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Title : Good Health and Patients Win! Maintenance Therapy Settlement Gets Preliminarily Approval!. Elvonda
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Good Health and Patients Win! Maintenance Therapy Settlement Gets Preliminarily Approval!. Elvonda

Physical therapists' patients can take cheer this holiday season, nestled all snug their beds, with the knowledge that Maintenance Therapy will still be here through Christmas.

The class action lawsuit filed and won by the Center for Medicare Advocacy has tremendous potential to simplify therapy decision making by managers, therapists and patients.

Just in time, too, considering the Byzantine complexity brought by Medicare Manual Reporting and, now, Functional Reporting for 2013.

According to the Center for Medicare Advocacy, on Sunday, December 9th, 2012:

"A proposed settlement agreement was filed in federal District Court on October 16, 2012. On November 20, Chief Judge Christina Reiss of the District of Vermont signed an order preliminarily approving the settlement agreement. 

By December 10, 2012, notice of the settlement will be posted on the websites of numerous organizations, including the seven national organizations that served as plaintiffs in the case, which will alert advocates and beneficiaries to the terms of the settlement."

Many observers believe that Medicare will somehow acquit themselves of 35-plus years of illegal behavior and continue to deny care based on the just-overturned "Improvement Standard".  The CMA announcement, however, implies that the class participants, not Medicare, are the ones in position to accept or deny the Settlement.

"Class members will be able to file written objections to the settlement. 

The court will hold a Fairness Hearing on January 24, 2013 'to determine whether the settlement agreement is fair, reasonable and adequate,' after which it is hoped that the judge will issue an order permanently approving the settlement agreement."

The Settlement only applies to the illegal Improvement Standard, or the idea that people must make significant and measurable gains in function in order to continue receiving therapy services. Two further conditions still apply: the services must be of sufficient complexity that a lesser trained provider could not safely perform the care and the patient must still demonstrate that the services are medically necessary.

I've had conversations with therapists who support the Improvement Standard on the grounds that "we can't afford to expand Medicare right now".

The Settlement is not an expansion of Medicare. The Settlement is a clarification of the Congressional intent to provide Medicare beneficiaries with a level of care that would not leave them disabled and institutionalized.

For my entire 20-year career, I've been told by well-meaning PT managers and staff that we must "show progress" in order to treat our patients. In turn, my managers had been told by the Medicare Carriers and Fiscal Intermediaries (mainly Blue Cross/Blue Shield and other commercial insurers) that claims would be denied if the patients didn't "show progress".

It turns out that the insurance companies, acting under the aegis of Medicare, were breaking the law.

Here is testimony the the CMA website:

"These changes [from the Settlement] are extremely meaningful, as my mother has repeatedly been denied the ability to continue the physical therapy she needs in order to prevent further deterioration of her condition. 

It has been extraordinarily frustrating, and after the last cessation of Physical Therapy and subsequent deterioration actually endangered her life, her quality of life was greatly affected, resulting in extremely expensive 24/7 care. 

If she could have kept her PT services, this would not have happened!" 

-Veronica, New Hampshire

If the Settlement sticks (as I think it will) it will be the best Christmas present of my entire career.

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