OT Connections Logo

Medicare patient stories

Public Forums

Public Forums
Forums available to everyone to read and post.

Medicare patient stories

  • Help AOTA help you! share stories (protecting confidentiality) of your clients who may or might meet the cap soon.  Include stories from previous years too!  AOTA needs this information to share with Congress to get the cap exception process restored.  Check the AOTA website for further information but share your stories here!

  • I am a Director in long term care.  In the 1st week of January, we had a resident who began chooking on her food and Speech was ordered for intervention. A few days later Physical Therapy was ordered due to  increased difficulty in transfers. Because of the sharing of the cap, the dollar available was used by the 3rd week in January. Occupational Therapy then began to intervene for the difficulty with eating and balance concerns. This resident was previously doing well with minimum assistance. While this significant change did not warrant a hospitialization, the resident definitely needed skilled intervention for this episode of decline.

        The resident does have Dementia, Osteoarthritis, HTN and Dysphagia. Now for the rest of the year, she will not have any Part B benefit available. Nursing can only do so much. Skilled therapy services are not included in the Medicaid room rate and there is no other fee schedule available.

        If the Part B exceptions process was in place, this resident would be able to receive any future skilled intervention to help her remain in her present environment and avoid hospitalizations. Transport to a hospital outpatient clinic is financially prohibitive and they do not know how to deal with LTC patients.

       The Part B premium is paid each month, but has become more restrictive than any other insurance type. I continue to contact my Senators and Representative. Hopefully a deluge of concerns from constituents will draw attention to this serious concern for beneficiaries.



  • I am an OT at a SNF, where we have a large number of LTC clients. These clients are often persons who make slow but consistent progress, and require increased repetition and time to rehabilitate.

    After the 1st week in January, we were forced to discharge approximately 80% of our clients who were under Med B due to the delay in processing the therapy caps. Although these persons were making gains, we did not want to utilize their entire benefit in the first of the year, when it is likely many of these persons could have an additional and possibly more major decline due to a fall, broken extremity or exacerbation of their condition.

    Also, we have one woman who recently exhausted all of her benefit under Med B. This woman had fallen and broke her foot. She is now returning home, I in ADLs, but not IADLS. This woman has cognitive deficits remaining that result in her requiring max assist in medication management, financial management and min assist in meal prep. In addition, she is a caregiver for her grown son, and is unable to safely return to this role. Services in our area are not able to assist this woman until the middle of March due to excessive health care needs and her lack of income. Because of this delay in therapy caps, we are not able to provide her with the best care possible given the limitations.

  • Leaders in Congress contacted AOTA for stories just this past week!  PLEASE send in client stories about how the cap will impact people.  We have to show the cap will do REAL harm to REAL Medicare beneficiaries!  Protect confidentiality but PLEASE SHARE!

  • I can't help wondering if ALL therapists provided ONLY medically necessary  therapy, would the caps even be in place? 

    I better solution is for Medicare to crack down on medically unnecessary therapy services, across the spectrum of OT/PT/SLP.  I see SO many patients getting therapy when it's not medically necessary, is it any wonder that Medicare placed caps on outpatient therapy.

    This message is not directed to the two therapists on this post, it's just a general comment.

  • I'd be interested in hearing about the non-medically necessary OT that you are seeing, how often you see it and where you are seeing these services delivered.

  • My post was addressed to Ron.

  • Carol, my comments are directed to therapy in general, not just OT.

    However, working in home health, I witness a plethera of therpay, primarily PT, being given to patients when it's not medically necessary.  Now, the term "medically necessary" is vague and one man's opinion of necessary can be vastly different from another. Medicare does provide guidelines on medical necessity but they are also vague.

    None the less, I see PT dragging out therapy with their patients, doing routine exercises or mobility training for patients who are essentially independent in their homes.  I see them doing ROM to patients who have no hope of showing improvement.  But, the real problem relates to Medicare reimbursement based on therapy visits. In our area, home health agencies get a big reimbursement bump for 7 therapy visits and then again at 11. Thus, there is a push to get therapy visits to fall near these bumps.   Thus, therapy is sometime "strung out" to help ensure these bumps are met.  Or, in the case of some ortho patients who are not on HH very long, the visits are "front loaded", not to benefit the patient, but to benefit the reimbursement to the agency.

    Overall, I think the world of therapy is ripe with "abuse" and max utilization.  It should come as no surprise that where money is to b e made and there is little over-sight, abuse will exist.

  • I am a rehab director in a SNF, we have had to discharge at least 5 people per week because of the cap.  We recently had a patient that has been working since her 100 skilled days- this patient was mostly bedridden, and as of her last part B day, she was walking 6-8 feet in the parallel bars.  It is very sad to think how far she COULD have gone had she been given the opportunity to continue with her therapy.  She will remain on a restorative nursing program, but sadly they will be unable to give her the skilled services she truly needs.

  • Your concern (Ron) about unnecessary therapy is not going to help that lymphedema patient, or that burn patient, or that patient with a crushed hand get their therapy.  We can all agree that there may be some need to improve oversight of therapy but  if you look at the history of the cap it was just another way to save money in the Balanced Budget Act.  All therapists should provide therapy in an ethical, legal and appropriate manner.  But making some patients who truly need intervention suffer is not the answer. 

    Tell us a story about appropriate care that needed to go over the cap.  I'm sure when you provide medically necessary care it can sometimes go over the cap.

  • So sad. Great story. Thanks.

  • A couple comments:

    1) The therapy cap was designed to save money but it never really worked. The use of the KX modifier helped ensure that beneficiaries continued receiving therapy.

    2) Companies and therapists can and should provide pro bono and/or reduced fee therapy for the patients  who "truly need intervention". How much therapy a company or an individual therapist should provide without reimbursement is obviously an individual choice. But, to shout on one hand, these patient's NEED therapy and then not providing it SOLELY because of no reimbursement seems a little odd.

    3) There are other options for therapy for patients exceeding the outpatient therapy cap.

    Please understand, I KNOW that people needing skilled OT will be denied because of the therapy cap. And I am not suggesting that these people should be denied, but there ARE options to consider other than pleading for more money from Medicare (i.e. tax payers).

  • This is in response to Ron's last comment.

    I would love to hear how you are seeing the current cap situation impact the care you are providing currently, on a day to day basis.  I feel it is important to hear these stories with concrete examples of how care is being impacted, and not be distracted by the associated issues, so that we can better understand the situation we are in on a more national level.

    I believe you are bringing in important issues that are tied to, but not directly addressing the topic proposed.  I understand there are many complex issues regarding ethics, reimbursement justification and sustainability of our healthcare system on both large and small scales, but I see these as larger issues that are diverting this conversation. I would like to hear how the current Med B cap situation is impacting the care you are providing, or that which you are seeing being provided.


  • Please remember most beneficiaries pay a portion of their Medicare Part B premium each month.  Medicare covers therapy if the beneficiary needs it and will benefit by it.  Why should patients have to pay for covered services?  Why should they get "charity" care like in the years before Medicare?

    Yes, there are better ways to manage access to and use of therapy.  We can always improve.  But there will always be beneficiaries who have a great need because of a catastrophic situation.  This is not pleading for more money from taxpayers; this is arguing for their rights.


  • Hey I read and appreciate your posts on the health care caps. I'm an OTA student and have been asked to write to my senators about why the caps are bad, when I don't really understand them. I may decide that they're no good, but so far I haven't heard much other than shouting about how we must get rid of them. Thanks for offering some perspective. It would be nice to see some alternative ideas that AOTA might have to put in place of the caps.