Outpatient Therapy and In-Home Health Care Conflict

We would like to increase awareness among local Care Coordination Organizations (CCOs) of a recent conflict arising out of Aspire’s (Article 16) Outpatient Therapy Clinic. This information is pertinent to any individuals WITH Medicare AND receiving services in Aspire’s Outpatient Therapy Clinic.

For these individuals who have Medicare, Part B benefits pay for outpatient therapy services. They are also entitled to Part A benefits which cover in home health care, hospitalizations, skilled nursing, etc. The conflict arises once this individual on Medicare AND receiving ANY outpatient therapy service receives ANY Part A service. When this happens, they lose their eligibility for ANY Part B service. For example, if a person gets outpatient Physical Therapy (PT) in our clinic and then develops a wound that requires in-home nursing care, they are no longer eligible to receive PT or any other outpatient therapy.

Recently, we have received a number of notifications from Medicare about in-home healthcare services disqualifying individuals for their therapy service(s) which are just as important as their medical care, thus creating a significant issue for the individual.

We are asking Care Coordinator/Managers to identify those individuals you support that may fit this criteria and to notify the Aspire Outpatient Therapy Clinic if and when this individual begins receiving or is targeted to receive in-home health care service(s). This will allow us to approach the situation proactively.

To reach our clinic, please call (716) 505-5652.

For questions about this notice or to learn more, please contact Martha Farewell, Vice President of Clinical Services at Martha.Farewell@aspirewny.org or (716) 505-5636.