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  • The Hard Therapy Cap Is Here: Answers to Some Common Questions

    Because of inaction by Congress, the hard cap on outpatient therapy services under Medicare has been implemented. The cap, which began on January 1, 2018, includes no KX modifier exceptions and has created uncertainty for providers, patients, and their families.

    APTA has requested that the US Centers for Medicare and Medicaid Services (CMS) provide information and guidance for providers on how the (temporary, it is hoped) hard cap will be managed. While the association waits for that response, here are a few questions and answers that shed some light on where things stand.

    What is the therapy cap for calendar year 2018?
    The allowed dollar amount for 2018 for outpatient physical therapy and speech-language pathology combined is $2,010. For occupational therapy, the cap is set at $2,010.

    What Part B outpatient therapy settings and providers does the therapy cap apply to?

    • Physical therapists' (PTs') private practices
    • Offices of physicians and certain nonphysician practitioners
    • Part B skilled nursing facilities
    • Home health agencies (visits provided on an outpatient basis)
    • Rehabilitation agencies (also known as outpatient rehabilitation facilities)
    • Comprehensive outpatient rehabilitation facilities
    • Critical access hospitals (CAHs)

    What is the targeted medical review threshold for 2018?
    With the implementation of the hard therapy cap on January 1, 2018, there is no targeted medical review threshold. This is subject to change, pending congressional action.

    Does the 2018 hard therapy cap apply to hospital outpatients?
    No. Hospital outpatient departments or clinics (OPs) were not originally included under the therapy cap when it was first enacted as part of the Balanced Budget Act in 1997. That exclusion was lifted when hospital OPs were added to the manual medical review process in 2012. Later, hospital OPs were regularly made subject to the cap as part of the stopgap exceptions routinely enacted by Congress. But in 2017, Congress not only failed to end the hard cap; it failed to create an exceptions process of any kind, meaning we're back to the hard cap as originally written, which doesn't include hospital OPs.

    Does the hard therapy cap apply to observation-status patients in hospital outpatient departments?
    No. The hospital setting is not included under the hard therapy cap that went into place on January 1, 2018 (see hospital outpatient question above). Hospital outpatients include those in observation status. Therapy services furnished to patients on observation status are billed as outpatient therapy services under Medicare Part B; however, because the hospital setting is not included under the hard cap, observation status patients are excluded.

    Does the hard cap apply to Critical Access Hospitals?
    Yes. Before October 1, 2012, the therapy caps applied to all outpatient therapy services except those furnished by outpatient hospitals and CAHs. Beginning January 1, 2014, the outpatient therapy caps, and related provisions, were applied to therapy services furnished by a CAH. Therapy services furnished by a CAH are counted toward the therapy caps as if the services were paid under the Medicare physician fee schedule.

    When are therapists required to issue the mandatory Advance Beneficiary Notice (ABN) for therapy services?
    Providing the patient with an ABN transfers liability and charge to the beneficiary, and becomes a crucial duty of the therapist now that the no-exceptions cap is in place. Providers must issue a valid, mandatory ABN to the beneficiary before providing services above the cap when there is no therapy coverage exceptions process. Therapists also are required to issue the ABN to original (fee-for–service) Medicare beneficiaries before providing therapy that is not medically reasonable and necessary.

    Wasn't Congress ready to permanently end the hard cap? What happened?
    It's true: over the fall, a bipartisan, bicameral deal was reached that would have permanently eliminated the hard cap on therapy services. That deal was part of a larger piece of legislation that included other changes to Medicare, such as payments for ground ambulances and reauthorization of special needs plans. This package of so-called "Medicare extenders" was supposed to be adopted in early December. Unfortunately, the debate over the tax reform legislation dominated Congress in the final weeks of session, pushing nearly all other issues to 2018.

    What happens next?
    The Senate returned to Washington on January 3, and the House will return on January 9. The first opportunity to address the hard cap will come when Congress takes up a spending bill that must pass in order to keep the government open after January 19. There are also opportunities for the cap repeal to be included in any of a number of other critical health care programs that expired on December 31, which Congress must act on immediately. Unfortunately, there are no sure bets: given the current political climate in Congress, including other unrelated, controversial issues in play, it is unclear if Congress will act quickly. APTA, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and other allies in the Therapy Cap Coalition will continue to keep pressure on Congress to take quick action on the therapy cap in January.

    Will Congress retroactively apply any fix to the Therapy Cap back to January 1, 2018?
    Nothing is certain at this point. APTA and its partners are asking Congress to apply any fix retroactively to January 1, 2018.

    What can I do?
    It's important for the physical therapy profession to advocate for this critical permanent fix to the therapy cap. Contact your members of Congress today via email, phone, and social media, and urge them to pass the therapy cap permanent fix as soon as possible. Visit APTA's Medicare Therapy Cap webpage for more information, download the APTA Action App to keep up-to-date on action alerts, and be sure to stay tuned for additional updates.

    Comments

    • Is the cap on billed out charges or Medicare allowable? Also patients will presumably be calling their insurance to figure out how much money they have left. If they received service recently at another PT clinic the charges may not have fully posted yet. Any suggestions around managing that? Thank you for this great info!

      Posted by Emilie Jones on 1/5/2018 4:58 PM

    • Physical Therapy is the only thing that works for my pain management. As a younger Veteran I am very concerned with the future status of access to PT/OT or worried about a cap. I refuse to take stong medications or opiods that our national health organizations keep pushing. PT relieves my migraines, bi-lateral carpal tunel, bi-lateral plantar fasciitis. Natural therapies that work would benefit so many. I'm worried that the pharmaceutical industry has thier hand in this congressional delay. Good luck!!

      Posted by Karen Reed on 1/6/2018 3:04 AM

    • Prior to October 1, 2012, the therapy caps applied to all outpatient therapy services except those furnished by outpatient hospitals and critical access hospitals (CAHs). The therapy caps, and related provisions, were first applied to outpatient hospitals on October 1, 2012; and, this application was extended through MACRA until January 1, 2018. Beginning January 1, 2014, the outpatient therapy caps, and related provisions, apply to therapy services furnished by a CAH. Therapy services furnished by a CAH are counted toward the therapy caps as if the services were paid under the Medicare Physician Fee Schedule (MPFS). The amount counted toward the caps for services furnished by a CAH also reflect any applicable therapy multiple procedure payment reductions (MPPR). This provision does not change the actual method of payment for therapy services furnished by a CAH. Can you please provide the source for your findings. If CAHs has the caps and exceptions applied to them after HOPDs I would like to know what legislation changed that order. It seems that if it reset to 1997 they would be excluded.

      Posted by Wendell Nall on 1/7/2018 11:22 AM

    • Fix this please....totally ridiculous to have PT and Speech combined....separate them out the way it should have been before someone errored. And no exceptions??? You better hope you don’t suffer a stroke and need rehab to recover. Rehab enables improved independence and decreased healthcare costs in the long run. Best to pay it forward to save later.

      Posted by Darla Schultz on 1/7/2018 1:59 PM

    • Why is an ABN required to be given to a Medicare beneficiary when they have exceeded the annual therapy cap dollar threshold and no exception process is in place? In this case, outpatient therapy is statutorily non-covered and an ABN is not required for statutorily non-covered services. Is this requirement due to the American Tax Payer Relief Act of 2012?

      Posted by Rick Gawenda -> =IY`?L on 1/8/2018 11:16 AM

    • Does the cap apply for non HOPD or “off campus” hospital outpatient sites? I’ve been unsuccessful thus far in finding an answer.

      Posted by Keith Abruzzese on 1/8/2018 8:41 PM

    • @Wendall Nall- Thanks for the comment! Prior to October 1, 2012, the therapy caps applied to all outpatient therapy services except those furnished by outpatient hospitals and critical access hospitals (CAHs). The therapy caps and related provisions were first applied to outpatient hospitals on October 1, 2012; this application was extended through MACRA until January 1, 2018. In the 2014 Medicare Physician Fee Schedule Final Rule, CMS noted that after reviewing the Balanced Budget Act they felt it was the intention in 1997 to have CAHs come under the therapy caps, but to exempt other hospitals, based upon the 1997 legislation. Beginning January 1, 2014, the outpatient therapy caps and related provisions apply to therapy services furnished by a CAH. Therapy services furnished by a CAH are counted toward the therapy caps as if the services were paid under the Medicare Physician Fee Schedule (MPFS).

      Posted by APTA Staff on 1/9/2018 8:08 AM

    • @Emile Jones - Thanks for your question Emile. After the patient pays his or her yearly deductible for Medicare Part B ($183 for 2018), Medicare pays its share (80%) and the patient pays his or her share (20%) of the cost for therapy services. Medicare will pay its share for therapy services until the total amount paid by the patient and Medicare reaches the cap limit. Amounts paid by the patient include costs like the deductible and coinsurance. All providers and contractors may access the accrued amount of therapy services from the ELGA screen inquiries into CWF. Suppliers who do not have access to these inquiries may call the contractor to obtain the amount accrued. Hope that helps!

      Posted by APTA Staff on 1/9/2018 8:35 AM

    • Where can we verify that hospital outpatient departments are now excluded from the cap, again, with the 2018 changes? I can't find this stated anywhere on Medicare website. Our billers will want to verify this. Thanks

      Posted by Lori on 1/9/2018 3:30 PM

    • Why won’t the secondary insurance pick up when Medicare won’t pay anymore ?

      Posted by Stephanie on 1/9/2018 7:53 PM

    • I agree with Rick Gawenda and would love to see an APTA response. Thanks!

      Posted by Tracy Fritts on 1/10/2018 12:18 PM

    • I work in an outpatient Hospital setting an am echoing the question by Lori posted 01/09/18 regarding further documentation to substantiate your reports above that we are not bound by the $2010 cap. Thank you- This is membership value! Joe

      Posted by Joe Grabicki on 1/10/2018 2:52 PM

    • Reading the comment above about patients in an observation stay inside the hospital and those charges not going towards the cap, why then are G Codes required for billing? Our billers always ask for G Codes on these observation designated patients. Thank you for your fact sheet as well!

      Posted by Elisa Harris on 1/10/2018 4:38 PM

    • Thanks

      Posted by Martha Decoster,PT on 1/10/2018 4:43 PM

    • I am so confused medicare website stated the following: The therapy cap limits for 2018 are: $2,010 for physical therapy (PT) and speech-language pathology (SLP) services combined $2,010 for occupational therapy (OT) services You may qualify for an exception to the therapy cap limits. If so, Medicare will continue to pay its share for your therapy services after you reach the therapy cap limits. And continues after explaining what the therapist need a to do As part of the exceptions process, there are additional limits (called “thresholds”). If you get outpatient therapy services higher than the threshold amounts, a Medicare contractor may review your medical records to check for medical necessity. The threshold amounts for 2018 are: $3,700 for PT and SLP combined $3,700 for OT What is an exception? No exemption, but exception??? Help. Lynn PT

      Posted by Lynn A Culbertson on 1/10/2018 4:59 PM

    • How is Jimmo v. Sebelius, come in to play here?

      Posted by Ronald Agrigento on 1/10/2018 5:31 PM

    • How can the therapy cap NOT APPLY to hospitals and only to private practices? It seems that insurance companies and the government are all trying their best to squeeze out small practices and force everyone to have no choices in healthcare.

      Posted by Caryn McAllister on 1/10/2018 6:25 PM

    • Thanks for the questions, everyone! Here are some responses to various comments (more to come)-- @Rick Gawenda: Prior to the American Taxpayer Relief Act (ATRA) of 2012, original (fee-for-service) Medicare claims for therapy services at or above therapy caps that did not qualify for a coverage exception were denied as a benefit category denial, and the beneficiary was financially liable for the non-covered services. CMS encouraged suppliers and providers to issue a voluntary Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, as a courtesy, to alert beneficiaries to potential financial liability. However, issuance of an ABN wasn’t required for the beneficiary to be held financially liable. Section 603 (c) of the ATRA amended §1833(g)(5) of the Social Security Act (the Act) to provide limitation of liability (LOL) protections (See §1879 of the Act) to beneficiaries receiving outpatient therapy services on or after January 1, 2013, when services are denied and the services provided are in excess of therapy cap amounts and don’t qualify for a therapy cap exception. Now, the provider/supplier must issue a valid, mandatory ABN to the beneficiary before providing services above the cap when the therapy coverage exceptions process isn’t applicable. @Keith: Whether an offsite facility or outpatient site is considered part of the HOPD depends upon the relationship between the two providers. Please reach out to advocacy@apta.org to discuss this in further detail. @Lori: Under section 1833(g)(1) [therapy caps for PT and SLP services], services furnished in hospital outpatient departments are generally not subject to the cap. That exclusion was changed temporarily for the period beginning October 1, 2012 and subsequently extended via the American Taxpayer Relief Act, Protecting Access to Medicare Act of 2014, and finally the Medicare Access and CHIP Reauthorization Act, through December 31, 2017, and thus the cap did apply to those services in those HOPDs during that time period. @Stephanie: You may bill the secondary insurance. Before providing services over the cap, the provider must first obtain a signed Advanced Beneficiary Notice from the patient. Then the therapist can collect cash from the beneficiary or bill the patient's secondary insurance. The secondary insurance may require a denial from the Medicare program before it will cover these services. For more information about the Fee-for-Service ABN, please see: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html

      Posted by APTA Staff on 1/11/2018 6:39 AM

    • Why doesn't anyone realize that Medicare is paying through the nose with the 2 caps and the secondary insurances are getting away with murder!! If there is no cap at all then Medicare pays and pays and the secondary pays a measly amount.

      Posted by Tricia on 1/11/2018 9:25 AM

    • @aptastaff So if an acute-setting PT provides PT services to a patient who has been hospitalized for an outpatient procedure (e.g. TKA), they are not subject to the $2010 cap. However, do charges accumulated count toward their cap at an independent outpatient clinic following discharge? That is, if the patient has $0 toward the cap at the time of admission, receives $510 in PT while hospitalized, do they now have $1500 of remaining benefit for use with their outpatient provider after discharge? (presuming that outpatient provider isn't tied to the hospital, as you have noted above)

      Posted by James on 1/11/2018 10:40 AM

    • @Caryn McAllister: The "Balanced Budget Act of 1997" imposed $1,500 cap on outpatient therapy services. Section 4541 (c) and (d) of the act increased the financial limitation to no more than $1500 of the incurred expenses in a calendar year, and applied it to outpatient therapy services furnished in skilled nursing facilities, physician’s offices, home health agencies (Part B), skilled nursing facilities (Part B), in addition to physical therapist private practice offices. Until October 1, 2012, therapy services furnished by a hospital to an outpatient, or by another entity under an arrangement with a hospital, did not count toward the therapy caps. However, effective October 1, 2012 through December 31, 2017, outpatient therapy services furnished by a hospital were subject to the therapy cap.

      Posted by APTA Staff on 1/11/2018 12:07 PM

    • @Lynn Culbertson: Unfortunately CMS has not updated its website to reflect current policy as of January 1, 2018; this is probably because CMS is waiting to see what Congress does in the coming days before modifying their webpages.

      Posted by APTA Staff on 1/11/2018 12:08 PM

    • @Elisa Harris: Thanks Elisa! As for your question, Beginning January 1, 2013, CMS implemented a claims based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy. The system is designed to provide for the collection of data on patient function during the course of therapy services. All practice settings that provide outpatient therapy services billing under Medicare Part B must include functional limitation data on the claim form. Specifically, the policy will apply to physical therapy, occupational therapy, and speech-language pathology furnished in hospitals, critical access hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and in private offices of therapists, physicians, and nonphysician practitioners. More information is available about functional reporting on APTA's website at http://www.apta.org/Payment/Medicare/CodingBilling/FunctionalLimitation/.

      Posted by APTA Staff on 1/11/2018 12:10 PM

    • @Joe Gabicki: Thanks for your comment, Joe! As for your question, under section 1833(g)(1) [therapy caps for PT and SLP services], services furnished in hospital outpatient departments are generally not subject to the cap. That exclusion was changed temporarily for the period beginning October 1, 2012 and subsequently extended via the American Taxpayer Relief Act, Protecting Access to Medicare Act of 2014, and finally the Medicare Access and CHIP Reauthorization Act, through December 31, 2017, and thus the cap did apply to those services in those HOPDs during that time period.

      Posted by APTA Staff on 1/11/2018 12:11 PM

    • @Ronald Agrigento: Jimmo v. Sebelius has no influence on the expiration of the therapy cap exceptions process. All outpatient therapy services in Part B settings (apart from HOPDs) are subject to the cap’s limitations.

      Posted by APTA Staff on 1/11/2018 12:12 PM

    • Wow, this just keeps on getting better. I went to school to become a Doctor of PT, continue to advance my clinical skills certification, advocate for the APTA, practice only evidence based practice, consistently have positive outcomes, own my own practice and provide one on one quality patient care every visit, every time, provide free consultations, spend hours upon hours doing in depth documentation, participated in PQRS on 100% of patients, I am currently gathering informstion for a proposal, advocating free PT services for those who might want to consider getting off part time disability and perhaps full time disability and get them back into the work force. Quite the challenge but would save the tax payers a bundle. It's sad for me to say this, but with ever increasing regulation, work and decreased reimbursement, I am getting burnt out. I feel like I am being punished for working so hard to be the best PT and Private Practice owner I can be. I remember when I used to love this job. Nothing was better than helping others get better and help prevent them from having surgeries. But I this garbage being shoved down our throat just keeps getting worse and I am getting paid scraps while my wife and kids rarely see me. I basically live at work. If these lobbyist bought and sold, sell out, politicians don't change and help America with a Health Care epidemic by rewarding those who go above and beyond to provide quality care vs just setting a flat rate reimbursement, regardless of patients condition or care provided, then I will change to get for service and no longer be Medicare/Medicaid provider. The patients will then go to the subsidized "charity care" hospital OP Rehab units, get charged more, and they will collect. It's, not just politicians who are failing. PTs are as well. I am just fed up with this crap care that I have seen PTs perform. It's no wonder there's a cap when many of the folks I worked with in tge past saw their patients for years and years for feel good, "I need a tune up," massage parlor therapy. I've seen charts on patients 3 inches thick. If they have a progressive autoimmune or pediatric developmental issue. I can understand. General aches and pain...no! When I worked at a hospital, I remember pulling out this fat chart out of tge file on a lady with a diagnosis of "foot pain." She was placed on my case load as the primary PT was on vacation. When I met her, she seemed sweat enough. We walked back to the treatment room and she flopped down on the plinth and uttered, "now, rub my feet." I was in shock! Perhaps that's why I did actually rub her feet. Now days, we have to do better than the old fashion 5 word soap note (S: no new complaints, O: Rx as before, A: tol well, P: Cont.) However, the pendulum has swung to far. Perhaps it's time I go back to Fire Fighting or logging. One of my patients said that she had a 24" base lodgepoll that she wanted cut down. Not even close to her house. 1 he later, the man had the tree cut down, bucked up, limbed and loaded for his wood stove and paid $800 in cash. Documentation included: Waiver...sign here. She was happy and he provided a service that put a smile on her face and his. I've been cutting down trees for free for 30 years. Perhaps it's time to get back to the great outdoors. Or perhaps, I could just provide the bare minimum time with my patients, the bare minimum documentation required, hire lots of tech's and pay them penny's why I check in every 8 visit, and say, "how's your, um, um. How you doing man?" Do only required allotted CEUs online in one day. That's how you make it big. It truly does pay to be a crappy PT these days. Thast is truly a shame. Brett

      Posted by Brett Jenks, PT, DPT, Cert. MDT on 1/14/2018 5:07 PM

    • @aptastaff So if an acute-setting PT provides PT services to a patient who has been hospitalized for an outpatient procedure (e.g. TKA), they are not subject to the $2010 cap. However, do charges accumulated count toward their cap at an independent outpatient clinic following discharge? That is, if the patient has $0 toward the cap at the time of admission, receives $510 in PT while hospitalized, do they now have $1500 of remaining benefit for use with their outpatient provider after discharge? (presuming that outpatient provider isn't tied to the hospital, as you have noted above) Posted by James on 1/11/2018 10:40 AM

      Posted by Gueorgui Petrov on 1/17/2018 9:35 PM

    • I work in home health and was recently told be a clinician that the therapy cap now applies to home health, but not in the same sense. We've been informed that now if we wish to send our patients to outpatient after completing home health (no longer homebound but still need PT) that the amount used during home health gets applied towards their cap when they try and go for outpt (thus many have nearly met or exceeded the cap before they get to outpt.) Is this true and if so where can I find the source? It doesn't seem accurate based on prior years, but hey these days you never know! Thanks!

      Posted by Laura on 1/18/2018 10:25 AM

    • @Laura: Therapy visits furnished during a Part A home health episode do not count towards the therapy cap. The therapy cap applies to Medicare home health therapy visits provided on an outpatient basis (type of bill 34X). https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/TherapyCap.html

      Posted by APTA Staff on 1/19/2018 8:55 AM

    • We are a CAH providing outpatient therapy services. So does the cap apply to our outpatient therapy? I see in one question it applies to CAH, but another question indicates that the cap does not apply to hospital outpatient. Historically, the cap did not apply to our CAH outpatient services until 2012. Thank you!

      Posted by Rachel Judisch on 1/19/2018 10:41 AM

    • Laura, Is there a chance that your clinician friend was referring to the joint bundle and not the cap? The cap and the joint bundle are 2 very different things.

      Posted by Donald on 1/19/2018 11:35 PM

    • @Rachel: To clarify, the cap applies to outpatient therapy furnished in critical access hospitals. The only Part B setting currently excluded from the therapy cap is acute care hospital outpatient departments.

      Posted by APTA Staff on 1/22/2018 3:03 PM

    • Am I correct in assuming that the "budget" that was cobbled together by our congressional leaders on 1/22/18 did nothing to address this issue? I see where they managed to extend CHIP but saw nothing about rehab caps.

      Posted by Carla Cullman on 1/24/2018 1:30 PM

    • I just attended Noridian's webinar today on "Outpatient Rehab Therapy Services 2018" and was informed that the 2018 therapy hard cap applies to all therapy setting, private practice to OP hospital setting. Is this correct? Based on the Q&A above, specifically question 4, "does the 2018 hard therapy cap apply to hospital OP?", it states otherwise... Any help will be much appreciated

      Posted by Lynne Padua on 1/25/2018 3:40 PM

    • I just attended Noridian's webinar today on "outpatient Rehab Therapy Services 2018" and was informed that the 2018 Hard Therapy cap applies to all therapy providers from private practices to hospital outpatient settings. Based on question #4 on this article - "does the 2018 hard therapy cap apply to hospital outpatient?", it indicated otherwise. Can someone help clarify these information?

      Posted by Benjamin Bertrand -> ANS\>N on 1/25/2018 3:46 PM

    • If we issue an ABN to a patient that states they will be financially liable for therapy services after the $2010 threshold, how do we make sure that Medicare then codes it as PR-119 not CO-119. The only way I know how to make sure the MEOB states PR-119 is to add the GA modifier but to my understanding, the GA modifier tells medicare that the therapy services are NOT medically necessary. Here we feel that the therapy services ARE medically necessary. I need the correct verbage on the MEOB's so that I can bill secondary insurances that do pay past medicare cap.

      Posted by Maggie Bosna on 1/29/2018 3:53 PM

    • @Maggie: thanks for the question. Providers and suppliers use the GA modifier to bill for certain services or items that they expect to be denied as not reasonable and necessary and to indicate an ABN is on file. Without an exceptions process (KX modifier) applicable at this time, before furnishing services over the therapy cap, you must issue an ABN to the beneficiary. When submitting the claim to Medicare, the provider or supplier should affix the GA modifier to indicate that an ABN is on file and it is expected Medicare will deny the service or item as not reasonable and necessary. Using the GA modifier will trigger a Medicare denial, which should have an adjustment amount identified with a PR group code, which then allows the provider or supplier to either bill the patient or submit it to the beneficiary’s secondary insurance. For resources on ABN use, please see: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-CMS-Manual-Instructions.pdf https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ABN_Booklet_ICN006266.pdf

      Posted by APTA Staff on 1/30/2018 4:24 PM

    • Why don’t we strike? What would America’s response be to a day or a week without Physical Therapy.? It is a joke that we are push overs and let everyone trample on is with caps and MPPR’s from Medicare, crappy payments for services like ultrasound, worker’s compensation (in CA), Medi-Cal fee schedule and no increased payments for services rendered in patient’s homes that are not home health, rather outpatient home visits. First off we need a seperate fed schedule so that when congress decides to lower the cost of care (driven by medical costs, not Physical Therapy as we typically reduce hospital admissions, surgery and medication use) it doesn’t unfairly impact us. Secondly direct patient care has a cost that isn’t covered by some insurance policies so a standard minimal payment threshold must be established per region for all payments even capitation! Thirdly MPPR’s should. not punish physical therapists for providing more one unit as it was targeted at physicians billing practices. Now many of them in response to MPPR just create access issues causing patients to make seperate appointments to receive address of multiple conditions or to receive additional procedures so that they get maximal payment, What would it be like if PT’s responded the same way? I know impossible, but MPPR policy is stupid and has to be addressed in regards to PT and physicians. Fourthly fraud needs to be addressed by the APTA in a way that holds state boards and Insurance companies (including federal programs) to fully investigate all claims made by the public and clinicians, as well as instititing a “secret shopper program” that addresses the billing of services that are billed as skilled but are really a patient doing a HEP in a PT gym, unsupervised PTA’s and aides or MA’s in the case of physician office services. Fourthly the same standards of medical review, establishment of POC, goals, etc should be applied to services supplied by directly Physicians, PA’s and NP’s. They should also have to pass the National PT exam to be even provide these services. I haven’t met anyone in these professions that can deliver the same services of a PT with the exclusion of DO’s for musculoskeletal disorders. Finally if we do not combine forces with other rehabilitative professions to take a real stand, we deserve to be what we have alway’s been “door mats.” I know this is forum on the cap, but this issue isn’t in a vacuum! Nurses regularly strike, when was the last time PT’s and other rehabilitative professionals striked?

      Posted by Trevor D’Souza, PT, DPT on 3/7/2018 6:33 AM

    • What happens if a patient has met their cap for the year and needs more therapy, either for the same issue or a new injury? Are they able to go to a hospital based OP department since there is no cap for this facility?

      Posted by Dianna Webb PTA on 9/17/2018 3:52 PM

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