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NS-Paying for Therapy Post Stroke
Jan L. Warner & Jan Collins

Queston: My father was hospitalized in mid-February after a stroke that left him paralyzed on the left side and unable to talk. His doctors began the therapy process almost immediately and, after 10 days, began discussing discharge for continued therapy. My mother has been so upset that she does not understand what happens next or who pays for what.

My father is 71, has Medicare Parts A and B, and a supplement policy from his former employer. My parents have minimal assets and live on a fixed income. I am sending this by e-mail so that, hopefully, you can reply to us as quickly as possible as I work full-time, my husband was just laid off, and we need a "down and dirty answer."

Answer: When a person loses bodily function, even the simplest activities become difficult. The rehabilitation process is time-consuming and can be frustrating for both the patient and family. Based on the description you give, your father will probably need physical, speech and occupational therapies -- called "PT," "ST," and "OT" -- which are delivered by trained professionals in various settings.

Physical therapists use exercise and equipment to help relieve pain, maintain elasticity and increase mobility and strength. Occupational therapists teach functionally impaired individuals to how to do what used to come naturally, like getting dressed. Speech therapists help those like your father who have lost the ability to speak or swallow. Assuming the best result from these therapies, your father may be able to return home; however, your family must be prepared for the potential that he may need to continue to be institutionalized. At a minimum, these therapies are needed to prevent your father from further deterioration and to preserve the functioning he has retained.

Who pays for these therapies can be a complicated issue. With certain limitations and so long as the therapy meets the "reasonable and necessary" test, Medicare will generally pay for PT, OT and ST in the hospital, in a skilled nursing facility for up to 100 days, in the home setting under specific circumstances, and at special therapy facilities. There must be either a reasonable expectation that your father will improve or that these services are needed to maintain him and not allow him to deteriorate.

In 1997, because of billing abuses by nursing homes and rehabilitation centers that charged Medicare $600 per hour for therapy services they contracted for $25 per hour, Medicare placed limits on the amount that would be paid for therapy outside the hospital; however, in 1999, these limits were removed for the years 2000 and 2001. If you really want to get confused and see your government at work, check out http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp.

Because of the importance of the discharge planning process and because of the complexities of the payment issues, we urge anyone whose family member is being discharged from the hospital for therapy or rehabilitation to take an active part in the discharge-planning process. Because most families will not understand all ramifications until it is too late, we believe that it is wise to include a private geriatric-care manager or case manager in the planning process.



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