HEARING - U.S. Senate Special Committee on Aging

10,932
134
New Davelopments
492 346
has been ordered by the piatient's treating physi- D. 7he Effects ot Plaintiffs of Deniafs of
dan. Tr. 33. 239.240.
Benefits
defendants cover- ~17. Skilled physical therapy can enable many
9. it is the defendant's prsctice to deny c er- lderly patients to leave the nursing home and
ge for physical therapy received during the ruin to the community to live independentlY.
Anom weligbeinmg" stage of rehabiltaton. Tr T . 282-2B4. 313, 315.316. Indeed. as one of the
13, 51-52. 71. 285 315.
plaintiffs' experts testifired credibly, if more eld
10. t isthedefedant prctic to eny erly persons received skilled physical therapy
to. It is the defendant's practice to decny after sustaining a stroke or fracture, fewer Of
coverage for physicia therapy administered to these persons would have to spend the remaina
Itmputees who have not yet been fitted with der of their lives in nursing homes. Tr. 3146 326.
prostheses Ti. 70-71,S4-JS
18. Patients who are denied Medicare cover-
11. It is the defendant's practice to deny age are responsible for paying for their own
coverage to patients receiving "maintenaifnt" physical therapy through insurance, personal
physical therapy. Tr. 317.318.
avvinp or contributions from family member
Tr. 50. 5, 164, 211. In such circurnstance
12. It is the defendant's practice Lo terminate many patients forgo medically necessary physioveragie
for physical therapy when the patient cal therapy because they or their families
is sbk to walk with the supervision of an aide, believe that they cannot afford to pay for auch
Tr. I. However, as was established by uncon- therapy themseves. Tr. 8, 21. 26-27 43-44.
tauverted expert testimony. such patients still 49-50, 56-57
may not recove r fully unless they recive addi- 1.Ap--' eoey b dzd
tional skilled physical therapy on a daily bsis. 19.MAApatiet's r vy be jeopardized,
according to the ceedible awunconstovet-
Tr. 20. 84 testimony of the plaintiffs' medical expert if
13, Itfisothe dfendanyl ts p ractice toes terminate the patient forgos medkicly necessary Physicat
Iv gt ioc the dp tient's able tocmae 0 therapy during the ween s immediately lollowing
fee with supervtision. ti.n i 1 Hoever, a sw his injury or illness. Tr. 25-27, 56-57, 283.284.
estaished by dse typiexper d testimony, an In 2Nthe some cases, a patinsreoer is o rnh
distancie oui thatapatient isablentof aMbulatewieth ited by the ermoional distres that may rIt
copervist isi not. tb itienlf deterinatcuived o hi from a dental of Medicare coverage. T 252 r.
need for datilyt bi ctkilledp therapy. Ti. 318. 20. ATcordingl .the denial of medically necessary
physical the py benefits has significant
14. It is the defendant's practic ert e physioloical, emotional and financial implicacoverag
for physical therapy that consists o tions for many memberb of the plaintiff class.
Passive "Tran0g1e-motion" exercises. T 7orod it4ndns
e Determinatio7n6
15. The reason typically advanced b an 21. The SNF is responsible as an initial mUt-
Intermediry to justify t dicare ter for determining whether a newly admitted
coverage is that the physical therapy required patient is to receive Medicare coverge Ti. 13,
by the patient is not "skiled." Tr. 74-75. How- 144. 48; HIM.13 a*to3439.1). If the SNF'
pymeindnt'frsuc Co rvkerag De eouldnot btoes
ever, as was established by credible expert testi- decides that the services to be received by the
mssny, the intermediaries often deny coverage pentcar e redi by Medice, but th ter
without giving ad te consideration to the mediay ate eveises the p's dec e
physical ttherap k resmqured til in a particular SNF must absor b the co o at h if
case.Tr. 102. 311, 313, 344.5 it"nwbrcude epce okota
16. Before acting on a claim. SNt personnel made. under rt A of Meir 42USC
may telephone the intermediary to discuss I 1395pp(b), Ti. 64.
whether the patient is covered by Medicare- Tir
28.29. 240-241, 328329, 220-221. However, the 22. An SN!' that grants a claim for Medicare
testimony at tnal revealed few instances in
the intermedisry
which these informal communications signifi- with extensive documentation of the patient's
cantly affected an intermediary's coverage medical condition, the services rendered to the
determintions. Tr3 1921.
patient, and the extent of the patient's recovery.
11 hb &teuedaat clais tbat one witnss' tessmimy that a,,sseu that rnnmbd his oae-.tmdins that "ktr as
he~5d55.a tae win -skitr~ 55 Ias ai-twis concept ing asd .,inll nihabiltit~icat ws iees M, dteni to Put.
bit WarsY "is luaply a thembicid be) whic they sr twea.1 cimeics~as ac r~ic, -fwtucsihed di-etly hYw
amperrepdi ytoa' s=a rincd becuausdseiinmdi dn a d( l $ic cl as ylrusicat thee
ac ,hdr.an 'cthe estaiode ,lticit,e i -skil.l Dees Wm Csic49.3she3 Ipenwe li V )Se
dasa. Poat-Trial Maeasortfl8W at isis9 a A.. This area. asnul' 42 1I..403ta1lerpa .pin.Se
aaest is w~inha _5it insim ew ath. Iarmtsirroy by sIw Tr. 340.21.-
J35,374 019,CrinreCern os~I