Re: Failure to Improve Is Still Being Used, Wrongly, to Deny Medicare Coverage | New York Times | September 12, 2016
I read the recent article titled Failure to Improve Is Still Being Used, Wrongly, to Deny Medicare Coverage. The fact that some Medicare contractors continue to cloak denials under the false "improvement standard" ultimately puts patients at risk. Striking down this standard helped empower the clinician to determine a comprehensive management plan and to ensure patients receive the necessary services to maintain mobility, independence, and quality of life.
As your article points out, many are unaware the improvement standard is no longer required and still adhere to it. At the same time, clinicians who are aware and try to treat appropriately are at risk of payment denial and audits by Medicare contractors who are unaware. Access to these services is vital for many patients. Only through education of all involved in delivery of care, not just of providers, but of Medicare contractors, medical reviewers, and patients too, can we ensure people are appropriately served.
Medicare provides coverage of and payment for health care services it deems "medically necessary" and that meet generally accepted professional standards. The criteria for medical necessity are laid out in the Medicare regulations and have been recently modified to delete any references to the improvement standard and allow for clinicians to provide skilled maintenance. The sole determining factor for whether or not skilled maintenance is medically necessary is the professional judgement, skills, and expertise of the clinician. APTA is working to educate our providers on this change and we hope Medicare crafts an educational campaign that highlights the critical importance of the clinician’s professional judgment as well.
Sharon L Dunn, PT, PhD
President, the American Physical Therapy Association