• Tuesday, June 21, 2011RSS Feed

    Medicare Advantage Resources Now Available

    APTA recently developed an FAQ document to help association members understand the coverage and cost-sharing arrangements of various Medicare Advantage (MA) plans. The questions address billing and coding requirements, the therapy cap and KX modifier, plan of care requirements, how to appeal claim denials, reporting data under the Physician Quality Reporting System, audits, and requirements regarding face-to-face encounters, among other issues. 

    A summary of the 2012 Medicare Advantage final rule also is available from APTA. The final rule makes revisions to the MA program (Part C) and prescription drug benefit program (Part D) to implement provisions specified in the Patient Protection and Affordable Care Act, in addition to other changes. Some examples of pertinent changes for physical therapists include cost sharing in skilled nursing facilities, payment to non-contract providers, and revised requirements for the review of medical necessity determinations.


    Here in Hawaii the Advantage plans consider PT's "Specialist" and require the $45/copay. The plans also state that patients can go to see a "specialist" without a referral, but that apparently doesn't mean you can go to your PT without a referral (direct access passed in Hawaii 2012). It is difficult to understand how we can be specialist is one part of the contract, but not throughout. More important though, how can we help our clients out of these terribly increased co-pays. Based on facts: the cost of PT service has increased so minimally in the past 10 years that copays would not need to be increased for our services. Patients should not be required to pay more than 20% and now in some cases they are paying over 40%. What can we do besides encouraging the patients to complain to their insurance company. Then the insurance company tells the patient they should by the higher price policy. Plain to see why the insurance companies make more than the PT's
    Posted by Betty Fackler -> @KQ\A on 1/25/2013 11:10 PM
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