Update on Therapy Cap Exceptions Process and HR 3630

NASL, 12/14/2011

Last night, the House of Representatives passed HR 3630 “The Middle Class Tax Relief and Job Creation Act of 2011″ by a vote of 234 to 193. The bill contains many provisions including a payroll tax cut, the Keystone oil pipeline, a fix of the SGR cut for two years therefore stabilizing the physician fee schedule, and a two year extension of the therapy cap exceptions process. The exceptions process is modified in two ways. First, the bill adds a layer of review once therapy costs reach $3,700 for PT and SLP and $3,700 for OT (we do not know yet the details of this review). Second, the NPI of the physician reviewing the therapy plan of care must be included on the claim.

 

The bill has to be paid for according to House rules. The extension of the exceptions process is paid for by including hospital outpatient therapy under the therapy cap. There are significant cuts to hospitals in the bill. Nursing homes are subject to a phase down of their ability to get reimbursement for bad debt. In addition to all of this, the President has said he would veto the House bill if it was sent to him in this form.

 

The action now turns to the Senate. Conversations with Senate Finance staffers this morning revealed that action on the Senate bill could extend to late next week. The Senate could draft a very different bill with a different approach to the exceptions process including a one year extension of the exceptions process. We support a two year extension with a clean exceptions process just as it is now. Continued grassroots communications with your Senators is necessary to keep the pressure on the Senate to deal with this issue before December 31st! 

 

Your Advocacy Voice for Quality in Long Term and Post Acute Care – www.NASL.org via Article Details.

LeadingAge: Medicare Therapy Caps Exceptions Process Expires December 31

LeadingAge: Medicare Therapy Caps Exceptions Process Expires December 31. With the Medicare therapy caps exceptions process set to expire as of Jan. 1, 2012, all Medicare beneficiaries once again are at risk for the cost of physical, speech and occupational therapy costs in excess of the annual caps.

We urge everyone to Contact Congress and tell your legislators to extend the Medicare therapy caps exceptions process before Congress adjourns for the year.

About the Medicare Therapy Caps

The caps, $1,880 annually for speech and physical therapy and $1,880 for occupational therapy, are arbitrary and do not take into consideration the amount of therapy older people often need following a stroke, hip fracture or other serious illness or injury.

The caps also would impose a hardship on beneficiaries who experience more than one injury or spell of illness in a year.

The exceptions process allows Medicare beneficiaries with specific health conditions to have coverage for the amount of medically necessary therapy they require without regard to the caps.

The process has worked well since its implementation a few years ago, protecting against over-utilization of the therapy benefit while giving beneficiaries access to therapy services they need.

If the process is not extended, beneficiaries have the choice of seeking therapy from a hospital outpatient department, paying out-of-pocket for therapy that exceeds the caps or delaying therapy and potentially suffering a deterioration in their condition.

Congress’s Must-Pass List for 2011: Therapy Cap Extension

Your Advocacy Voice for Quality in Long Term and Post Acute Care

via Article Details.

Congress must protect access to critical therapy services for Medicare beneficiaries, says long term care providers

 

Washington, DC - The long term care profession today called on Congress to act and extend the therapy cap exceptions process for medically necessary Medicare Part B outpatient therapy services. Extending the exceptions process would help ensure tens of thousands of beneficiaries receive the critical therapy services they need for their recovery, providers argue.

“As 2011 draws to a close, one item on Congress’ must-pass list has to be exemptions to therapy caps,” said Mark Parkinson, President and CEO of the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL). “The care provided to patients is as diverse and individualized as the patients themselves, and this essential step in the recovery process would be halted if Congress allows the cap to go into effect at the beginning of the new year.”

(Click link above for more)

Congressional Action Expected on Therapy Caps

by Ingrida Lusis

Capitol Hill staffers indicate that Congress will most likely address the Medicare therapy caps issue by the end of the year, but aren’t predicting how.

Since 1997, Medicare has capped the amount of Part B therapy services each beneficiary may receive each year. The caps—one for combined speech-language pathology and physical therapy and one for occupational therapy—were designed to control costs, but do not consider a patient’s need for treatment or the provider’s clinical judgment. Every year, Congress has either extended a moratorium on the caps or instituted an exceptions process that allows medically necessary services beyond the cap. Provider and consumer groups, however, are looking for a permanent solution rather than an annual congressional “fix.”

Observers indicate two viable options:

• As the Joint Select Committee on Deficit Reduction formulates its recommendations on debt reduction under the Budget Control Act, larger Medicare legislation, including a new formula for establishing reimbursement rates, could be part of its recommendations. If the “Super Committee” addresses the formula, ASHA, the American Physical Therapy Association (APTA), and the American Occupational Therapy Association (AOTA) will urge committee members to address therapy caps at the same time.
• If the Super Committee does not address Medicare payment issues, observers anticipate Congress will pass a more modest approach—including a possible one-year extension of the current exceptions process.

Caps were never intended as a long-term payment policy. When they were instituted, Congress also called on the Centers for Medicare and Medicaid Services (CMS) to develop a payment system for outpatient therapy services. To date, CMS has provided no recommendations on payment alternatives. ASHA, APTA, and AOTA have formulated a proposal that would create new billing codes for physical and occupational therapy (moving away from time-based codes to per-session codes), refine the therapy cap exceptions process, and repeal the therapy caps in 2015. The three organizations hope the proposal will be adopted as part of larger Medicare reforms, and are working with members of Congress to move it forward.

The yearly moratorium to the caps and the exceptions process indicate lawmakers’ recognition that arbitrary limits on outpatient speech-language, physical therapy, and occupational therapy services are not in the patient’s best interests. However, the cost of repealing the caps and the lack of a viable alternative have forced Congress to maintain the status quo.

ASHA and other stakeholders have worked with CMS for many years to develop an alternative payment system for outpatient therapy. ASHA also worked with CMS and its contractor to develop speech-language pathology-specific questions for a patient assessment tool for the Developing Outpatient Therapy Payment Alternatives project. The tool is in the data collection phase. Given that a new policy is unlikely in the near future, ASHA, APTA, and AOTA will continue to advocate for new payment methodology. ASHA also met separately with CMS in September to discuss health care reform legislation and potential long-term therapy cap alternatives.

Ingrida Lusis, director of federal and political advocacy, can be reached at ilusis@asha.org.

Legislative Action Alert: Therapy Cap

Legislative Action Alert: Therapy Cap. Only 88 days remain for Congress to take action on the therapy cap and Medicare payment cuts. It is critical that Congress pass legislation before December 31, 2011 to extend the therapy cap exceptions process and to avoid the scheduled 29.5% cut in provider payments under the Medicare physician fee schedule. (APTA) (Click Link Above for more)

New Avalere Health Analysis: New Medicare, Medicaid Cuts from Congressional Super Committee Could… — WASHINGTON, Aug. 23, 2011 /PRNewswire-USNewswire/ –

New Avalere Health Analysis: New Medicare, Medicaid Cuts from Congressional Super Committee Could… — WASHINGTON, Aug. 23, 2011 /PRNewswire-USNewswire/ 

Analysis Underscores Stark Threat to Stability of America’s 2nd Largest Health Facility Employer as Washington Policymakers Seek Job Creation Strategies

WASHINGTON, Aug. 23, 2011 /PRNewswire-USNewswire/ – As Washington policymakers search urgently for ways to help boost a sagging economy and create local jobs, a new analysis from Avalere Health finds that further cuts to Medicare and Medicaid – on top of the 11.1 percent to 14.6 percent Medicare funding reduction resulting from a new Centers for Medicare and Medicaid Services’ (CMS) regulation – could push America’s second largest health facility employer into negative operating margin status, thus further destabilizing a reliable local employer in the midst of the current recession. Nursing facilities generate $201 billion in economic activity annually, help create 2.52 million jobs nationally, and directly employ 1.69 million Americans. (click link above for more)

How the SNF PPS Final Rule Will Affect Therapy Providers on ADVANCE for Speech-Language Pathologists and Audiologists

How the SNF PPS Final Rule Will Affect Therapy Providers on ADVANCE for Speech-Language Pathologists and Audiologists.

Leigh Ann Frick, PT

Posted on: August 21, 2011

The post-acute therapy world suffered a major setback on July 29 when the SNF PPS Final Rule for fiscal year 2012 was released.

The implementation of Minimum Data Set (MDS) 3.0 and RUGs IV last fall modified minute recording, requiring individual, concurrent and group minute delineation. It also changed the definition and allocation of concurrent minutes.

Concurrent therapy was defined as two residents who are not performing the same or similar activities at the same time, regardless of payer source. Both must be in the line of sight of the treating therapist or assistant.

The minutes would be divided by two, allowing a therapist/assistant to only get credit for half of the minutes delivered to each resident. CMS recognized concurrent therapy as a valid method of service delivery but believed it was not being utilized properly.

This change penalized everyone, creating the need for increased staff hours to deliver the same amount of therapy prior to Oct. 1, 2010. CMS made no changes to the parameters surrounding group therapy until now.

In the Final Rule for Oct. 1, 2011, CMS changed the definition of group therapy to “the treatment of four residents, regardless of payer, who are performing similar activities and are supervised by a therapist or assistant who is not supervising any other individuals.”

The limitation of 25 percent per discipline per week still applies, but the minutes provided in a group setting will be divided by four. If four patients are in a group for 60 minutes, each will have only 15 of the 60 minutes apply to their rehab RUG category or count as “reimbursable therapy minutes” (RTM). (Click link above for more)

New Medicare PPS Changes Could Affect SNF Revenue and Therapy Contracts: LarsonAllen LLP

New Medicare PPS Changes Could Affect SNF Revenue and Therapy Contracts: LarsonAllen LLP. CMS released the final rule for skilled nursing facilities’ prospective payment system and consolidated billing on August 8, 2011. It contains changes that will likely affect your SNF’s Medicare revenue and therapy contracts in any number of ways. These adjustments are scheduled for October 1, 2011. (for more, click the link above)

Medicare cuts will cause pain—but for whom? | Blog | Long-Term Living Magazine

Medicare cuts will cause pain—but for whom? | Blog | Long-Term Living Magazine. - Posted on: 8.16.2011 8:57:04 AM Posted by Luke Fannon

 October 1, 2011, is the day that an 11.1 percent reduction in Medicare payments to SNFs is implemented. It’s when we really begin feeling the pain. But, are we all going to feel the pain? Is there something you and your team can do to deal with this looming change? (Click link above for more)

What your team needs to know about the COT OMRA | Articles & Archives | All Issues | Long-Term Living Magazine

What your team needs to know about the COT OMRA | Articles & Archives | All Issues | Long-Term Living Magazine.

What your team needs to know about the COT OMRA Another Medicare required assessment Elisa Bovee, MS, OTR/L

At the end of July, the Centers for Medicare & Medicaid Services (CMS) published the “Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2012” final rule. The majority of changes in the original proposed rule for updates to the SNF PPS system for FY 2012 were adopted by this final rule, including those related to the Change of Therapy other Medicare required assessment (COT OMRA). This newly implemented requirement will become effective October 1, 2011, and will require education, systems review and oversight to ensure accuracy in completing the indicated MDS assessment changes. (click the link above for more)