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CashPT for Medicare Beneficiaries as After Care

by | Sep 7, 2022 | Cash Based Practice

CashPT for Medicare Beneficiaries Who Want Something Better

This is a copy/paste of a post I shared on Facebook on September 9, 2022:
“Medicare (and many other 3rd party payers) still pay the same rate for 97161, 97162, and 97163.
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I love simple cases. Easy fixes and short plans of care. Nearly all of my evaluations are 97161.
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But I know some of you want to flex your clinical muscle and tackle challenging cases.
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Since Medicare has essentially benchmarked the reimbursement rate at the lowest complexity level, what if I suggested that those of you who want to treat more complicated cases, wait for those patients to be discharged from other Medicare providers?
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If a complicated patient has been discharged by a different Medicare provider then you have reasonable evidence to suggest continued services are not medically necessary and not covered under the Medicare program.
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This would allow you to truly utilize your 20 years of experience and expertise to deliver services at the highest clinical level for reasonable cash rates. … And when I say reasonable cash rates I mean YOUR cash rates. $250 to $500 a session.
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You aren’t delivering the standard of care. That was done by someone else. What you are delivering is far above and beyond Medicare-covered services.”

Mandatory Claim Submission Law

40.33 – Mandatory Claims Submission (Rev. 222, Issued: 05-13-16, Effective: 08-15-16, Implementation; 08-15-16) Section 1848(g)(4) of the Act, “Physician/Practitioner Submission of Claims,” regarding mandatory claims submission, does not apply once a physician or practitioner signs and submits an affidavit to the Medicare contractor opting out of the Medicare program, for the duration of the physician’s or practitioner’s opt-out period, unless the physician or practitioner knowingly and willfully violates a term of the affidavit.

Other Non-Covered Medicare Services for CashPTs

  • Anything related to recreation and sports.
  • Services that have been deemed as not medically necessary by the patient’s physician.
  • Services rendered in a location other than the patient’s home or your clinic.
  • Services delivered by asynchronous electronic communication such as email or text messaging.
  • Asynchronous video programming.
  • Some versions of home exercise programs.
  • Services delivered by someone other than a licensed therapist or assistant working under the direct supervision of a therapist.

Build Your Provider Network

If I were still in the cashPT only business model I would network with other Medicare contracted providers to build my provider network.

In this video, NGSMedicare MAC explains how when a patient wants 5 days a week of physical therapy services, but only 2 days a week is medically necessary, the patient may choose to self pay for the additional three days a week.

In this case, an ABN would be issued by the contracted provider if the contracted provider is supplying the additional 3 days a week of treatment.

If the extra treatments are provided by an unaffiliated physical therapist no ABN is issued.

Screencapture of ABN Triggering Event for CashPT Video

Can a CashPT use an ABN?

No. Only Medicare contracted participating and non-participating providers may use a  CMS Advance Beneficiary Notice (ABN).

Medicare Advantage

Does the ABN apply to Medicare Advantage plans?

No. The ABN is not applicable to Medicare Advantage insurance plans. Keep in mind that the Mandatory claim submission law does not apply to Medicare Advantage plans. Physical therapists that are not affiliated with Medicare Part B in any way are allowed to treat patients with Medicare Advantage insurance.

Can a Contracted Medicare Provider Offer CashPT?

Yes! The best of both worlds is to become a contracted Medicare provider who offers both Medicare covered and non-covered services.

For example, Medicare does not cover dry needling CPT Code 20560 and CPT Code 20561 when delivered by a licensed physical therapist. If you are a contracted Medicare provider your initial physical therapy evaluation would be a covered service, then if you determined that dry needling would benefit your patient and you are capable of delivering the dry needling intervention you would be allowed to charge a self pay rate for the dry needling intervention.

Medicare Covered Initial Evaluation and Dry Needling CashPT

In this case, Medicare would reimburse the Medicare allowed amount for the physical therapy evaluation CPT Code 97161 – $98 and you would charge the patient your standard CashPT rate for CPT Code 20560 – $60. 

The total revenue for a 30-minute session would be $158.

Both of these services may be provided in the same day. You may choose to supply an optional ABN as a courtesy to your patient, but it is not required.

Summary:

  • The federal mandatory claim submission law requires all healthcare providers to submit claims for service to Medicare when providing Medicare-covered services.
  • If you are a cashpt with no affiliation to Medicare Part B and you want to help Medicare beneficiaries an easy way to accomplish this is to work with a contracted Medicare provider.
  • If you become a contracted Medicare provider you would be allowed to provide both covered and non-covered services.

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