Therapy Above $3700 for Medicare Patient’s

June 13, 2016
Rick Gawenda


We have a patient that is coming to us that received Speech Therapy in another facility which used his PT/Speech Medicare benefits to the point of the therapy cap dollar threshold and has since discharged him. He now has started coming to our clinic for shoulder rehab under his Medicare benefits; however, we are having to KX the charges so we can get paid and provide the necessary care to improve his ROM, strength, and function. Since we do not desire to use up ALL of his PT benefits (to the point of $3700 total) in case he should experience another incident before the end of the year, we were discussing the possibility of transferring him to OT for continued shoulder rehab. His OT benefits have only been partially used and he still has ample benefits under OT that would allow him to receive therapy without having to KX or exhaust his benefits. Would this create a problem with Medicare if we were to transfer the patient to OT for the same diagnosis requiring shoulder rehab?


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  1. Can you explain to me why outpatient PT practices not affiliated with a hospital get reimbursed at a lower rate than a hospital outpatient facility? Why does it matter?
    A few examples come to mind…
    1) Aetna reimburses outpatient private practice PT in 3 tiers with the lowest being 175$ per year and up to 500$ per year for involved Neuro patients, so I had a ACL/PCL/MCL repair that was seen 48 visits and received 175$ !! needless to say I had several patients on my schedule with Aetna and had to drop the insurance or I would have gone out of business. Cigna or ASH group and ATA or Aetna seem to get better rates at hospitals than in private practice. Why is that?

    1. Hospitals tend to have a higher cost of doing business and do more pro-bono and uncompensated care that private practices, hence, they tend to get paid at a higher rate. Additionally, if it’s a large hospital system, they may be able to negotiate a higher payment rate based on the volume of care they provide to the beneficiaries of that insurance carrier.