Medicare/Physical Therapy/Medical 2016
By – Sheri de Grom

The Centers for Medicare and Medicaid Services passed a law that’s good for the patient and not the establishment.

The settlement agreement means that there have been changes to the manual that Medicare contractors use to process claims. These claims will no longer be evaluated based on potential for improvement but on the need for skilled care. Skilled care will qualify for Medicare even if the medical record reflects that the patient continues to deteriorate or maintains their current condition.

PHOTO ID 100469476 Stuart Miles/Digital

PHOTO ID 100469476
Stuart Miles/Digital

Facilities are rating an increasing number of patients as needing the highest level of therapy. This level requires 120 minutes of intense therapy daily and documenting this amount for high payment. The reality is that most patients cannot endure the scheduled therapy prescribed to meet those high standards of payment.

Medicare classifies nursing home residents into one of 66 groups depending on the patient’s needs. More than one-third of the groups are for patients who require physical, occupational or speech therapy. Medicare pays more for patients who need the most therapy.

The New York Times reported Oct. 5, 2015 that nursing homes and rehabilitative units bill Medicare for more therapy than patients need.

One of the best kept secrets in nursing homes and rehabilitative care units is that they operate at a profit.

Photo Credit: StauratMills/Free i.d. 100352582/annankhml


‘Profit’ used in conjunction with nursing homes and rehabilitative units is something we don’t hear about. This segment of health care is not eager to open their accounting books for anyone to examine.

The facilities receive more in Medicare payments than it costs the provider to give the patient care, exploiting the billing system while they are attempting more therapy than the patient needs, or can tolerate.

Common sense [obvious to those in the medical profession, caregivers and families of patients everywhere] is that chronically ill patients often require skilled care before returning home from the hospital. These people are too ill to withstand any type of rigorous physical therapy. Physical therapy adds unwarranted pain for this frail population.

Thank you to Birdie Avarialte for posting this photo.

Thank you to Birdie Avarialte for posting this photo to her Pinterest site.


The changes I’ve described above apply to the traditional Medicare program and to private Medicare Advantage plans. They apply to people 65 and older, as well as to people under 65 who qualify for Medicare because of disabilities.

Medicare’s new law, now in place, should circumvent the nightmares families face across the nation. Patients upon discharge from the hospital and too ill to go home no longer must meet the rigorous demands of physical therapy, as in days gone by. They may go to skilled care for recovery [unless your medications are too expensive or you have a mental illness diagnosis]. I’ll be discussing these problems in a separate blog.

Thank you for spending time with me. I sincerely hope the changes in Medicare will enhance your life and the lives of those you love.


About Sheri de Grom

Retired Fed/JAG, 5 yrs. on Capitol Hill. Former book buyer for B and N. Concerned citizen of military drawdown. Currently involved in mental healthcare reform, health care strategist and actively pursuing legislative change wherein dual retirees are exempt from enrolling in Medicare at their own discretion without losing tertiary healthcare benefits. Monitor and comment on Federal Register proposed legislation involving Mental Health, Veterans Affairs, Health and Human Services, Medicare and rural libraries. Licensed OSHA Inspector to include Super Fund sites. Full time caregive to Vietnam era veteran. Conceptualized, investigated possible alternatives, authored, lobbied for, and successfully implemented Title X, Section 1095 (known as the Third Party Collection Program of Federal Insurance).
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  1. Sheri,
    This is an interesting topic. This also leads into how medicare will reimburse treatment of progressive disorders that demand skilled treatment from physical therapists. What I am gathering from your article is that when I am in practice in 2 years as a PT, I will be able to bill Medicare for a patient that has Parkinson’s for example, as long as I can demonstrate the need for skilled therapy regardless of the patients progress with my treatment?

    • Actually, what the law allows is the client can still receive skilled nursing without having to endure physical therapy. If they are not making progress in therapy or therapy has become a painful experience for them, the patient is allowed to stop the therapy. In days gone by this would have meant the patient would have had to go home. Now, the pt can stay for the skilled nursing and not have to have physical therapy at the same time. You as the physical therapist may be able to document the need for physical therapy but the patient may be to ill to gain anything from further physical therapy or simply in to much pain. At that point, even if you say the pt can have more therapy, the pt or their family has the right to say no and the pt may remain in the facility. Thank you for asking the question and I hope this answers your question.

  2. PTcontender says:

    Wow! Just happened to find your blog and love this post. I don’t know anything about how insurance works, but one day I will be physical therapist and have been wanting to understand it better. Thank you for making a difficult subject easier to read! Learned a lot 🙂

  3. Denise Hisey says:

    Healthcare is no longer about healthcare. It’s a business. Plain and simple, it’s about money not healthcare.

    • You are so right, Denise. Over the past year I’ve seen more and more evidence of money hungry healthcare and ancillary providers. We no longer have providers of healthcare in the U.S. unless the family provides for it.

  4. inesephoto says:

    No wonder they don’t want us to know. Hope for more good changes.
    Have a lovely week, Sheri. Love to you both ❤

    • Inese – Hello, it’s good to see you. There’s so much going on with Medicare and all health plans, it’s difficult to keep up. I’m forever thankful I did the long range planning that I did. Of course, Congress could come along and rip that right out from under me at any time.
      Tom played superman a few days ago and decided to cut the Weeping Willow Tree back – Not a good choice.
      I hope you and those precious grandbabies are doing well.

      • inesephoto says:

        Oh, let the tree be! I don’t think any of you is ready for that superhero project. Break off a few small branches, or trim them.

        It is our third baby. I can see a decline in medical care very clear…
        Take care, enjoy October! xx

    • I wish I had a good news blog. That would be a real change of pace.
      Here’s to you and yours.

  5. Hi Sheri, I hope you’re well and good to see you still posting important information that will help others.

  6. Gallivanta says:

    What’s on my mind? A fair bit of despair that nursing home residents are classified into one of 66 groups depending on the patient’s needs.I am not sure why humans feel such a need to place people in neat strait-jacket boxes, like an item on a balance sheet! Anyway, I am so glad to hear that Tom is home again. 🙂

    • Yes, Indeed. You captured it on the head for me Anne. Tom being home is the best thing in the world for me and Bailey has been doing his happy dance for almost a week now. He’s a silly one, he is. He’ll give Tom all of his toys during the day then when night falls, he takes all the toys away and puts them in a pile where they belong. A friend of mine suggested a toy box but I’m wondering if that might be a bit extreme for a dog like Bailey.

      I have to catch up with you as I want to know how your gardens did for you while I was away. We had such a hot, hot, hot summer – everything burned to a crisp. Sure I watered and most things would bloom for a day or two but nothing could take the heat for a day or two but then tear themselves apart with the heat. I tried running a fine mist 24 hr/day since the leaves are made of 80% water but I think the mist evaporated before it hit the flowers.

      I’m open to all suggestions for easy to care for and heat and humidity resistant flowers for next years garden. If they are available in plant form now, I plan to go ahead and plant them as plants vs seeds. Seeds are so much cheaper but I had to plant my seeds 3 times last year as the rain kept washing them away . . . gurr. I’m also looking for vines that will survive the same conditions. I’m in the process of digging up 6 of my roses that have been in the ground 8 years or so. They are not happy with me and making the task difficult. With my being a caregiver for Tom, I don’t have as many hours to spend in the garden and that’s okay. Our temperatures are hotter every year. I simply can’t take 30 days in a row of 100 degree temps and 98% humidity.

      Take care and thank you for stopping by to read with me and by all means, for taking the time to leave a comment. P.S. I was outraged when I saw a patient could be shoved into 1 of 66 slots. Let’s face it, that’s a lot of categories and nursing homes and skilled facilities use the slot wherein they’ll receive the highest payment.

      • Gallivanta says:

        Bailey is so cute. My Jack has one toy which he loves more than any other and he likes to bring it to his favourite person of the day. And he usually remembers to collect at the end of the day. And, goodness, your temperatures make me exhausted just thinking about them. In such conditions you are doing an amazing job with your garden. My garden is a wreck at the moment. I have let the weeds take over. The only benefit of weeds is that they provide ground cover and keep as much moisture as possible in the ground!

        • By the middle of Sept I said, “No more.” The heat was simply to intense. Once again I have the garden books and am planning on saving what doesn’t die and go from there. Everything new going in must be on the surviver side of things!

  7. Thank you, Sheri. Very useful information, especially as our parents and we ourselves age and our health deteriorates.

    • Kitt – I see this as doubly important for you. If I remember correctly, your parents are in private care. A nursing home or skilled care would likely attempt to take advantage of you if they only needed skilled care. These facilities will also often attempt to send the patient home with Home Health. Yes, you want Home Health but not until you’ve used up all the ‘free’ days you are entitled to with Medicare. Additionally, your parents may have long term care insurance or other health care insurance that will assist in the payment of their stay.

      • Unfortunately, their memory care facility is considered the “Rolls Royce” of memory care and doesn’t bill Medicare. Medicare pays for visiting doctors, visiting psych nurses, and but not for memory care or “in-house” nursing. When my mom is psychiatrically hospitalized, as she’s been three times, that’s 100% Medicare.

        • Oh, Kitt. Im’ so sorry both of your parents require memory care. That makes it really hard on you. By the facility being a “Rolls Royce” and therefore I’d guess they are highly selective of which patients they consider taking in, and can make their own rules. I’d also guess they play on everyone’s greatest fears. When I went on the walk-about [almost a full day] of the 7 different locations I had to consider for Tom, there were only 2 I considered marginally appropriate. The facilities were so dirty and with Tom’s compromised immune system, he would have been dead within 36 hours of being a resident [I think the ratio of patients to rodents was pretty even] . I was really pushed into a corner for a period of time. One of the reasons I’m blogging so much about our experiences now is that I hope to keep others from suffering the same treatment.
          Of course, if I remember correctly, you mother would have had to pass state testing before being placed in a ‘regular’ facility. The whole thing is terribly unfair and I’m starting to work on legislation [i have 2 pieces I’m working on]. We had a letter from Tom’s psychiatrist stating he had not required hospitalization in 11 years and that he had been stable that entire time and still we had to wait for the state. In the meantime, Tom was off all of his daily medications 21 days, to include both his psychiatric meds and his regular medications [1 of them keeps his blood thin enough to go through his stent]. I’ll just say I thought I was walking through a nightmare.

  8. I am not happy about going into the Medicare system. Luckily, I’m fairly healthy and my doctors have continued. We’ll see.

    • Jacqui, I hear you loud and clear. I’m still kicking and screaming. Medicare was a good system for my parents but we’re a different generation. Because they survived through the great depression and managed to come out the other side and were able to tell about it tells much about their ability to survive. Many in our generation have made other arrangements for their medical needs to be met yet government cannot seem to comprehend this simple concept.
      What’s interesting to me is that some of the ‘very best’ doctors are leaving civilian practice and going to work for the Veterans Administration. They’ve made good money in the civilian sector but with everything Medicare is putting the doctors thru to get paid, mountains of paperwork not to mention not being able to keep a patient in the hospital beyond 3 days even if that means discharging them from ICU.
      Medicare has cut the doctor’s fees so much, they can double their salary at the VA and have minimum paperwork compared to private sector.

  9. GP Cox says:

    I haven’t liked one nursing home I’ve ever been in when visiting people I’ve known. I’ve even seen drastic downward signs in patients the longer they stay. For me personally, my insurance pays for a program called Silver Sneakers and today will be my first visit to actually use the gym and try to put-off the need for a nursing home.
    Thank you for these informative posts, Sheri and please give Tom my best!

    • Silver sneakers is a good program across the nation and I hope you encounter a good one. If you aren’t satisfied, by all means, find another one. Tom and I would be in Silver Sneakers but we have full pay BC/BS and not the Medicare Supplement; therefore we don’t qualify for the free Silber Sneakers Program.
      I don’t think anyone is in a nursing home, skilled nursing or step down unit because they want to be there. It’s necessitated by a medical need. I’m with you, exercise keeps the body lubricated so hopefully we can keep up.
      Tom is still home and improving everyday.

  10. Good to know this. It’s hard to keep up with all the print. And small print.

  11. Thanks, Sheri. Good to know.

  12. ksbeth says:

    this is such good news and thank you for sharing this new info, sheri. you are the one i always look to for first-hand information.

  13. Would love to comment but it won’t let me. Thank you for letting us know about this change, Sheri.


    • Hello, Patti. I fought with word press over 3 hours last week attempting to comment to the comment you left on my post. I never could move my real response over to the blog. I’d answered you in what I call the galley. I have no idea what the real name of the area is but it makes it much faster to like and comment on posts. Anyway, I posted you 2 responses telling you I was trying to reply to you.
      This particular change in Medicare is the only positive one I’ve seen in a very long time. The present law doesn’t help patients with expensive medication requirements and/or mental health issues [rather they are symptomatic or not]. It’s a crazy making process.

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