Medicare Coverage for Dementia Patients Clarified

The federal government has clarified its policy regarding Medicare’s coverage of some services for people affected by dementia to permit for greater access to speech, occupational, and rehabilitation therapies. Other services, including neuro-diagnostic testing, medication management, and psychological therapy may also be more readily available to individuals with Alzheimer’s Disease.

The policy change signals a greater opportunity for seniors and caregivers to individuals with Alzheimer’s Disease to appeal unfair denials and work with doctors to provide therapy services. It is not a guarantee that all requested services will be approved, that all denials will be reversed, or that more services are now available.

According to the internal memorandum that mandated the policy change, Medicare may now consider on a case-by-case basis paying for evaluation and management visits to a doctor, as well as physical therapy for an individual with dementia. Therapy claims had been automatically denied if an individual had been diagnosed with dementia.

“The fact that [the Center for Medicare and Medicaid Services] is directing carriers to obey the law is a good thing,” said Robert M. Hayes, President of the Medicare Rights Center, told ElderCare Online on April 3. “This is nothing more than an administrative directive to stop practices that were clearly illegal.”

History of Unfair Denial of Claims

Until recently, some contractors had programmed their reimbursement systems to automatically deny reimbursement for therapy services solely because the individual has dementia. Advocates for people with Alzheimer’s Disease, including the Alzheimer’s Association and the American Bar Association, had petitioned the government to make sure that the contractors were treating individuals with dementia the same as other Medicare beneficiaries.

The policy change is effective September 1, 2001. However, advocates have yet to see a dramatic change in the number of denials for needed services, according to Mr. Hayes. He said that the change from an automatic system to one where each request is checked individually may take time. “There probably will be some resistance based on history and inertia in this area,” he noted.

Medicare is the U.S. federal government’s program to provide hospital and doctor services to the elderly. It is managed by the Center for Medicare and Medicaid Services/CMS (the government agency formerly known as the Health Care Financing Administration/HCFA), but administered by numerous contractors that operate much like insurance companies, sending reimbursements, and enforcing payment policies.

Advances in pharmaceutical treatment and testing are making it easier for doctors to diagnose Alzheimer’s Disease at the earliest stages. Depending on the individual’s medical condition, some therapies may still be beneficial in slowing mental and physical decline.

“Alzheimer’s advocates came to us with what seemed to be a significant problem for Alzheimer’s patients,” said Tom Scully, the administrator of CMS, on April 1. “Intuitively, this longstanding approach appeared to discriminate against Alzheimer’s patients, and we were happy to fix it.”

What Should Caregivers Do?

Now more than ever the caregiver is the individual with Alzheimer’s Disease’s best advocate. This is an opportunity to argue for more comprehensive services through your doctor, as well through the formal appeals system.

You don’t need a lawyer to file and win an appeal. Individuals have a very high success rate when appealing denied services, Mr. Hayes said. Only one percent of claims are ever appealed, but more than half of those appeals are actually reversed.

Mr. Hayes warned, “The same services that were being automatically denied may still be denied. However, when a physician now orders a service such as speech therapy, the person with Medicare will be in a very good position if they appeal a denial.” He added that the behavior of doctors is now critical to making therapy more available to individuals with Alzheimer’s Disease. “Families should remind the physician [to order therapy services] if they think it is reasonable. It is covered – push the physician. If it is denied, then appeal. The appeal should be likely to succeed.”

Advocating for Necessary Services

• Collect all denied claims after September 1, 2001 (if any) that relate to physical and occupational therapy.
• Request from your doctor a copy of the original order for the service.
• Ask the doctor to write a brief note that outlines his rationale for originally ordering the therapy.
• Include a copy of the new memorandum with your appeal.
• Speak with your loved one’s doctor about ordering these types of services for your loved one in the future.
• If necessary, provide your doctor with a copy of the new memorandum to demonstrate that the service is now available.
• Check denials to make sure that the “primary diagnosis” is correct. For example, if your loved one has been discharged from the hospital after a hip fracture, the primary diagnosis should NOT be dementia, even though she may be affected by it.

This policy change does not open the door for some of the most useful services, such as homecare or support services for caregivers. “This policy change will hopefully enable Alzheimer’s patients to receive physical therapy, occupational therapy and/or speech/cognitive therapy where appropriate,” said Helene Bergman, President of Elder Care Alternatives, a geriatric care management practice in New York City. “It will not, however, provide homecare. Medicare homecare still is minimal and more commonly doled out for the short period following hospital discharge.”

Resources

 - Medicare Program Memorandum for Intermediaries/Carriers Transmittal AB-01-135 (available in Adobe Acrobat format)
 - Filing Appeals for Medicare Claims Denials  http://www.ec-online.net/Knowledge/Articles/meddenials.html
 - Tips on… Organizing Insurance Paperwork  http://www.ec-online.net/Knowledge/Articles/insclaims.html
 - Medicare Rights Center  http://www.medicarerights.org

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