Ch-ch-ch-changes: We’ve seen a plethora of regulatory changes this year in the PT space—from the ICD-10 delay to the therapy cap increase. Although some of these legislative twists and turns have caused headaches for therapists, others have been hugely positive. For instance, some form of direct access is now available in all 50 states as well as Washington, DC, and the US Virgin Islands. Read on to learn this year’s top regulatory changes.
With all of the blog space we’ve devoted to PQRS this month, it’s easy to forget that Medicare’s final rule addresses more than just our favorite four-letter acronym. But buried deep within CMS’s annual 1,000-plus-page behemoth of government jargon is one more major item of interest to those in the PT, OT, and SLP industries: the therapy cap.
Health and Human Services have developed a proposal for plan auto-enrollment for Affordable Care Act Marketplace consumers.
For any private practice PTs, OTs, or SLPs interested in making their clinic more successful, join us at Evolve DC on May 15, 2014.
Everyone has been gearing up in preparation of the October 1, 2014, ICD-10 implementation deadline. (Even CMS changed their claim form requirements: beginning on April 1, 2014, if you submit paper claims, you must use CMS1500 version 2/12 instead of version 8/05.) No one thought there would be another delay—that is, until Thursday, March 27, when the House of Representatives passed HR 4302, a bill that contained a provision to delay the implementation and extend the therapy cap and its exception process until 2015.
For years, rehab therapists have had a love-hate relationship with Medicare’s therapy cap exceptions process. On the one hand, therapists often see it as a barrier to providing patients with the care they need; on the other, it’s the only means for therapists to continue treatment after a Medicare patient has exhausted his or her annual payment allotment for therapy services (a.k.a. the therapy cap). Reform of the cap has been a long time coming, and yet, year after year Congress has instead opted to merely re-extend the exceptions process. At the end of 2013, lawmakers issued a temporary extension to the cap with plans to reconvene in 2014 to revisit the issue. But that extension is set to expire March 31, and a permanent solution has yet to emerge from Capitol Hill.
The Story of the Cap and its Exceptions Process
Introduced as part of the Balanced Budget Act (BBA) of 1997, the therapy cap places a yearly limit on Medicare’s coverage of outpatient therapy services. In 2014, that amount is $1,920 for occupational therapy and an additional $1,920 for physical therapy and speech therapy, combined. The cap applies to all Part B outpatient therapy settings and providers, including private practices, skilled nursing facilities, home health agencies, outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities, and hospital outpatient departments.
This limit was always meant to be a “hard cap.” But in 1999—the first year an absolute cap was set to go into effect—and every year since, Congress has acted to prevent the enforcement of a true cap. And that’s how the exceptions process came to be: since 2005, therapists have been allowed to continue treatment above the therapy cap as long as their services qualify as “medically necessary” according to Medicare.
Eventually, the exceptions process evolved into a two-tiered system in which therapists can continue treating past the cap up to a second cap threshold—$3,700 in 2014—as long as they attest that ongoing therapy is medically necessary as justified by supporting documentation in the patient’s medical record. (They do this by attaching the KX modifier to any post-cap claims they submit to Medicare.) However, providing services beyond this secondary threshold involves a tedious manual medical review process that, according to this report from the Center for Medicare Advocacy, “deters many providers from processing Exceptions, thus limiting beneficiary access to needed therapy services.” Essentially, the $3,700 threshold “serves as a de facto absolute cap for many beneficiaries,” meaning “many beneficiaries who need ongoing therapy go without therapy services altogether.”
This is especially true for individuals with chronic conditions who require care on an ongoing, long-term basis. While Medicare has made strides to ensure coverage for these individuals—most recently as part of a court-ordered effort to dispel the myth of patient improvement as a condition of reimbursement—conflicting Medicare policy verbiage makes it unclear as to whether Medicare will apply this rule above the cap. Specifically, Subsection A of the Medicare Claims Processing Manual reads: “…atypical use of the automatic exception process may invite contractor scrutiny. Particular care should be taken to document improvement and avoid billing for services that do not meet the requirements for skilled services, or for services which are maintenance rather than rehabilitative treatment.”
If there’s one thing that lawmakers and therapy providers can agree on, it’s that there has to be a better—and less confusing—alternative to the therapy cap exceptions process. But while government leaders tend to err on the side of cost savings (i.e., putting a total kibosh on treatment above the cap), providers are calling for a system that will ensure patients always have access to the therapy services they need. Of course, the definition of “need” is an endlessly debatable topic, as discussed in this blog poston medical necessity. With so many different points of view, it’s no wonder the proposals on the table vary so widely, with possibilities ranging from doing away with the cap entirely to making it even more restrictive.
Here’s a breakdown of the proposed solutions included in the Center for Medicare Advocacy report referenced above:
Senate Finance Committee: Repeal and Replace the Cap
The Senate Finance Committee (SFC) introduced legislation that would eliminate the cap and replace it with a medical review program involving prior authorization of services. With this system, the Secretary of Health and Human Services would be responsible for identifying services for medical review based on factors like “outlier billing patterns and newly enrolled providers.”
According to the report, the SFC still needs to flesh out the details of how this system would work, but as the report states, “it is clearly an acknowledgement that the current therapy cap policy is broken and needs to be repealed, along with instituting a more targeted approach toward medical review.”
Ever since the federal government got the ball rolling on healthcare reform legislation—a.k.a. the Affordable Care Act—it’s been a hot topic of conversation among providers and consumers alike. For the last few years, discussions about the effects of the new healthcare law were purely speculative; but now that the ACA go-live date has come and gone, a clearer picture of its impact—particularly in the realm of outpatient physical therapy—is starting to emerge. Here’s a breakdown of how the new healthcare law is affecting therapists:
Last year, the Florida state legislature passed the 2012 Personal Injury Protection (PIP) Insurance reform, which included an exclusionary clause requiring physical therapy providers to gain licensure and accreditation as a healthcare clinic before they could receive reimbursement for providing PIP-related services. As a result, Florida-based physical therapist Amado Mendoza saw a significant reduction in the number of referrals his clinic, A&M Therapy, received.
In 1997, Congress passed the Balanced Budget Act, which led to the creation of the sustainable growth rate reform (SGR) formula as well as the Medicare therapy cap. According to the APTA—and Congress—these measures were meant to save money. However, there are some serious flaws in both. As a result, every year, Congress has acted to address said flaws and stop the implementation of a hard cap. (For more information on the therapy cap and how it applies to you, check out this blog.)
If you’re in the same boat as I am, you may be wondering where summer went. It was just July. And yet somehow, Tuesday marks the first day of October. That means we should expect to see Christmas decorations cluttering grocery store aisles any day now and that Health Care Reform Notices (a.k.a. notice of coverage options under Fair Labor Standards Act) are due to employees. So here is your friendly reminder to send them out—soon. If you have no idea to what I’m referring, here’s a quick breakdown from this National Law Review article:
As a small business owner, it can seem like an uphill battle simply trying to keep everything straight—and with increasing caseloads, regulations, and legislation, you certainly have your hands full. That’s why we here at the WebPT blog have been busy compiling all sorts of useful, actionable information for you—think of us as a much-needed third hand. Today, your third hand is going to tackle the Affordable Care Act.
Woohoo! On April 15, 2013, California’s Senate voted against SB381, the bill that would have prevented physical therapists from being able to provide manipulative care. This marks a huge victory for the physical therapists in California and for our industry as a whole. And that deserves some serious celebration.