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If CMS really wants to put "patients over paperwork" in physical therapy, it could start by allowing PTAs to provide maintenance care across settings and easing PTA supervision requirements. And while it's at it, the agency could abandon outmoded approval requirements for plans of care, increase direct access to PTs, and expand PTs' ability to bill for care provided by a qualified substitute when the primary PT is unavailable. Those are just a few of the options that APTA and two of its components put on the table in recent comment letters.

Ask and CMS shall receive
The most recent comment letters — from APTA, the APTA Academy of Geriatric Physical Therapy, and the association's Home Health Section — were produced in response to a call from CMS to provide recommendations about eliminating Medicare regulations that require more stringent supervision than is required in existing state scope of practice laws, or that limit health professionals from practicing at the top of their license. CMS also asked for input on ways to strengthen its "patients over paperwork" initiative intended to ease administrative burden on health care providers as it relates to the specific areas in regulation that restrict providers from practicing to the full extent of their education and training.

APTA took up CMS on its offer, as it typically does (in 2019 APTA submitted approximately 100 comment letters on proposed federal regulations and policies) including the most recent invitation to comment specifically on how scope of practice issues might be improved to make the system less cumbersome. As with several past calls for comment, APTA was joined by association components who have particular interest in the subject at hand. The result: multiple perspectives but a unified voice on how things could be improved.

Opening possibilities for PTAs
A common thread between the recommendations involved PTAs — specifically, allowing PTAs working in private practice to move to a "general supervision" model and expanding the PTA's ability to provide maintenance therapy across settings.

Current Medicare regulations say that PTAs working in all settings except private practice may receive "general supervision" from a qualified PT, which doesn't require the PT to always be physically present. State laws can impose more stringent requirements that must be followed, of course, but the reality is that 44 states currently take the general supervision route.

Private practice, however, is a different matter: In that setting, CMS stipulates onsite supervision, a rule that APTA believes severely limits practices and results in delays in care "that may be harmful to functional outcomes and quality of life." APTA and the geriatrics academy both press for CMS to relax the requirement.

The letters from APTA and the Academy of Geriatric Physical Therapy also push for an expanded role for PTAs related to maintenance therapy under Medicare Part B. Right now, PTAs may furnish skilled maintenance therapy in skilled nursing facilities — SNFs — and home health settings under Medicare Part A only, and they are prohibited from providing maintenance therapy in private practice settings. the submitted letters assert that PTs are perfectly capable of making a determination as to whether it's clinically appropriate for a PTA to provide maintenance therapy, and that leveling the requirements "would provide regulatory alignment and afford providers more latitude in resource utilization."

Getting real with plans of care and direct access
PTAs weren't the only focus of the letters: Clunky provisions around whether and how PTs create plans of care and needless limits on direct access to PT services both received attention from APTA and the two components in various combinations.

Both APTA and the Home Health Section argued for changes that would allow PTs to establish home health physical therapy plans of care, as they are allowed to do in outpatient settings. In its letter, the Home Health Section writes that PTs "are unnecessarily burdened by asking physicians to establish and review therapy plans of care in home health, and physicians are unnecessarily burdened by establishing and reviewing those same plans of care."

Another provision that prevents PTs from practicing at the top of their license, according to APTA and the Academy of Geriatrics Physical Therapy: so-called "certification requirements" for plans of care that gum up care delivery. Under current rules, outpatient plans of care for therapy must be accompanied by a physician or qualified nonphysician practitioner signature, a requirement that frequently leads to delays in providing needed therapy while the PT waits for (and sometimes repeatedly reminds) the physician to sign off.

Both letters describe the certification requirement as an "untenable" administrative burden for PTs, with APTA writing that "[PTs] and other therapy providers should not be held responsible and possibly subject to medical review due to a physician's inaction."

Both letters also express that it's high time for CMS to extend direct access to PTs in hospitals, including critical-access hospitals, and SNFs.

"Medicare beneficiaries [in these settings] who require rehabilitation frequently are admitted to a hospital but then must 'sit and wait' until a practitioner can sign an order," APTA writes. "While hospitals are showing a statistically significant decrease in specific health care-associated infections, the evidence regarding hospital-associated disability is mounting, clearly indicating the medical necessity of early and progressive mobilization during the acute period of the episode of care."

These dangers could be avoided, both letters argue, if CMS would permit stronger direct access provisions in these settings, with the letter from the Academy of Geriatric Physical Therapy stating that "direct access increases choice in the selection of a health care professional, offers access to less expensive and more timely care, and is a simple yet extremely effective way to meet the goals of increased access and cost containment."

Expanding locum tenens
While it's technically true that CMS affords PTs locum tenens — the provision that allows a provider to retain a substitute when she or he is absent because of illness, vacation, pregnancy, or continuing education and still receive payment — the allowance is currently limited to specific geographic areas that have been identified as having gaps or shortages in health care. In its letter, APTA urges CMS to work with Congress to change language in the 21st Century Cures Act to extend locum tenens to all qualified PTs regardless of geographic location.

Also on the list
Alone or in combination, the letters recommend a number of other changes including allowing PTs working in the home health and SNF settings to make "insignificant" changes to plans of care without being required to notify the physician (in the event that CMS doesn't adopt the larger plan-of-care suggestions), standardizing data submission, removal of certain data collection requirements and standardizing others, and prohibiting Medicare Administrative Contractors from requiring a physician order for PTs to furnish wound care.

APTA regulatory affairs staff is in regular contact with CMS staff and will continue to press for needed changes and share information as it becomes available.


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