Let’s take a little trip to the past: the year was 1997. “Titanic” was smashing box office records as moviegoers flocked to theaters for their third or fourth viewing; “Wannabe” by Spice Girls was hitting the airwaves on every Top 40 station; and large-scale healthcare reform was barely stepping into the legislative limelight. To hamper exorbitant healthcare spending, the Clinton administration signed the Balanced Budget Act into law and thus, introduced the Medicare therapy cap. Fast forward 20 years, and a lot has changed: for one thing, I’ve long since removed that Soundgarden poster from my bedroom wall. But at least one thing remains the same: the cost of healthcare continues to be a tremendous burden, and the Medicare therapy cap for PT, OT, and SLP in 2017 continues to cause major headaches for patients and providers alike.

How to Set Up a Google My Business Page for Your PT Clinic - Regular BannerHow to Set Up a Google My Business Page for Your PT Clinic - Small Banner

It’s Detrimental to Patients

In its current form, the therapy cap can throw a lot of roadblocks into the patient care path, preventing therapists from doing what they do best: helping patients improve function and mobility. But the tangled web of rules, regulations, and myths incites much confusion within the rehab therapy community. For one thing, many providers mistakenly assume that Medicare will not pay for services beyond the initial $1,980 limit—with or without the KX modifier. Some providers are also hesitant to enter the exceptions process due to Medicare’s murky definition of “medical necessity,” especially as it relates to maintenance care coverage. Of course, Medicare covers maintenance care as long as it’s medically necessary. But again—and as we learned from Jimmo v. Sebelius—defining medical necessity isn’t always cut and dried.

Furthermore, many rehab therapists have been led to believe that frequently exceeding the cap could be a red flag to Medicare—which could increases their chances of being audited. As providers feel pressured to press pause on the course of care, these breaks in the care plan make patients vulnerable to regression and re-injury. Some patients may even end up turning to more invasive—not to mention expensive—care options, which leads to unnecessary spending in the long run. So in the end, the therapy cap that was supposed to keep the healthcare system from hemorrhaging money could actually—theoretically—create even more unnecessary spending.

It creates a serious dilemma for speech and PT patients.

It also means that some patients might have to choose between physical therapy and speech therapy, both of which are covered under the same cap. In the event of a major cardiac or neural event—such as a stroke—a patient might find that the allotted amount is only enough to cover one or the other, leaving that patient with an unfathomable choice: mobility or communication.

Professional associations are on board.

According to APTA Chief Executive Officer Justin Moore, the fundamental problem that the cap was intended to solve in 1997 still exists in 2017: the yearly allowable amount is so low that strictly adhering to it would prevent patients from obtaining crucial, medically necessary treatment. True, there’s an exceptions process in place for those who exceed the therapy cap, but that process is often disruptive and can create gaps in ongoing treatment plans. This past July, Moore—along with representatives from the American Speech-Language Hearing Association (ASHA) and the American Occupational Therapy Association (AOTA)—reiterated this very point to the House of Representatives Subcommittee on Health. As he put it, "This pattern of yearly extensions without a permanent solution creates uncertainty for beneficiaries and providers, threatens access to care, and is not in the best interest of patients, providers, or the Medicare program."

Time is of The Essence

Granted, there are inevitable costs associated with a repeal, but—as history has taught us—those costs will only increase the longer Congress delays action. According to the APTA, “The [current] effort to end the therapy cap marks the 17th attempt to move away from what originally was intended to be a temporary provision adopted as part of the 1997 Balanced Budget Act.”

The updated medical review process shows promise.

But, Moore and other rehab therapy leaders are advocating for a more permanent fix. During his testimony on Capitol Hill, Moore referred to the manual medical review process changes implemented in 2015, noting that this update “set the stage for viable review programs that would ensure appropriate spending without resorting to caps.” Based on the overall success of these changes, he suggested replacing the cap with a "thoughtful medical review that is more targeted, ensures that care is delivered to more vulnerable patients, streamlines the ability to deliver that care, and ensures the long-term viability of the Medicare program.”

The Rehab Community Must Act Now

Language in the Balanced Budget Act indicated the cap would serve as a temporary fix until a better solution became available. By now—thanks to programs like PQRS, FLR, and manual medical review—we’ve collected enough data to support the importance of rehab therapy and solidify its role in the recovery and habilitation processes. With 177 cosponsors, the current bill to repeal the therapy cap (HR 807) has strong bipartisan support. That—coupled with the encouraging results of medical review update and strong grassroots efforts in all areas of the rehab therapy profession—puts our industry in the perfect position to create real change and maybe, just maybe, nix the therapy cap for good.

Ready to stand up for your profession and join the movement? Here’s how you can take action right now:

  • Join APTA and stay up to date on advocacy efforts.
  • Be an active member of PTeam—APTA’s advocacy team.
  • Contact your representatives about repealing the Medicare therapy cap.
  • Visit www.apta.org/takeaction to stay current on various advocacy efforts.

Clearly, the American healthcare system is in flux. As Congress dukes it out over healthcare reform and insurance payers adjust their reimbursement models, fixing and removing outdated policies is inevitable. By advocating for this necessary change now, rehab therapists can help push the leviathan-sized healthcare reform process onward and upward. Sure, crushed velvet t-shirts and Doc Martins have made a comeback, but ’90s healthcare policy is less than fashionable. It’s time for CMS to get with the times—and that’ll only happen if the community stands together and rallies as a united front.

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • The Ultimate ICD-10 FAQ: Part Deux Image

    articleSep 24, 2015 | 16 min. read

    The Ultimate ICD-10 FAQ: Part Deux

    Just when we thought we’d gotten every ICD-10 question under the sun, we got, well, more questions. Like, a lot more. But, we take that as a good sign, because like a scrappy reporter trying to get to the bottom of a big story, our audience of blog readers and webinar attendees aren’t afraid to ask the tough questions—which means they’re serious about preparing themselves for the changes ahead. And we’re equally serious about providing them with …

  • The Ultimate ICD-10 FAQ Image

    articleSep 1, 2015 | 21 min. read

    The Ultimate ICD-10 FAQ

    Yesterday, we hosted the largest webinar in WebPT history . Thousands of rehab therapy professionals attended the live session, which focused on ICD-10 coding examples . As expected, we received a lot of questions. Below is a collection of the webinar’s most frequently asked questions. The Seventh Character Craze What is the seventh character? The seventh character didn’t exist in ICD-9 , so it’s caused a great deal of confusion. Essentially, it’s a mechanism for applying greater …

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum . As expected, we received more questions than our Medicare experts could answer during the live session, so we've provided the answers to the most frequently asked ones below. Don't see the answer you're looking for? Post your question in the comment section at the end of this …

  • articleNov 19, 2013 | 4 min. read

    Therapy Cap Recap

    If you’re a rehab therapist who treats Medicare patients, you’ve got a bevy of rules and regulations to follow and knowing all of them inside and out is a tall order, to say the least. If decoding government legalese isn’t really your thing, don’t worry—we’ve dedicated this entire month to serving up a smorgasbord of digestible, easy-to-understand guides on the important Medicare policies that apply to you. On today’s menu: the therapy cap. As part of the …

  • Hot Out of the Oven: Highlights of the 2017 Final Rule for PTs, OTs, and SLPs Image

    articleNov 9, 2016 | 8 min. read

    Hot Out of the Oven: Highlights of the 2017 Final Rule for PTs, OTs, and SLPs

    Halloween may be over, but if you didn’t get your fill of scares, I’ve got the perfect activity for you: reading through 1,401 pages of pure Medicare gobbledygook. Screaming yet? (Or should I check back at around page 500?) I kid, of course; there’s no need for you to slog through this year’s extra meaty Final Rule —which details the Medicare fee schedule and other important Medicare regulatory and reimbursement changes for physical therapy, occupational therapy, and …

  • The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP Image

    articleOct 27, 2016 | 33 min. read

    The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP

    In October, we hosted a webinar dedicated to the most common Medicare misconceptions . We received a lot of questions from the audience—so many, in fact, that we’ve organized them all into one huge FAQ. Scroll through and check them out, or use the link bank below to skip to a particular section. The Therapy Cap ABNs Modifiers Supervision Prescriptions and Certifications Cash-Pay Rules and Regulations Re-Evaluations Everything Else   The Therapy Cap If a patient reaches …

  • CMS’s Final Bow: The 2019 Final Rule Image

    articleNov 5, 2018 | 8 min. read

    CMS’s Final Bow: The 2019 Final Rule

    Last week, the Centers for Medicare and Medicaid Services (CMS) published its 2019 final rule . Clocking in at just over 2,300 pages, the final rule isn't exactly a light read—especially because the legal lingo can be harder to interpret than Shakespearean verse. Luckily, we have the script—with all its twists and turns—decoded and ready for you to review. Here's the synopsis of all the physical therapy, occupational therapy, and speech-language pathology Medicare changes for 2019: Out, …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.