, in fact, mortality rates among nursing home residents often exceed 5 percent.

Patients with influenza typically present with systemic signs of infection, including fever, myalgia, headache, sore throat, and cough. Outbreaks occur nearly every year during the winter months and significantly increase morbidity and mortality from all causes, especially cardiovascular and pulmonary diseases, and certain metabolic conditions.

Seniors should be vaccinated for the flu before December, according to recommendations from the CDC. The influenza season peaks between December and February. For adults over the age of 65, the flu vaccine's effectiveness can decline “significantly” in the months following vaccination, the CDC noted. While delaying vaccination may help older adults have greater immunity later in the flu season, the CDC encourages seniors to get vaccinated before the virus begins to circulate.  

This push for earlier vaccinations in seniors comes after a particularly nasty flu season, which saw higher-than-usual flu cases in nursing homes and other healthcare facilities. During the first full week of 2015, adults over 65 were hospitalized for the flu at a rate of 91.6 per 100,000, up almost 20 points from the same period in 2013, the CDC said.

Persons older than 65 years accounted for more than 90 percent of the deaths attributed to influenza in a recent study.  In addition to heightened susceptibility because of age, skilled-care and nursing home residents also have a higher risk of exposure. Nursing home staff, personal visitors, volunteers, and other visitors from the community provide numerous sources of exposure to the influenza virus.

As a result of these risks, influenza attack rates typically range from 20 to 30 percent among residents of nursing homes, and even higher rates have been documented. In addition, mortality rates during such influenza outbreaks often exceed 5 percent.

The influenza vaccine is recommended as the primary way of preventing the illness and its complications. Brian J. Kingston, M.D., and Charles V. Wright, Jr., M.D., M.M.M., of the Texas Tech University Health Sciences Center at Amarillo, writing for American Family Physician, have reported the results of studies that show that vaccination of nursing home residents and staff can significantly decrease rates of hospitalization, pneumonia, and related mortality. When an influenza outbreak occurs in a nursing home, several measures can be implemented by the treating physician.

Once an outbreak has been established, the doctors report, control measures, including vaccination of unvaccinated residents and employees, and limitations on resident movement and visits, can be implemented.

Administration of the influenza vaccine is the primary method of preventing the disease and its severe complications, the doctors said. A report from the Advisory Committee on Immunization Practices noted that the primary target group for the influenza vaccine is persons 50 years of age and older, and “a specific subgroup consists of residents of nursing homes and other long-term care facilities that house persons of any age who have chronic medical conditions.”

The vaccine has been shown repeatedly to decrease the serious complications of influenza in the nursing home setting. Although it is only 30 to 40 percent effective in preventing upper respiratory illness, the efficacy of the vaccine improves with the more serious effects of influenza infection. One recent analysis has shown vaccine efficacy of 50 percent in preventing hospitalization, 53 percent in preventing pneumonia, and 68 percent in preventing death.

A number of studies have also shown that nursing homes with high rates of vaccinated residents have fewer outbreaks of influenza than nursing homes with lower vaccination rates.

Staff members, too, would be well advised to get the flu vaccination.  The higher the proportion of staff receiving the influenza vaccine, the lower the incidence of influenza among staff and residents during an outbreak, the doctors have found.  In addition, vaccination of both residents and staff can lead to herd immunity. To achieve this goal, the vaccination rate among residents and staff should exceed 80 percent.

With the concurrence of the attending physician, all consenting nursing home residents should receive the vaccine at the same time before the influenza season begins, the CDC says. Nursing home staff should also receive the influenza vaccine at this time, and new nursing home staff and new nursing home residents admitted between October and March should also be offered the vaccine.

It’s the best antidote to date to a very dangerous condition!

 

Sources:

McKnights Long-Term Care News

American Family Physician

 

 

Preventing Falls adds to length and quality of life.

“Help! I’ve fallen, and I can’t get up!”

It’s not funny when it happens to you or a loved one.

Especially among the elderly, falls are no laughing matter. Each year, one in three Americans 65 and older falls, and about 30 percent of those falls require medical treatment.

The Centers for Disease Control reports that more than $19 billion annually is spent on treating the elderly for the adverse effects of falls: $12 billion for hospitalization, $4 billion for emergency department visits, and $3 billion for outpatient care. Most of these expenses are paid for by the Centers for Medicare and Medicaid Services through Medicare. It is projected that direct treatment costs from elder falls will escalate to $43.8 billion annually by 2020.

That’s why The Falls Free™ Coalition, a group of national organizations and state coalitions working to reduce the growing number of falls and fall-related injuries among older adults, became the driving force to push the adoption of the federal Safety of Seniors Act in 2008.

The American Physical Therapy Association (APTA) was among the coalition of health and consumer groups that undertook to educate members of Congress and their staffs about the importance of falls prevention.  In an appearance in Washington, D.C., shortly after the enactment of the Safety of Seniors Act, APTA member and Falls Free Coalition representative Bonita Lynn Beattie, PT, MPT, MHA, told legislators that "falls and falls-related injuries are not normal consequences of growing old. There are evidence-based interventions that can help reduce older adults' risk of falling and can affect the rate of falls and falls-related injuries and death."

Beattie, who also represents the National Council on Aging (NCOA), urged Congress to fund efforts to increase the falls risk assessment and intervention skills of health care providers and promote collaboration with the aging services network.

“Physical therapists are taking an active role in educating consumers about how to safely prevent falls as well as treat those who have fallen and suffered injuries as a result, added then-APTA President R Scott Ward, PT, PhD. “This education will ultimately improve the health and quality of life of our nation's seniors."

The Safety of Seniors Act authorizes the secretary of Health and Human Services to oversee a national education campaign focusing on reducing falls among older adults and preventing repeat falls.  It awards grants, contracts, or cooperative agreements to design and carry out local education campaigns.

Meanwhile, a British study indicates that prevention exercises can help the elderly avoid falls, and may also reduce injuries when a fall occurs.

In a 2013 study published in the British Medical Journal, researchers reviewed results of 17 trials involving aged patients who received falls prevention exercises with those who did not, and included data on subsequent falls and the extent of injury sustained. Authors of the analysis then grouped the injuries according to standardized classifications and reviewed seriousness of injuries across the studies.

The research revealed that in addition to lessening the rate of falls, prevention exercises also reduced the severity of injury when falls do occur, with estimated reductions of 37% for all injurious falls, 43% for severe injurious falls, and 61% for falls that produced fractures.

 Authors of the study wrote that "it is…thought that exercise prevents injurious falls not only by improving balance and decreasing the risk of falling, but also by improving cognitive functioning, and the speed and effectiveness of protective reflexes (such as quickly extending an arm or grabbing nearby objects) or the energy absorbing capacity of soft tissues (such as muscles), thereby diminishing the force of impact on the body."

The Centers for Disease Control and Prevention's (CDC) new STEADI Tool Kit gives health care providers information and tools to assess and address their older patients' falls risk. The STEADI (Stopping Elderly Accidents, Deaths and Injuries) Tool Kit is based on a simple algorithm adapted from the American and British Geriatric Societies' Clinical Practice Guideline. It includes basic information about falls, case studies, conversation starters, and standardized gait and balance assessment tests (with instructional videos). In addition, there are educational handouts about falls prevention specifically designed for patients and their friends and family.

APTA members who are experts in falls prevention assisted CDC with the development of the toolkit, specifically with the evidence-based community falls prevention programs. A link to the toolkit also is available on APTA's Balance and Falls webpage under "Related Resources."

The American Physical Therapy Association (www.apta.org) is a national organization representing physical therapists, physical therapist assistants, and students nationwide. Its goal is to foster advancements in physical therapist education, practice, and research. Consumers can visit www.findapt.us to find a physical therapist in their area, as well as www.apta.org/consumer for physical therapy news and information.

Resources:

The American Physical Therapy Association

Centers for Disease Control and Prevention

 

 

Medicare says ‘no.’ Now what?

It’s no secret: In order to stay in business, you must be paid for the services you provide.  That’s as true in physical therapy as it is in any other private practice endeavor. 

In most cases, the Centers for Medicare and Medicaid Services (CMS) pays claims. But  suppose for a moment that CMS denies your claim.  What will you do?

Would it surprise you to hear that most therapists don't know what they’d do?  If you’re among them, it’s time to sharpen your information skills.

Appealing Medicare denials is becoming more and more of a likelihood for all outpatient therapy providers , and it can be a daunting task rife with stress. However, most Fiscal Intermediaries (FIs) or Medicare Administrative Contractors (MACs) send specific guidance on information they need to see in a denial. As this information sometimes differs, we’ve included here some general information that may be helpful.

In some cases, denials may be due to incomplete billing, such as a claim lacking the modifier applied to the CPT code. Denials can also result from inadequate supporting documentation that has been submitted in response to an Additional Documentation Request (ADR).

 Audit contractors are instructed to deny services if they meet any of the following
conditions:

  • The item or service does not fall into a Medicare benefit category.
  • The item or service is statutorily excluded.
  • The item or service is not reasonable and necessary.
  • The item or service does not meet other Medicare program requirements for payment.

Auditors must adhere to CMS-issued national coverage determinations (NCDs) and regional local coverage determinations (LCDs). In the absence of NCDs or LCDs, the contractors are responsible for determining whether services are reasonable and necessary, based on the following criteria:

  • It must be safe and effective.
  • It must not be experimental or investigational.
  • It must be furnished in accordance with accepted standards of practice for the diagnosis or treatment of the beneficiary's condition.
  • It must be provided in a setting appropriate to the beneficiary's medical needs and condition, and ordered and performed by qualified personnel.
  • It must meet, but not exceed, the beneficiary's medical need.

It’s not uncommon for denials to result from billing coding errors or claims that include diagnoses that fall outside the LCD. So let‘s say that, for whatever reason, your claim has been denied. Here’s what you should know to prepare an effective appeal:

  1. Medicare has a formal appeals process; your MAC will have interactive PDF forms and instructions to get you started.  Also check the CMS appeals website for complete rules and references.
  2. Recoupment (for post-payment review) will begin on the 41st day from the date of the demand letter if your MAC does not receive, by the 30th day from the date of the demand letter, either payment in full, a request for an extended repayment schedule, or a valid redetermination request.
  3. Organize all the documents and include a cover letter with a case executive summary (think of it as an excellent D/C report), a rebuttal of the denial as well as an index of documents.  Make an effort to put items into evidence as early as you can in the appeals process.
  4. In spite of  a 24-to-30-month delay on ALJ hearings right now, appeal your case if you have deemed it defensible.  CMS collects data on appeals, and when you win, you will get interest on your payment.

Auditors can review billing history obtained from Medicare databases,  any documentation submitted with the claim, or other documentation
subsequently submitted by the provider. Information submitted by the provider must corroborate the documentation in the beneficiary's medical record and confirm that Medicare coverage criteria have been met.

In general, your appeal letter should include:

  • Nursing notes that support the functional level of the patient and the ongoing need for therapy.
  • Physician skilled certifications (for Medicare Part A patients).
  • Documentation from other disciplines that may support cognitive/communicative difficulties experienced by thepatient.
  • Dietary consultations that may support the presence of swallowing disorders.
  • Hospital History and Physical to add medical diagnoses that serve as complexities to the case.

You should compile an expanded, detailed summary of progress from the start of care; it should include both objective data and other supporting information that may not have been contained in the original documentation. Write the appeal as an explanation of why the services were rendered, what could have happened if they weren't rendered, and what functional outcomes the patient achieved because of the services.

It is important to remember that the issuers of denials are not typically therapists. They are trained auditors who determined, for whatever reason, that the services rendered were not reasonable and/or medically necessary.  Your task is to persuade them differently!

Resources:

Physical Therapist

Physical Therapy

Healthpro Rehab

Managed Care in Post-Acute Settings

Many patients require continued medical care, either at home or in a specialized facility, following a hospitalization for injury or illness. “Post-acute care” refers to a range of medical care services, including therapy, that support the patient’s continued recovery from illness or management of a chronic illness or disability.

Skilled-nursing facilities provide skilled nursing, medical management and therapy services on a 24-hour basis to patients who do not require as high-intensity services as provided in the hospital setting.

There are several other settings for post-acute managed care:

Home health care is a regulated program of care provided through certified home health agencies, delivered by health care professionals in the patient’s home for treatment of a medical condition, illness or disability.

Hospice provides comprehensive, interdisciplinary health care to terminally ill patients, as well as bereavement and support services to the patients’ loved ones.

Medical rehabilitation focuses on improving or restoring functional independence for patients with disabilities resulting from injury, illness, or a medical condition. Medical rehabilitation is provided at all levels and locations of health care, including in general acute-care hospitals, inpatient rehabilitation facilities, skilled-nursing facilities, long-term-care hospitals, outpatient programs and home health agencies.

Long-term-care hospitals provide hospital-level care for medically complex, long-stay patients. They meet the same requirements as general acute-care hospitals, but have significantly longer average lengths of stay — 25 days or greater.

All of these facilities face the obstacle of new reimbursement schedules, as presented by the Centers for Medicare and Medicaid. Managed care programs for Medicare patients, called Medicare Advantage programs, are presenting the dual challenge of lower payments and increased paperwork.

Professional observers of the health care system say Medicare Advantage plans are attractive to beneficiaries because they often offer lower co-payments or co-insurance.

As more beneficiaries enroll in Medicare Advantage plans and as more states look to rein in costs through expansion of Medicaid managed care, post-acute providers such as nursing homes face the same kind of managed-care growing pains hospitals experienced in the 1990s.

Providers and patient advocacy groups worry that managed care might have harmful effects on post-acute patients, particularly those with disabilities who need long-term services and support in their homes and communities.


Nevertheless, post-acute-care providers are finding they can no longer survive solely in the fee-for-service world. Instead of primarily billing traditional Medicare and Medicaid, these providers increasingly are negotiating with managed-care plans to increase their revenue stream and stay viable.

As Medicare Advantage grows, providers are having to contract with those plans to get those patients. This has created challenges for providers who know what they get paid under traditional Medicare, but, when dealing with managed-care plans, must negotiate rates and comply with each plan's requirements.


Providers say that traditional Medicare payment rates are better than Medicare Advantage rates. Depending on the market, managed-care rates are 10% to 40% less than traditional Medicare rates. Some providers may accept lower rates with the hope— not always realized — that insurers will drive volume to their facilities.

Meanwhile, states are moving more long-term services and supports — including personal services in the home, assisted living or residential arrangements — into Medicaid managed care.

No doubt about it, post-acute care providers face challenges in navigating the new managed-care world in Medicare and Medicaid. But providers, advocates and policy analysts agree they don't have much choice. It’s the new way of doing business, and advisors agree that “to ignore it is to your own detriment.”
 

Resources:

Alix Partners

California Hospital Organization

Modern Health Care

 

 

Documenting therapy services is essential to the case

As is most service areas, “the job’s not done until the paperwork’s done.”  In the case of therapy service provided in skilled-care facilities, this means the provider therapist must provide sufficient documentation to the Centers for Medicare and Medicaid Services to meet requirements for payment.

Documentation plays a critical role in explaining the need for Medicare therapy services and justification on the use of the exceptions process.  Therapy providers are required to provide documented reports of each patient’s initial evaluation, diagnosis, prognosis, and plan of care; added documentation covers followup visits, reexamination, and subsequent discharge.

Documentation should also include objective measures of the patient's improvement as a means to justify therapy services above the cap. Because documentation is usually reviewed by Medicare contract nurses, rather than therapists, it should not be assumed that the reviewer will understand why the service requires the skill of a therapist. Providers must be careful to ensure that documentation is legible, relevant, and sufficient to justify the services billed.

The Centers for Medicare and Medicaid Services (CMS) states that therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services. Documentation must comply with all legal/regulatory requirements applicable to Medicare claims. CMS outlines its minimal documentation requirement in the Medicare Benefit Policy Manual Publication, 100-02, Chapter 15, Section 220.3. Also available is a guide to educate providers on common documentation errors for outpatient rehabilitation therapy services.

In general, Medicare requires that therapy services are of appropriate type, frequency, intensity, and duration for the individual needs of the patient. Documentation should:

  • Establish the variables that influence the patient's condition, especially those factors that influence the clinician's decision to provide more services than are typical for the individual's condition.
  • Establish through objective measurements that the patient is making progress toward goals. CMS is aware that regression and plateaus can happen during treatment, and recommends that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.

The following types of documentation of therapy services are expected to be submitted in response to any contractor request for documentation, unless otherwise specified. The timelines are minimum requirements for Medicare payment.

Evaluation: The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings. Evaluation shall include a diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated; a Plan of Care consistent with the related evaluation; Progress Reports at least every 10 days to provide justification for the medical necessity of treatment; and discharge documentation that includes all treatment provided since the last progress report and indicates that the therapist reviewed the notes and agrees to the discharge.

All documentation must include adequate identification of the patient/client and the physical therapist or physical therapist assistant. The patient's/client's full name and identification number, if applicable, must be included on all official documents .All entries must be dated and authenticated with the provider's full name and appropriate designation.

Documentation must be authenticated, depending on the level of the therapist (skilled, assistant, student, etc.), by properly certified persons and should include indication of no-shows and cancellations.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

Sources:

Centers for Medicare and Medicaid

American Speech-Language-Hearing Association

American Physical Therapists Association

How does the Affordable Care Act help older Americans?

On March 23, 2010, President Obama signed the Affordable Care Act, which put in place comprehensive health insurance reforms aimed at making health care more affordable, accessible and of a higher quality, for families, seniors, businesses, and taxpayers alike.  Beneficiaries include previously uninsured Americans and Americans who had insurance that didn’t provide adequate coverage and security.

Refinements to the law have followed every year. Here are the highlights:

In 2010,  a new Patient's Bill of Rights went into effect, protecting consumers from the worst abuses of the insurance industry. Cost-free preventive services began for many.

In 2011,  people with Medicare began getting key preventive services for free, and also received a 50% discount on brand-name drugs in the Medicare “donut hole.”

In 2012,  Accountable Care Organizations and other programs helped  doctors and health care providers work together to deliver better care.

In 2013, open enrollment in the Health Insurance Marketplace began.

In 2014, all  Americans were given access to affordable health insurance options. The Marketplace allows individuals and small businesses to compare health plans on a level playing field. Middle and low-income families get tax credits that cover a significant portion of the cost of coverage. And the Medicaid program was expanded to cover more low-income Americans. All together, these reforms mean that millions of people who were previously uninsured now have coverage.

And in 2015,  the program was amended to begin paying  physicians based on value,  not volume.  The new provision ties physician payments to the quality of care they provide; those who provide higher value care will receive higher payments than those who provide lower quality care.  

Older Americans are benefiting also, as the Affordable Care Act provides affordability, access and quality for this age group.  New protections include strengthening Medicare, offering a range of preventive services at no cost, and giving discounts on drugs when in the coverage gap (also called the “donut hole”) in prescription drug coverage. For instance,  if you have Original Medicare, you may qualify for a yearly wellness visit and many preventive services for free.

Learn the details of how the health care law affects all people with Medicare:

Statistics show that Medicare is stronger today, thanks to the Affordable Care Act. In 2014, the Medicare Trustees projected that the Medicare Trust fund financing Medicare’s hospital insurance coverage will remain solvent until 2030, four years beyond what was projected in the 2013 report. Just a few years ago, the Medicare Trust fund was projected to run out of money by 2017.

For more information, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Or click here to go online to the government’s Website for the Affordable Care Act.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.

This information only applies if you have Original Medicare. If you have a Medicare Advantage Plan (like an HMO or PPO), check with your plan for information about your plan’s coverage rules.

 

 

Looking at rehab after surgery? Blue Sky will be there!

What are the chances you’ll need some form of surgery – and some form of therapy afterwards – during your senior years? 

Very good.  Count on it.

You can also assume you’ll be undergoing that therapy in a short-term rehabilitation program,  often inside a skilled nursing facility.  Although friends and family may be willing and able to assist in this goal, optimal recovery can only be achieved through medical professionals.
Short-term rehabilitation facilities provide therapy for patients recovering from a surgery, illness or accident. Generally, programs for those needing short-term, in-patient rehabilitation last for as little as a couple of days to as many as several weeks.

In short-term rehabilitation, we help our patients to achieve their maximum functional capacity and get back to their normal lives in the shortest time possible. To achieve this goal, they receive physical, occupational and speech therapy from therapists who are part of a team with the patient’s physician, nurse, social worker, and, when needed, a nutritionist.  This team prepares the patient’s individualized treatment plan.

When your rehab facility calls on a therapist from Blue Sky Therapy, you can rest assured.  We’re a therapist-owned provider of contract rehabilitation services.  We’re widely known for our innovations in resident-centered care, and we can proudly claim to have set the standard in the rehabilitation industry, providing physical, occupational, and speech therapy to residents throughout eastern Ohio and western Pennsylvania.

Patients in Blue Sky Therapy’s partner facilities can relax and recover while receiving care and rehabilitation services.  Programs can involve more than one therapy session in a day, at a pace designed to enhance abilities without inhibiting healing.


What are the different kinds of therapy?

Physical therapy addresses musculoskeletal and neurological issues including joints, muscles, bones, nerves and spine. Therapists teach the skills needed to achieve maximum functional mobility as well as health, wellness and injury-prevention strategies.

Occupational therapy addresses the skills needed to perform the daily activities of life at home, at work, and in the community. Our therapists teach adaptive skills: how to use assistive devices, how to simplify processes, and how to improve mobility, range of motion and endurance.

Speech therapy focuses on the ability to communicate and interact with others. Therapists concentrate on restoring skills such as listening/hearing, speaking and writing,  as well as overcoming swallowing disorders and breathing/respiratory problems.

In addition, there are specialty programs that address joint replacement, balance and falls prevention, pain control, low vision, cognitive evaluation, and management of lymphedema (swelling in arms or legs), among others.

Depending on the skilled nursing facility, Blue Sky Therapy will provide six to seven days a week of rehabilitation.  Afterward, to ensure a smooth transition to home, the rehabilitation facility will usually assist with setting up homecare services.

Remember, if you have Medicare coverage you will need to qualify for skilled care in order for Medicare to pay for short-term rehabilitation. 

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.

Resources

Fifty-Plus Advocate

Manual Medical Review Process for Therapy Claims extended through 2017

On April 16, 2015, the President signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (see the entire bill by clicking on the link), which temporarily extends the therapy cap exceptions process and modifies the manual medical review process for therapy services through December 31, 2017.


In the meantime, providers should continue to apply the KX modifier on claims above the therapy cap.


The manual medical review process for Medicare Part B therapy services that exceed a $3,700 threshold was mandated in 2012 and requires reauthorization annually. Under the mandate, claims above $3,700 for physical therapy and speech language pathology services combined, and above $3,700 for occupational therapy services, are subject to manual medical review by recovery audit contractors (RACs). The caps are calculated per beneficiary, per year.
Manual medical reviews of outpatient therapy claims above the cap were put on hold last year, but existing RACs received approval on January 16, 2015 to resume sending additional documentation requests (ADRs) to Part B providers.


Review Process
Under a new post-payment review system introduced by the Centers for Medicare and Medicaid Services, RACs are required to review outpatient therapy claims using a tiered approach to ADRs. The new process, which went into effect in January 2015, permits RACs to review 100% of a provider's eligible claims using a 5-step approach to ADRs:
•    A RAC's first ADR may only review one claim, but …
•    The second ADR may review up to 10% of eligible claims,
•    The third ADR may review up to 25% of eligible claims,
•    Tthe fourth ADR may review up to 50% of eligible claims, and  
•    Finally, a RAC's fifth ADR to a particular provider may review 100% of the provider's total eligible claims. The new tiered approach retains the RAC's cycle of 45 days between ADRs.
The process allows for 100% review of provider claims above the $3,700 therapy caps ("eligible claims"), but prevents the RACs from requesting large and potentially unmanageable amounts of records at one time.


CMS believes the new manual review process meets the congressional mandate of a 100% review rate for outpatient therapy claims above the outpatient therapy cap, but will do so in a more equitable manner.


For now, the review process is limited to claims reviewed by existing RACs for claims made from March 1, 2014 through December 31, 2014. CMS has not yet finalized the process for claims made in 2015. The manual medical review process is also limited to claims made by Part B outpatient therapy providers, including but not limited to therapists' private offices, offices of physicians, Part B skilled nursing facilities, home health agencies, and hospital outpatient departments.


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Resource:

Wachler & Associates Health Care law firm