NOTICE OF FINANCIAL LIMITATION: Medicare has placed an annual financial limit (cap) on therapy services. The calendar year starts January 1 and ends on December 31. There is an exception process by which Medicare will pay for services beyond the cap if the services are determined to be medically necessary and meet specific criteria. The annual cap for 2016 is $1,960 for Physical Therapy and Speech Therapy services combined.
HOW DOES THE CAP WORK? Medicare bases the cap on the allowable charges covered by Medicare. In other words, it is based on what Medicare considers the maximum reimbursement that it will make for a service. After you have met your Medicare deductible of $166.00, Medicare will pay 80% of the $1,960. You will be responsible for 20% of the $1,960. However, most secondary insurances will pick up this 20%. These numbers are based on the annual therapy cap.
WHAT HAPPENS WHEN THE CAP IS REACHED? If your therapy services will exceed the cap you have some choices. You can: 1. Continue services under the exception process, if you qualify, OR 2. Continue therapy on a self-pay basis, OR 3. Transition to the PRO Wellness program.
DISCLAIMER: We are in opposition to the limitation that Congress has imposed on the benefits that you receive under Medicare. We will work with you to ensure that you receive the medically necessary care that you need.
Medicare Questions & Answers
Q: I just received a letter from Medicare (CMS) that shows how much has been paid for therapy services. The letter also states I could be responsible for services not deemed “medically necessary”. Should I be concerned?
A: CMS is notifying all beneficiaries regarding the amount of services they may have used year to date. PRO Therapy closely monitors the amount paid by Medicare to keep you informed. More importantly, at PRO Therapy we focus on providing “medically necessary” services closely monitored by physical therapist.
Q: Can I come to PRO Therapy if I have had prior treatment by a different therapist at a different facility?
A: Yes. As a courtesy to you we always verify your benefits, amount of services you may have used, and inform you of what coverage you currently have. In addition, we continue to closely monitor your benefits.
Q: Do I need a doctor’s referral to see a P.T. at PRO Therapy?
A: No. Arizona is a direct access state and therefore allows you to seek the services of a licensed physical therapist when you desire. As a courtesy to you we will notify your physician if therapy is needed.