Is it really December already? As business professionals, our days seem to get longer—and our years shorter—the further we get into our careers. (I still can’t believe WebPT is celebrating its 10-year anniversary this year.) And with the way time keeps on slippin’, it’s easy to overlook the major milestones our profession has seen recently. This year, I’ve made a personal commitment to being more present in my day-to-day life—and I think that pursuit extends to my profession, as well. In that spirit, I’d like to take some time to appreciate and reflect on how far we, as rehab therapists, have come this year. Here are the best moments for PTs, OTs, and SLPs in 2018:
When the Therapy Cap was Repealed
This year started off on a rather inauspicious note: on January 1, 2018, the hard cap on therapy services went into effect, meaning any Medicare charges in excess of $2,010 were stuck in limbo—and would face denial without further action. After weeks of back and forth, the US Senate voted in favor of a stopgap budget bill—known as the Bipartisan Budget Act of 2018—that officially repealed the Medicare therapy cap.
PTs, OTs, and SLPs across the nation breathed a collective sigh of relief, but as with most things legislative, there was still a lot of confusion about what this actually meant. After all, the language in the bill indicated there would still be a “limit” of $2,010 for occupational therapy services and $2,010 for physical therapy and speech therapy services combined. And, as in years past, a Medicare beneficiary could still exceed this limit, provided that:
- continued treatment was medically necessary, and
- the patient’s therapist affixed the KX modifier to any claims above the threshold.
From the provider perspective, it seemed like very little had actually changed—aside from the targeted medical review threshold lowering from $3,700 to $3,000.
So, what actually changed?
Back in 1997, President Clinton signed the Balanced Budget Act of 1997—the bill that originally introduced therapy cap legislation—into law. This law imposed a hard cap on therapy services, placing financial liability for any claims exceeding the hard cap on Medicare beneficiaries. However, every year since the cap’s adoption, Congress has voted to extend an exceptions process for claims exceeding the hard cap. But lawmakers never intended for the exceptions process to be a permanent solution. And as we learned in January, implementation of a hard cap without an exceptions process has been a very real threat for the past 20 years.
To sum it all up, with this historic action, the constant threat of a hard cap is gone, and Medicare beneficiaries can still obtain medically necessary therapy services beyond the now-$2,040 limit—often referred to as the “soft cap.” And that means patients can get the services they need—regardless of whether they’ve exceeded that cap. So, while it’s not perfect, it is a step in the right direction—one worthy of celebration.
Download your 2018 State of Rehab Therapy report now.
Enter your email address below, and we’ll send you a free comprehensive report on the trends shaping the future of the industry.
When FLR Got the Boot
Another high five-worthy development: Starting in 2019, rehab therapists will no longer have to submit functional limitation reporting (FLR) information to Medicare in order to receive reimbursement. It was a somewhat shocking—but decidedly welcome—move. Back in July, CMS released its 2019 physician fee schedule proposed rule, which officially put FLR on the chopping block. The reason: to reduce the regulatory burden placed on providers. But, that wasn’t the only driver behind FLR’s sudden expiration date. As we explained here, the FLR program ultimately fell short of the objectives it was created to achieve. In other words, FLR didn’t produce the kind of useful data CMS was hoping to collect.
However, it’s important to note that—despite FLR taking its final bow on December 31, 2018—the 42 non-payable HCPCS codes associated with FLR will stick around for another year. That way, providers and insurers have ample time to update their billing systems and policies (and avoid any potential claim rejections). And as we mentioned in our recent final rule post, “Because non-payable HCPCS codes are sticking around for another year, MIPS-eligible PTs, OTs, and SLPs may use six of the remaining G-codes for MIPS quality reporting in 2019.”
But, just because FLR is gone, it doesn’t mean we can take functional outcomes data collection off our radar. In fact, we should be deeply concerned about CMS’s admission that the FLR data it collected proved pretty fruitless in the end—because that means CMS still doesn’t have the data it needs to make informed decisions about PT-related regulations and payment policies. So, perhaps we should view this as an opportunity to put the time we would have spent fulfilling FLR requirements into amassing data that is actually meaningful—data we could use to advocate for better payment rates and more worthwhile quality reporting programs.
When CMS Announced the Inclusion of Rehab Therapists in MIPS
Speaking of MIPS: As you (hopefully) know by now, PTs, OTs, and qualified SLPs will be eligible to participate in the Merit-Based Incentive Payment System (MIPS) program in 2019. I’ll admit it: more data reporting doesn’t exactly sound like a win. However, for those qualifying providers, MIPS opens the door to an opportunity to increase Medicare reimbursements over the next several years. Furthermore, this decision is a nod of acknowledgment from CMS toward PTs, OTs, and SLPs. The agency is recognizing therapists as equals to other healthcare providers by putting us on a similar playing field.
Now, it’s worth mentioning that based on the existing participation criteria (and contrary to a lot of the recent advertising hype you may have come across), the vast majority of outpatient rehab therapists will not be required to report MIPS data—and even if you are able to opt in, I’m not necessarily saying you should. But, at the very least, we’ll have representation, and I think there is potential for the program to evolve in such a way that there will be more upside to participation for everyone involved.
When Optum Conducted a Massive Study on PT’s Effect on the Opioid Crisis
This year has also been a big one for the relationship between therapy providers and insurance payers. As I mentioned in this recap of the 2018 Graham Sessions, data will bridge the gap between payers and providers, which means we can’t be afraid to share our outcomes data.
During his keynote address at this year’s Ascend conference, David Elton, Senior Vice President of Clinical Programs at Optum, confirmed this. During his presentation, he gave attendees an inside look at Optum/UHC’s efforts to fight the rising cost of low back pain treatment. These efforts include a massive, soon-to-be-published study conducted by Boston University and jointly sponsored by UHC and the APTA. This study provided some pretty staggering data:
- Claims for musculoskeletal conditions accounted for more than 16% of total spending, which is more than the spending associated with any other condition.
- 75% of spending for musculoskeletal episodes went toward prescription medications. (For some perspective, a little over 11% of UHC’s total spend went toward claims for cancer treatment.)
- Approximately one-third of eligible patients attended conservative treatments—such as physical therapy or chiropractic care—as a first option.
- At the same time, low back pain patients who attended conservative therapies first were “75% to 90% less likely to have short or long-term exposure to opioids.”
Why is this so significant?
Aside from publicly verifying something PTs have known all along—that physical therapy can be instrumental not only in fighting the opioid epidemic, but also in reducing downstream healthcare costs to the tune of $200 million per year—this study was the impetus for change within UHC’s own benefits policies. As Elton stated, starting in 2019, UHC will waive the copay and/or deductible for each beneficiary’s first three physical therapy visits. He also alluded to the possibility of improving reimbursement rates based on patient outcomes.
And the impact of this data doesn’t necessarily stop with UHC. After all, if the results of this study were significant enough to convince one of the nation’s largest payers to make physical therapy more accessible to its beneficiaries, it’s reasonable to conclude that other major payers will take notice—and potentially follow suit.
When Tricare Added PTAs and OTAs to its List of Authorized Providers
On December 12, the President signed into law the National Defense Authorization Act (NDAA), which opened the door for Tricare to add physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) to its payment program. It’s a move that the APTA has long supported—one that will increase access to rehab therapy care for veterans—so this is certainly a massive win.
But, passage of the NDAA doesn’t automatically mean PTAs and OTAs can start treating Tricare beneficiaries. There’s more work to be done before therapy assistants officially get the green light from Tricare (to learn more about that, you can read our article explaining the law implementation process here). With any luck, though, I’ll be writing about this change going into effect in next year’s best moments recap.
When the PT Licensure Compact Expanded
The last time we covered the licensure compact on the WebPT Blog, 14 states had signed on, which exceeded the 10-state minimum requirement. As of this article’s publication date, 21 states have joined the compact, and one state has introduced compact legislation. This forward momentum is an incredibly positive sign for the future of our profession. The standardization of licensure requirements offers physical therapists a clear—and, for the most part, easy—path to practicing across state lines. This also increases patient access to PT, which is another major win.
When Alternative Business Models Started to Become More Commonplace
While we don’t have any definitive data to prove there’s been an increase in private-pay models or cash-based service offerings, based on my own experience, it certainly seems to be a trend. In talking with industry professionals, peers, and WebPT Members, I’ve come across a large number of therapists and practice owners who have gone out of network, added cash-pay wellness services to their offerings, or adopted other alternative business models. During our annual State of Rehab therapy survey, more than 20% of respondents reported that their organizations use a cash-pay or hybrid payment model (i.e., cash plus some commercial payers). In response to this data, cash-based practice owner and consultant Dr. Jarod Carter, PT, DPT, MTC, shed some light on the cash-pay PT movement: “Rising deductibles and copays—and less overall coverage for PT—is making it much easier to attract cash-pay patients than it used to be. So, cash-only clinics are becoming more scalable as healthcare consumers with high deductibles and copays are realizing there’s often little financial difference between going in-network and going out-of-network.” He also noted that, generally speaking, cash-only clinics are known for providing a high-quality patient experience, which contributes to the increased interest in alternative payment models from the patient’s end.
2018, we hardly knew you. The past 12 months have certainly had their ups and downs, but from where I’m standing, I see more wins than losses. And all things considered, I’m optimistic about 2019—and I certainly hope I’m not alone in that sentiment.
What were some of your favorite moments of 2018? What are you looking forward to in 2019? Share your thoughts in the comment section below.