Rehab Associates participates with the Medicare program. Medicare helps pay for medically necessary outpatient physical therapy when you have a referral from your physician for physical therapy services. On your first visit, your therapist will evaluate you and develop a plan for your treatment. This plan of care will be sent to your physician. Your therapist will periodically provide updates to your physician on your progress and length of treatment required.
Medicare limits how much it will pay for outpatient physical therapy services per year. These limits are called “therapy caps” or “therapy cap limits”. The therapy cap limits for 2017 are $1,980 for physical therapy (PT) and speech-language pathology (SLP) services combined, and $1,980 for occupational therapy (OT) services.
Coverage for Medically Necessary Treatment
If you require services that are medical necessary beyond the cap amount, our physical therapists are obligated to continue treatment without interruption and provide proof in your medical record that the services provided are medically necessary. If Medicare disagrees with our findings and decided that any of our services are not medically necessary, there is no financial risk to you.
Coverage for Treatment Not Considered Medically Necessary
If continued treatment is not medically necessary, we must discontinue treatment, or notify Medicare that we are continuing treatment that would be considered not medically necessary. We will notify you ahead of time if we feel that continued treatment is not medically necessary and explain your options.
Medicare Audits for Services Exceeding $3,700
For medically necessary services exceeding $3,700 for PT and SLP combined, we may be required to submit your records to a Medicare contractor for review, so they can confirm that the services are medically necessary. Again, there is no financial risk to you if Medicare denies payment because they disagree with our finding.
Payment for Medically Necessary Services
Medicare pays 80% of the Medicare-approved amount for all covered services. You will be responsible for the remaining 20% of the Medicare-approved amount after you have met your annual deductible. The annual deductible for Medicare Part B is $183 in 2017. You must pay this amount before Medicare will begin to pay the 80% for covered services.
If you have a supplemental insurance plan in addition to Medicare, it may cover your deductible as well as the 20% that it your responsibility.
Our Patient Care Coordinators and/or Insurance Specialists will be happy to answer any specific questions that you have about your Medicare coverage.