Eli's Rehab Report

Published on Tue Mar 03, 2015 PDF

Patients could suffer the most, therapists point out.

Therapists and their representative associations can’t help noting the catch-22 situation created by the combined effects of the IMPACT Act and the therapy caps. Quality of care is the core issue as far as the IMPACT Act is concerned; but the Medicare Payment Advisory Commission (MedPAC) recommended reducing costs by implementing therapy caps.

Important: Ongoing, medically necessary outpatient therapy services get halted for many Medicare beneficiaries because of current therapy cap limitations and onerous exceptions process that effectively serves as an absolute cap on coverage. MedPAC endorsed retaining an exceptions process with a more “streamlined” manual medical review process for therapy claims that exceed the cap.

You’ve had a reprieve from Medicare Part B Manual Medical Reviews (MMRs) since February 2014, but the Centers for Medicare & Medicaid Services (CMS) recently announced that MMRs will resume immediately (see story on page 19.)

Don’t expect your claims to squeak by. “Providers can be assured that CMS intends to review all claims that are above the $3,700 threshold,” cautioned Cyndi Ouellette in a Feb. 9 blog posting by for Harmony Healthcare International in Topsfield, Mass. “Understanding the process and managing these inquiries in a timely and detailed manner is critical in order to minimize recoupment of Medicare revenue.”

Crucial: If you receive an ADR notice, make sure you read it carefully and pay attention to the dates of service, Ouellette stressed. Ensure that you have all documentation organized in the medical record to streamline the potential review process — if you don’t submit all the required documentation, you could face total denial of the claim.

“Claims from private practices, group practices, university clinics, and other providers who submit using the CMS-1500 form or electronic equivalent will not be included in this resumption of the MMR process,” says the American Speech-Language-Hearing Association (ASHA) in a Feb. 12 press release.

All Hope Not Lost Yet For Ensuring Medically Necessary Therapy

Legislation to permanently repeal therapy caps, the Medicare Access to Rehabilitation Services Act, has been introduced in the U.S. House of Representatives on Feb. 5 by Charles Boustany (R-LA), working in close collaboration with key champions Representatives Xavier Becerra (D-CA), Marsha Blackburn (R-TN) and Lois Capps (D-CA).

“With the current therapy exceptions process set to expire on March 31st and a hard cap just on the horizon, early introduction of this legislation is critical to demonstrating to Congress the support behind repealing this long-flawed policy,” said Tim Casey, Director of Federal Affairs for the American Occupational Therapy Association (AOTA) in Feb. 5 AOTA press release. “We are thankful to the champions of this bill for lending their voice to an issue that has far-reaching effects on the ability of our nation’s seniors to get the care they need and deserve.”

This legislation has been welcomed by therapists’ associations. “The therapy cap exceptions process requires reauthorization annually and has historically been achieved within payment, tax, or fiscal related legislation,” ASHA reminds us on its website.

Stressing the need to “move beyond the harmful cycle of short-term extensions and address the therapy cap once and for all by fully and permanently repealing Medicare’s outpatient therapy cap,” AOTA Executive Director Frederick P. Somers said in the same press release, “for hundreds of thousands of Medicare beneficiaries seeking much-needed occupational therapy to improve or maintain their quality of life, the therapy cap continues to serve as an arbitrary barrier to care.”

Note: For more on MedPac recommendations see “Temporary Payment Policies in Medicare” — Statement of Glenn Hackbarth, Chairman, Medicare Payment Advisory Commission (January 9, 2014), available at: docs.house.gov/meetings/IF/IF14/20140109/101627/HHRG-113-IF14-Wstate-HackbarthG-20140109.pdf.