Home > Long-term care, Treatment > Medicare Revises Dementia Coverage

Medicare Revises Dementia Coverage

Last month, in response to a federal class action lawsuit, Medicare has made a significant revision to the way it covers rehabilitation services for persons with dementia.  The suit challenged something called the Medicare Improvement Standard, which required that recipients of physical, occupational, and speech therapy services be able to demonstrate the possibility for significant improvement in skills in order to qualify for Medicare coverage of said services.  This meant that persons with dementia and other progressive disorders were often unable to receive intensive therapy, and often were restricted to the development of a Functional Maintenance Plan.  (A therapist would spend 1-2 weeks completing a thorough assessment of the patient, developed strategies to enable the patient to function at his/her best, trained the nursing staff, and then signed off on the case.)  Now, according to the settlement agreement, Medicare must pay for services required to maintain the patient’s current condition or to slow down further decline.

Most persons with Alzheimer’s disease and related forms of dementia are 65 years of age and older, and are eligible for Medicare services.  In my capacity as a speech-language pathologist, I have frequently been asked to evaluate a person, and assist the staff in dealing with one problem or another.  The person may have started choking on his food, or he may have suddenly started striking out at anyone who tries to help him undress.  He may have begun to drool profusely, or grind his teeth.  These are all things that fall within the scope of my profession to treat, and as such are appropriate referrals.

Now, sometimes an individual’s problems are easy to diagnose, and it is relatively a simple matter to develop some compensatory strategies and teach them to the staff.  But, there are other times when the problem may be more complex, and the individual may require a longer period of treatment.  After he reaches a certain stage in his dementia, he will not be capable of learning new information.  However, he may be able to develop a habit with repeated exposure to select stimuli by a professional trained in such things.

Medicare does have other requirements that I have to meet when I work with patients, and these haven’t changed.  For example, I have to be able to document that I am providing a “skilled” service.  That means that I have to do things that only someone with specialized training (such as my Master’s degree in Speech Pathology) would be able to do.  I might be able to feed a patient, but so could any nurse’s aide worth her salt.  But that aide wouldn’t be able to evaluate laryngeal elevation while that patient swallows, or provide thermal stimulation to help strengthen the swallow reflex.  And so, those of us working in the therapy department have to do considerable paperwork to prove that our patients really do have a problem worthy of being treated by someone of our training, and that the therapy we provide is something that not everyone can do.  We also have to document that the patient is benefiting from our services.

But, now, we can say that our patients benefit from our services because their dementia is not progressing as quickly as it might, or because their overall quality of life is improved.  There are still a lot of things to be worked out, with regards to just how this is going to be accomplished, and how it is going to be documented, but this action is a big step in the right direction.

 

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