Small study showed high accuracy but hurdles remain, two experts said
by SarahGrey on Tue Jan 22, 2013 01:15 AM
just curious if anyone else has gotten discharged (booted) from physical therapy because you 'could no longer meet measurable goals?' really upset here... my husband has been going to PT for months and theyre going to discharge him soon because he's been 'at the same level' and hasnt really improved over the past few months. what the heck, he has a brain tumor and has had setbacks from the doc reducing his steroids. it's like he's being punished for something out of his control... and it's heartbreaking because without PT he'll probably be back in a wheelchair in two weeks... :(
just curious if anyone else went through this?... :(
by kat54 on Tue Jan 22, 2013 02:28 AM
Sarah you can apeal this decision and get a referal to someone else. speak with you dr or patient advocate at the hospital
by herrmajo on Tue Jan 22, 2013 05:19 AM
Sounds like a cold therapist. Kevin did physical therapy for a few weeks, but before our therapist started working with him he researched GBM, had a conference with his doctors and told us straight up he did not know if Kevin would benefit or not but he was willing to give it a shot. well we got to a point that he told us that he recommended therapy to stop as he didn't think it was helping(and it wasn't) and he didn't want us to pay for something that wasn't working along with the frustration it made Kevin feel trying so hard to do and just couldn't. He came to the house a couple times to see how we were getting along and make sure that what he taught me at therapy was working out at home. He is a spiritual man so gave us some of that while he was here also. Sometimes the therapy just isn't gonna do the trick and our doc warned us not to get our hopes up.
Maybe there are things you can help him with at home that he did in therapy?
Best to you and your husband.
by KPANDBP on Tue Jan 22, 2013 05:40 PM
Its usually the insurance company rules, not the therapist. My wife had the same thing happen, the hospitals will gladly take your money for therapy its the fricken insurance companies that dont care if its helping them hold a decent level. Their rules say you have to improve so much, not just stay at a certain level.
by oceanswimmer on Tue Jan 22, 2013 07:59 PM
KPANDBP is right, it is usually because of the insurance co. The insurance co. will have medical guidelines with criteria that must be met for continued coverage of physical therapy. You should ask your husband's plan for a copy of the guidelines, so you know what the criteria is (might be on plan website, in provider area), and appeal the decision if your husband is told that PT can no longer be covered for him.
Most plans used to require that you continue to be making progress, and if you reach a point you can no longer make progress, they'd stop covering it, saying it is no longer a benefit for you, and thus not medically necessary. However, that is changing with many plans, and has changed with Medicare. Medicare now allows PT to continue if it will allow you to maintain your functional level and prevent decline, and this is a new and recent change in medicare's rules. Some health plans use the same criteria as medicare for PT. Even if your plan does not, it would be worth filing an appeal since your husband can still benefit from PT even if he is not showing improvement, if it is maintaining his functional level. (If there have been times he wasn't able to go to PT, and he had some decline, you can include this info in appeal letter.)
Be sure to get a copy of the rules for appeals or grievances for your plan, and don't do an appeal over the phone (some plans allow phone appeals). It is important to do it in writing, so your position is clearly stated and you can attach supporting evidence (copies of PT notes, letter from doctor supporting continued coverage of PT).
by SarahGrey on Tue Jan 22, 2013 10:10 PM
thanks everyone! wow, my husband is on medicare - you would think the therapist knew about the change in their stance. especially since we go to pt at a large hospital. sheesh.
i've asked the doctor for a new script and suggestion of new rehab place - preferably one that deals commonly with patients like my husband. his therapist didnt really seem to understand him or be able to handle our situation well and so maybe a change is best... i'll be polite and leave it at that.
by oceanswimmer on Wed Jan 23, 2013 03:30 AM
Medicare does have a dollar limit on what it will pay for outpatient physical therapy. I think it is $1900 (for PT and speech therapy combined, and another $1900 for OT). A provider can get approval from Medicare to exceed the limit if therapy is still needed and cap is reached, but then the continuing therapy needs to be preauthorized by Medicare.
If your husband has a secondary or medicare supplemental coverage, you should check the policy to see if the secondary will continue to cover the therapy once Medicare coverage is exhausted. Some plans do and some don't. If the secondary will, the providers often do not know that and will say that they can't bill your secondary if Medicare hasn't paid. But what they need to do is send the exhaustion of benefits letter from medicare to the secondary, and then the secondary will start paying as primary and will also do the utilization review to make sure the medical criteria for coverage is still being met.
by SarahGrey on Wed Jan 23, 2013 03:01 PM
oh wow, you know a lot about this! thanks soo much!
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