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What’s with the ObamaCare mandated Medicare paperwork?

Article By: Dale J. Buchberger, PT, DC, CSCS, DACBSP

It has been several months since I’ve written about ObamaCare. With an influx of complaints from Medicare recipients about having to chronically fill out Medicare required paperwork, it appears time to revisit this specific aspect of the ObamaCare mandates.

This particular part of the ObamaCare mandates are called “functional limitation reporting” and went into effect March 1, 2013. Functional limitation reporting is required by all practice settings providing outpatient therapy. The reporting process involves filling out questionnaires or “standardized assessment tools” regarding the patient’s particular condition. These are lengthy and extend the patient’s time in the office. For example, if a patient has lower back pain, they are required on the first visit to fill out an assessment tool called the “Back Index”. The Back Index consists of a list of statements that correlates the patient’s back pain to their daily function of routine activities. Each item is assigned a point value. The points are added to give us a score that is then used to determine the patient’s functional ability.

Once the assessment tool score is established, in this case the Back Index, it is correlated to a letter code or “Medicare impairment rating”. The Medicare impairment rating code correlates to a percentage of impairment or inability to perform certain activities. The healthcare provider is required to then convert these codes to non-payable “G-codes” accompanied by descriptive modifiers. These G-codes must be reported at the initial evaluation, every 30 days or 10 visits (whichever occurs first), and again at discharge, according to Medicare. In order for the provider to report these G-codes and modifiers, the patient must fill out the standardized assessment tool that applies to them at each reporting visit.

If your healthcare provider does not report these codes correctly and does not have the patient fill out the paperwork correctly, Medicare will deny payment for services that have already occurred. In other words, the provider’s reimbursement will be denied.

What are they doing with all of this information? That is a very good question. According to the American Physical Therapy Association, “Medicare intends to use these reporting outcomes in the future to reform payment for outpatient therapy services”. This seems quite ironic from the provider’s perspective. Medicare uses your functional limitation reporting scores to attest why they don’t feel your services are medically necessary and, in turn, aren’t responsible for payment. Medicare recipients should be aware of the annual therapy caps and the newly implemented monetary threshold. If a Medicare recipient exceeds the threshold for that year, the recipient’s care will be discontinued. There are a few exceptions to this rule, but it’s almost impossible to be reimbursed for services at that point. This is an entirely separate issue to be argued in another article.

We are also in prime insurance renewal season. Advertisements for Medicare supplemental plans will be in large volume on television from here until December. Medicare recipients need to have a clear understanding of the difference between a supplemental and secondary insurance plan. Supplemental insurance means if Medicare pays the claim, the supplemental plan will pay whatever percentage of the outstanding balance to which it has agreed. If Medicare either does not pay the bill or discontinues reimbursement, the supplemental will not pay any claims denied by Medicare. Secondary insurance acts independently from Medicare and typically pays the remaining balance from Medicare less co-pays, co-insurance, or deductibles. If Medicare denies a claim or stops paying for care with reason code “patient responsibility”, the secondary will act as primary and continue to pay for services within the limits it has established in your contract. As you can see, supplemental insurance is only intended to compliment Medicare and is far more limited in its coverage, while secondary insurance can give you more options. Be very careful and make sure that you fully understand the difference between supplemental and secondary insurance before you sign on the dotted line. Most people pick the type of plan based on their current state of health combined with their personal financial situation. It’s very important to consider all variables when choosing the insurance that works for you.

So here we are, years into the ObamaCare process and it only continues to get more complicated. The Affordable Care Act (aka ObamaCare) hasn’t made healthcare affordable; it has, however, forced millions of customers to be at the mercy of the insurance industry. The take home message is to do your homework; learn as much about your insurance as you can. More information about functional limitation reporting and therapy caps can be found at www.apta.org.