Ethical Issue Facing Health Care: Rehabilitation Therapy Caps

Over the years Medicare patients have been denied Physical, Occupational and Speech Therapy services due to therapy caps placed by Medicare. Many patients have not been able to receive the services that would allow them to return to their homes and maintain a quality of life because the therapy they needed could not be provided without paying out of pocket costs. This has caused physical, mental and financial hardship on many patients and their families. Over the past 7 years Medicare has placed a moratorium on those services, alleviating the financial, physical and mental burden from patients and their families; however, January 1, 2006 the therapy caps were once again put into place. The current therapy caps require patients to pay anything above and beyond $1,740 for Occupational Therapy and anything above and beyond $1,740 for a combination of Physical and Speech Therapy services, this information can be found on page 9, section C of the Medicare Claims Processing Manual.

Working in operations for a Rehabilitation Company has allowed me to observe upfront some of the ethical issues the therapists are faced with. As part of the company the therapists were told they were expected to meet budget regardless of the moratorium, which meant they had to decide what was ethical and what was not ethical. This was a tough choice for many of the therapists because they came into health care to provide a service to patients in need. They did not go to school to be involved with the financial end of the business. Many of the therapists exceeded the caps and still provided the service and told the patient they would not be billed for the service. This is not a practice that is allowed by the company nor Medicare. The amount billed has to be tracked and maintained for the calendar year to ensure the patients' benefits are not exceeded and to determine how close they are to exhausting their benefits. Therapists are not concerned about the billing and financial end of the services they provide they are only concerned with the well being of the patient and want to provide a quality of life as close as possible to the patients injury or illness. This attitude caused many problems in the past for the company and the therapists because some patients would be billed and others would not, depending upon what information the therapist provided the billing office. After several days of investigation it was noted fraudulent billing had occurred on several patients as well as a breech of contract for facilities we were contracted with. Between Medicare and our contracted sites we had to reimburse a substantial sum of money.

This type of ethical issue is difficult to determine the guilty party when you have a healthcare system that will not pay for a service that is deemed necessary by a physician, and a therapist that wants to provide the best care possible. The therapists clearly compromised their ethics by choosing to treat patients and not bill for the services. They would have also compromised their ethics if they had ceased to provide therapy to a patient that needed it because they did not want to bill them. This would be considered neglect and/or falsifying records because they would have had to state on the required forms the reason for the discharge from service.

Although I still feel it is an issue, Medicare has now provided an exception policy put into place for Therapy services which cover most Skilled Nursing Facilities and Assisted Living Facilities; however, this does nothing for the individual that refuses to stay home and not live in a SNF or ALF. The exceptions can be referenced from Transmittal 47, Publication 100-02 of the Medicare Benefit Policy. These exceptions basically state that there are going to be automatic and manual exceptions for patients needing therapy services. Automatic will cover the SNF and ALF patients in a majority of cases; they will need to provide medical necessity documentation, and also a manual exception process which will require a review for covered services. This is a start by Medicare to ensure the patients covered under Medicare are receiving the medical benefits and therapy necessary for quality of life.

References

CMS Manual System, (DHHS & SMS); Publication 100-02 Medicare Benefit Policy, Transmittal 47, February 15, 2006; retrieved on May 18, 2006 from http://www.cms.hhs.gov/Transmittals/downloads/R47BP.pdf.

Medicare Claims Processing Manual, (Rev 855); Chapter 5, February 15, 2006; retrieved on May 17, 2006 from http://www.cms.hhs.gov/manuals/downloads/clm104c05.pdf