"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Thursday, January 6, 2011

Physical therapists Can Fight the Medicare Improvement Standard with Patient Stories

Bob and Joanne are near the end...
Joanne can no longer care for Bob, who is increasingly weak and debilitated and is facing institutionalization despite a strong will to work hard, stay in his home and a loving spouse who supports him.

It didn't have to be this way...

Bob was discharged Jan 5th, 2010 from outpatient physical therapy working on falls risk prevention.

The Congress in 2010 failed to implement the Exceptions Process to the arbitrary $1,870 "PT cap" on Physical Therapy services in a timely manner and the patient elected to discontinue services (self-rationing) rather than risk hitting the cap with no Exceptions Process.

In January, Bob was not demonstrating measurable progress in a timely manner but had obvious deficits in mobility, self-care, safety and daily activities which limited his independence and caused a burden on his spouse, Joanne.

The Exceptions Process was finally implemented March 23rd with the signing of the PPACA but Bob and Joanne were lost to follow-up at that point and didn't get word.

Bob returned to outpatient physical therapy Nov 10th, 2010. At this time, we are able to document a measurable DECLINE in function, less strength, slower walking, greater use of assistive devices, higher (quantitative) falls risk and greater dependence on his spouse.

Click on ABC Functional Progress Graph to enlarge
We believe, and the patient believes, that the informal, non-statutory, widespread insistence on the Medicare Improvement Standard has led to a denial of physical therapy care and a greater risk of disablement, future institutionalization, chronic pain and future falls risk.

Bob has indicated a willingness to tell his story, in his own words - further, Joanne will describe the additional burden caused by the Medicare Improvement Standard and its financial corollary, the arbitrary cap on physical therapy services.

We can provide evidence of the patient's decline in in function from January to November 2010 - the period he self-rationed his care because of the Standard. We use multiple, validated measures of function recommended by Medicare and supported by the medical literature.

Bob and Joanne would very much like to spend their time together in their home, in comfort and dignity, rather than an antiseptic institution filled with strangers.

What can we do?
click image to enlarge
The Center for Medicare Advocacy would like physical therapists to provide stories of real patient burden faced by people who are unable to get their needed physical therapy as a result of the Medicare Improvement Standard.

The Medicare improvement Standard is illegal but physical therapists have long been taught by self-appointed Medicare auditors that "maintenance therapy" is not allowed and that patients must "improve" if we are to treat them and get paid. According to the Center for Medicare Advocacy...
"...the Improvement Standard conflicts with the law, it has become deeply ingrained in the system and ardently followed by those who provide care and those who make coverage determinations..."
This situation will continue unless physical therapists larn to speak truth to power and get patients to tell us their stories. Often, we are the ones telling the patient that we cannot see them - because we are afraid of Medicare.
"Beneficiaries are told Medicare coverage is not available if their underlying condition will not improve, if they have "plateaued," are not likely to improve, or if they need "maintenance care only".
As a result it keeps people with debilitating, chronic conditions from receiving the care they need. "
Many times, I have been in the position of telling patients I cannot see them when they've "plateaued" and their chronic condition is not improving - yet, I suspect that they will decline when they get back home and cannot train intensive, functional activities the way we do in the clinic. According to one Federal magistrate...
"An elderly claimant need not risk a deterioration of her fragile health to validate the continuing requirement for skilled care"
If you have a story, please contact the non-profit, non-partisan Center for Medicare Advocacy and share your patients' story.

Also, comment on this blog to increase its appeal for other physical therapists doing natural search - you can help this effort even if you don't have a patient story.

Thank you for all you do.


  1. What law are you referring to when saying that improvement is not necessary to justify therapy?

  2. The Medicare Improvement Standard was overturned by case law in two decisions in separate states (Vermont and Pennsylvania) near the end of 2010.

    You can read about it here:

    These decisions apply to these individual cases as a matter of policy.

    As a matter of law, the Center for Medicare Advocacy has elected to use this precedent to attempt to force Medicare to broadly recognize their de facto Improvement Standard that has been applied to ALL patients via administrative means for the last 20-25 years.

    They will attempt to initiate a class action that will apply to every patient seen under "skilled therapy" or "skilled nursing".

    A favorable decision in this case should apply to every setting (eg: home health, outpatient, hospital, SNF, etc.).

    Send in your patient stories - they may use your specific examples to improve their case and score a victory for Medicare patients everywhere!


Free Tutorial

Get free stuff at BulletproofPT.com

Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

Share PTD with your Peers!

American Physical Therapy Association

American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.