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Medicare Rehabilitation Standard Finally Revised

The long awaited update for Medicare rehabilitative services coverage is finally here. The Center for Medicare & Medicaid Services (CMS) has finally updated its Medicare manual regarding coverage for patients receiving rehabilitative services.  This necessary change will help patients and their families advocate for additional Medicare covered services.

Under traditional Medicare, the first twenty (20) days in rehab are covered one hundred percent; days twenty-one (21) through day one hundred are paid at eighty percent (80%) by Medicare and the patient is responsible for the remaining twenty percent.  Usually around day 20 the rehab facility would re-assess a patient and in many situations stop providing rehab services on the basis that “the patient is not likely to improve” or “has plateaued.”

Now, there is no longer an ‘improvement standard’ to determine whether Medicare will provide coverage for a patient needing skilled nursing care.  Medicare now recognizes that skilled care or rehab services may be necessary to maintain the level reached by the patient (and prevent further decline).  The new standard applies to skilled nursing services, home health services and out-patient therapy. Click here to read the transmittal on the CMS website.

Here is a helpful tip: if a rehabilitative facility tells a patient they are terminating rehabilitative services, the patient can request that services continue and that the facility bill Medicare. If Medicare agrees with the patient it will pay the facility; if Medicare disagrees with the patient and denies the claim then the patient is responsible for payment. This is referred to as ‘demand billing.’

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