How does this differ from traditional home health?

If you are receiving care in your home through our agency, then it is going through your part B outpatient benefit (even though in your home).  Each session is billed out to Medicare depending on the amount and type of services rendered that day.  Therapy services can go on for 6-9 months if needed, with average time frames being 6-12 weeks of 3 times per week therapy services.  Your Medicare benefits cover 80% of the charges, with your secondary, or supplemental, covering the other 20% unless there is co-pays or deductible (sometimes in advantage plans). This service can have PT,OT, and ST services see you in your home or in the clinic under the same pay structure and benefit rules.

 

Part A home health therapy, on the other hand, is provided by a Medicare Certified Home Health agency, and is a bundled service that is meant to bridge the gap between facility care and outpatient care.  It is designed to get you functionally safe, not necessarily as functionally independent as possible. It includes skilled nursing care and a home health aide to assist in some ADL like bathing if needed for a short period of time.  It is billed out to Medicare as a bundle of services and is not necessarily paid for each visit that you have but as a collection of services.  It is set up for 60 day periods with the average length of services being about 15-25 days now.  Part A home health offers PT,OT,ST, Skilled Nursing, wound care, IV services, home health aides, and social workers.

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What is PT, OT, and ST?

Physical, Occupational, and Speech Therapists (actually called Speech and Language Pathologists (SLP)) are integral members of the medical community when it comes to restoring function.  Therapists work in hospitals, nursing homes, specialty hospitals, home health, and outpatient centers. They work with children, burn victims, adults, seniors, athletes, wound care centers, Lymph-edem centers, developmental issues, acute care, post acute care, and just about anywhere there are people.

 

Therapists go through rigorous training, typically a Master's and or Doctorate degree is needed.  This is after 4 years of undergraduate studies and a Bachelor's degree.  Training often includes complex medical school like coursework combined with clinical rotations and residencies.  After this, they need to pass state and national examinations and obtain state licenses that they must maintain every 2 years.  Therapists are often times trained not only in restoring function, but have deep medical backgrounds as well and are a complement to the medical system at large. 

 

Therapists often specialize and get certifications of specialty as well.  Therapists have to keep up continuing education hours every year, and maintain a high level of standard to provide care including level 2 criminal background checks.  Our therapists undergo competency screening, reference checks, background checks, drug tests, and are systematically reviewed often to ensure we are using the best there is to offer.  

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Physical Therapy-PT- in this setting, is typically aimed at restoring balance, functional mobility, post surgical rehabilitation, neuro-rehabilitation after strokes or in conditions like Parkinson's.  PTs can work on neck pain, back pain, shoulder and elbow issues, hip and knee and ankle issues, cardiac rehab, pulmonary rehab, and virtually everything in between.  Often times, in this setting, we defer isolated upper extremity issues and hand issues to Occupational Therapists. 

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Occupational Therapy-OT-in this setting, is typically aimed at restoring function to the hands and arms as well as cognitive processing during Activities of Daily Living (ADLs), low vision programs, and assessing and identifying need for environmental modifications, adaptive equipment, and assistive devices. 

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Speech Therapy-SLP-in this setting typically deal with swallowing and feeding issues, cognitive issues affecting ADLs, communication issues (both expressive and understanding).  Speech therapists often work with patients who have mild cognitive issues from say a stroke, or swallowing issues from say spinal cord damage, or speech issues from Parkinson's, for example.

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How much therapy can I get?

The short answer is as much as you need.  The longer answer has to do with making sure your care is meeting the eligibility requirements set for by your payer (Medicare).  See the Patients link for more details. Care will need to be restorative, reasonable, skilled, necessary, and under a physician's signed plan of care every 6 weeks.  Medicare allows for $2110 in PT and ST services combined, and OT services by itself, before there is more documentation required to show why the care is still meeting conditions of participation.  At $3000 of billed services (about 30 sessions) there is a manual Medicare review process where an audit can determine if care is needed. therefore, when services have been used with "high" utilization, we may require even more frequent re-assessments and physician certifications. That being said, so long as the criteria in the Patients section are met, we will extend the services.  If the services do NOT meet the conditions of participation then you can elect to sign an Advanced Beneficiary Notice (ABN) that will elect to either be self pay or use a true secondary insurance benefit at times.  

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How am I billed?

Since so many insurances or so local and specific with changing plans, it is near impossible to tell you your exact benefits and financial liabilities.  We do check your benefits, but it is only as accurate as the computerized program is.  Since providers have a YEAR to bill for services, the system is not always up to date, so we have no way of being 100% sure of your benefits.  It is important to be open and honest with us about how much outpatient therapy you have had in a calendar year.  Therefore, we bill in the rears.  That is, after we get back our notices from Medicare, after we bill, we send out notices about explanation of benefits (from Medicare) and balance due notices that can be paid by check or credit card.  Often times, without any secondary or supplemental insurance, your liability will be about $20 per session on average.  With a secondary or supplemental insurance like AARP UHC or one of the other plans, you should typically not expect any amount due.  If there is a true documented hardship, we may be able to waive the 20% fees.  All patients are billed out at our customary fee schedule, and we legally cannot discount services for anyone even if they are paying cash without a hardship notice or without a discount insurance plan (ask us about this service if needed). NO MONEY WILL BE COLLECTED AT THE TIME OF SERVICE outside of the clinic (at home).

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What if?

I need to have more services like skilled nursing and not just therapy?

• We will help arrange for one of our trusted provider agencies to service your needs, and often times you can continue with the same therapist this way. Once home care ends, we can pick back up with a new physician prescription.

I am going to one place for part of my therapy, and then want you for the other part. For example, OT at one clinic, and PT with you.? ​

• Typically this is allowed, but makes it difficult as the two providers will need to coordinate billing some times.  It is best if you do this to make sure the services are on different days if possible.  However, you cannot have the SAME service (PT and PT or ST and ST) from us and another provider at the same overlapping time frame.

I change insurance carriers during treatment?​

• You are liable to tell us if you change plans or secondary insurances/supplemental insurances while you are under our services.  If you do not tell us this ahead of your next session, you could be liable for any charges incurred during this time.

I do not like my therapist, or want to change scheduled?​

• You can let us know, and we will do our very best to assign you a new therapist.  That being said, all of our therapists are rigorously screened and have been with us on average 7.5 years, so please try just communicating with them first, and if they are coming to your home, please understand it is difficult to pinpoint a time to the minute, so please allow a 1 hour window for them to show up.  Also there is just so many hours in the day, and not everyone can have 10:30 time slots. Please be flexible, knowing some patients have to go to dialysis and other factors that make scheduling a difficult thing in general.

I want to have one of my therapists I have had at home before?​

• We will do our best to keep continuity of care. We usually just assign one supervising therapist, and one treating therapist (sometimes the same person), and try to keep your same staff at new episodes from prior.  If you have a therapist who works free lance and is looking to see you, and they meet our criteria for hire, we would be happy to get them on-board so they can see you through our agency.

What Insurances do you accept?​

Currently we accept Medicare as the primary payer. We do contract with some Advantage plans, but are not currently in network with any outside plans.   We will take some outside attorney business on a Letter of Protection in a case by case basis.  We will direct contract with other providers as needed. We expect a VA contract to be in place by mid 2021.  If you have billing questions or insurance questions, please call.

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