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Medicare cap for rehabilitation
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Medicare cap for rehabilitation - December 30, 2005 5:34:00 AM
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lekar
Posts: 18
Joined: April 11, 2004
Status: offline
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Hi,
What is the real impact of the new cap on PT practice? I know that patients will have to pay out of their pocket after $1740 limit of PT and speech therapy services(in outpatient facilities). Obviously many patients (if not most) can't afford to pay on their own and refuse to get PT services more than allowed by the cap.
But what do you think in terms of PT earnings from now on ? Is it going to be severely damaged? Does it still worth it (financially) to attend the PT program (with so much expenses and different costs) ? Will the new graduates be able to pay off their debts and have a good living with this new law being in effect?
It just makes me really worry about the future of PT in practice. I can't believe they passed such a law.
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Re: Medicare cap for rehabilitation - December 30, 2005 3:42:00 PM
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jma
Posts: 2405
Joined: August 24, 2000
From: NY
Status: offline
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Here is an email from the APTA that was sent to me today.
"As of Sunday, January 1, Medicare will cap outpatient rehabilitation coverage at $1,740 per beneficiary for 2006.
Some beneficiaries and providers are confused by the recent flurry of attempts to keep the cap from being implemented – but I am sending this message to make sure that you and your patients are aware that Medicare therapy services are once again subject to two caps – one combined $1,740 cap for physical therapy and speech language pathology and a separate cap for occupational therapy.
In budget reconciliation legislation currently pending in Congress, there are provisions that would authorize the Centers for Medicare and Medicaid Services (CMS) to allow coverage for services beyond the cap if they are shown to be medically necessary. The reconciliation bill has been approved by the Senate but still must be voted on by the House, and this vote probably will not occur, at the earliest, before the end of January. In the meantime, the $1,740 caps go into effect on January 1 as described in current law.
APTA is working with Congress and CMS to minimize the impact of these caps on beneficiaries until we can replace them with a system that assures beneficiaries receive the clinically appropriate care they need. We are urging CMS to develop and implement a simple and effective exceptions process that will allow patients to receive clinically appropriate care exceeding the cap. We will continue to work with Congress to repeal the therapy cap and create coverage and payment policies that will assure no Medicare beneficiary is denied the care they need.
But today physical therapists need to take immediate action to make sure their practices are prepared on January 1 to protect patients and cope with the therapy cap. APTA has provided answers to some of the most “frequently asked questions” about implementation of the cap, but the following checklist should help all physical therapists in assessing their practices.
Complying with the Therapy Cap
Here are a few basic, important steps to take in providing services to your Medicare patients under the therapy cap:
1) Examine your intake process. Ask your patients if they have received physical therapy services during the same calendar year at any other location. Verify this information by accessing the patient’s accrued amount of therapy services from the “ELGA” and ELGB” screen inquiries into Medicare’s Common Work File (for more information see CMS Transmittal 759) or the HIPAA 2701271 eligibility inquiry transaction. If you do not have access to these electronic inquiries, call your Medicare carrier or intermediary. Keep in mind that physical therapy and speech-language pathology services share the same $1,740 cap.
2) Estimate the number of visits before your Medicare patient meets the cap. Take the approximate amount of your charges and divide them into $1,740 to estimate the number of visits before a given Medicare patient is likely to reach the cap. Keep in mind that the $1,740 includes both the amount Medicare pays and the beneficiary co-pay, for example, 80% of $1,740 is $1392. Beneficiary co-pays would constitute the remaining $348 of $1,740 (these figures apply to a participating provider).
3) Notify your Medicare beneficiaries that they are subject to the cap at your first therapy encounter and tell them their options once they’ve hit the cap amount: to either receive physical therapy services in an outpatient hospital setting or to pay out of pocket for your services. (Note: patients who are residents of the certified portion of a skilled nursing facility may not use outpatient hospital services.)
4) Give your patient a Notice of Exclusion of Medicare Benefits (NEMB) form if you estimate services beyond the cap amount will be needed. The NEMB notifies your patients in writing that the remainder of the services they are about to receive from you are statutorily excluded from the Medicare benefit and they will need to accept financial liability for all remaining visits.
5) You may provide contact information for hospital outpatient physical therapy services at a nearby hospital if the patient cannot afford to pay out of pocket or declines to do so for the remainder of their visits. Hospital outpatient services are not subject to the cap under current law.
6) Check the APTA website (www.apta.org) frequently for updates on the new exceptions process that CMS has yet to define. CMS is likely to issue instructions in the near future outlining the documentation requirements for these exceptions. In the meantime, make sure all of your documentation meets current Medicare requirements. Check your weekly PT Bulletin Online and the APTA homepage frequently for access to new information. In addition, train your staff to be knowledgeable about the therapy cap and be aware of its status and new developments. The APTA website provides up-to-date information from CMS on its Therapy Cap Instructions page.
I know it is very disheartening for all of us, after so much time and effort in 2005, that the New Year will begin Sunday with implementation of a flawed policy that limits the access of Medicare beneficiaries to physical therapy. But we must not waiver in our commitment to provide the best care we can for our patients. We must make the best of the therapy cap policy and renew our efforts to reform the Medicare program so that all beneficiaries will be able to obtain the physical therapy services they need. To this end, APTA will continue to push for passage of the therapy cap provisions contained in the deficit reduction legislation that awaits final action by the U.S. House of Representatives some time in late January. While not a perfect remedy, when enacted it will provide the authority for a critical exceptions process to the therapy caps. APTA will continue to keep you updated as this issue continues to develop.
Best wishes for a healthy and happy New Year.
Sincerely,
Ben F. Massey, Jr., PT, MA
President"
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Re: Medicare cap for rehabilitation - December 30, 2005 7:57:00 PM
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lekar
Posts: 18
Joined: April 11, 2004
Status: offline
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Thanks jima. I got the same email today too ! That's why I wanted to know what you guys think about its financial impact on PTs.
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Re: Medicare cap for rehabilitation - December 31, 2005 12:53:00 AM
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SJBird55
Posts: 2430
Joined: May 10, 2004
From: Michigan
Status: offline
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lekar,
There will be more than just a "financial" impact with the cap re-instated. There will be addtional headaches and time spent addressing the cap to the senior citizens whenever they attend physical therapy that isn't a hospital outpatient department. Toss in the additional confusion that speech therapy is combined with physical therapy in the cap. So, you just cost someone in an office an additional guesstimate of 15 minutes on the phone, maybe an additional 5-10 minutes educating prior to an evaluation just in explaining and clarifying the dumb thing. Then, a lot more time, and this is where I am really unsure, on attempting to verify the patient's account PRIOR to attending physical therapy. I'm not sure how long THAT will take, nor am I completely sure how accurate the information provided will be. So, there is some unknown behind the scene time spent on verifying accounts. Then, of coure, more scrupulous attention to total charges (now we won't just keep our eyes focused on a clock for every bit of time the patient is in the clinic but also focused on the almighty dollar)... more time spent discussing options IF it comes to that point where the capped amount is almost reached ... then potentially more paperwork depending on the patient's decision. Now, you realize, we don't get paid to educate the patient and if the patient asks questions to the physical therapist during a treatment session, if the activity needing performed is stopped to discuss the issue, wham, big hole of unproductive time to assist the patient with the insurance policy - can't bill for that...
Or the patient can just go to a hospital department for physical therapy if the patient has already had speech or physical therapy earlier in the year to avoid all the crap above. So, later in the year maybe around June or so, just guessing, it might just be a whole lot easier to just recommend the patient attend a hospital site? Loss of business there...
But, I would assume that if the altered billed is ever signed, the altered bill will supercede the current law that will be in effect tomorrow. I haven't seen the language of it, but have heard that there is a way to I guess be able to capture more money than the cap allows? I'm not sure how and I'm also not sure how long it would take to get authorization to continue therapy above the capped amount.
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Re: Medicare cap for rehabilitation - December 31, 2005 2:54:00 AM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
Status: offline
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don't forget, it is any BILLED therapy codes, we are not the only ones who use these CPT codes (unfortunately). chiropractors for one use these codes as well, so make sure the patient hasn't been to ANY offices for treatment, we ran into this problem last time we were capped-
Ben
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Re: Medicare cap for rehabilitation - December 31, 2005 11:06:00 AM
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lekar
Posts: 18
Joined: April 11, 2004
Status: offline
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This is unbelievable ! Not a long time ago, we were talking about direct access issue and how to deal with it as well as choosing between MPT and DPT and such topics. And now suddenly..Booom!.. the whole profession is in immidiate danger. This is like inviting PTs to look for another job to support their families. Who is going to invest in outpatient PT facilities anymore? Are there enough job opportunities in hospitals for all the current and new graduate PTs who will not be able to work in outpatient facilities anymore thanks to this new law?????
Are they out of their freakin' minds?????
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Re: Medicare cap for rehabilitation - December 31, 2005 11:10:00 AM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
Status: offline
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this is just for medicare pts...I know my last facility was only 5% medicare, so it is not the end of days or anything, and YES we do need to stand up and do something about it
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