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CAPS Dont CAP Costs – They Also Hide Costs

Written by: Mediware on Tuesday, March 25, 2014 Posted in: Outpatient Rehab

The word “caps” used to bring about a smile; it was a recollection of my brothers unrolling a pack of tightly rolled red paper with small grey dots that let the shiny silver hammer of their playgun snap a small sound as they hit the trigger.

Later, those same CAPS brought fear to me when an ‘enlightened’ child soaked his roll in the lawnmower gas tank, cracked the roll with a large rock and delighted in the fire and progressive pops that occured in the wooden fort of his play set. That was it, the last time I would see a cap in my household — they were banned and gone! I would bet that you are feeling the same about today’s therapy caps! I was smart enough to immediately make a parental decision. The fear had left! It’s that later memory that haunts me now when I hear the word CAPS.

Now we are all on a level playing field in the memory; explosive misdirected intentions. This is what we got when CAPs were introduced as a limiting therapy process.

CAPs drive administrative costs for providers and Medicare contractors – who measures this? Present studies limit themselves to the actual charges passed to the contractors. CAPs continue to resurface time and again as communication to the burdensome oversight somehow continues despite CMS’ own contractors stating that in medical review; the majority are for services appropriately provided.

Although CMS established a manual process to consider requests from beneficiaries who were not automatically eligible for exemption, it stopped the manual process in 2007. Its contractors told CMS that the majority of these requests were for services that were necessary and appropriately provided. As required by law, the exceptions process expired on Dec. 31, 2007. The Medicare Improvements for Patients and Providers Act of 2008 reinstated the exceptions process…” (MedPac Payment Basics 2009).

If you believed for a moment that CAPs are a new thing, think again. CAPs have been around since my childhood.  The most comprehensive education on CAPs that I have found is at the APTA website and is entitled ‘History of Medicare Therapy Caps’. CAPs began in 1972 to control costs for outpatient therapy services. Amazingly, we act as though they just started, right? Perhaps because for a limited number of years they were repealed and then reinstated as Congress looked for ways to carve out costs.

In 2004, CMS contracted with AdvanceMed (now CSC) to analyze therapy charge data and to help develop ‘alternatives to the cap’. In 2005 the then AdvanceMed provided a five point summation but essentially stated additional analysis with experts and policy guidance was needed.

A study released in 2008 entitled “Outpatient Therapy Alternatives; Payment Study 2”  analyzed 2006 calendar year data. It was a lengthy 35 page report and was helpful in gaining perspective on why policymakers may have felt the pain of the process and why it was worth continuing. To cut to the chase, go to pages 28 – 30 as those reveal the most vulnerable populations. Mostly, the silver lining seems to be recommendations waiting for a simplified payment alternative suggested from the 5 year study that included use of the OP CARE Tool. The study references this as ‘alternative condition-based payment system for outpatient therapy services’. In the meantime, CAPs keep resurfacing because they are purely more simple to extend present status than to leap a little further.

As we do the present process which mandates an exception process and whether it is pre-paid or post paid depending on your location; one thing is painfully evident to me.  CAPs have an administrative cost and burden that is being suffered at both ends. The highest cost might be the confusion of the already vulnerable aged populations highlighted in the 2008 study. Any of them reading the ‘Limits on Therapy Services’ would surely be confused. On page two, it asks the beneficiary to ‘document your need for medically reasonable and necessary services in your medical record’. I didn’t realize clinicians provided patients with their records for them to document in themselves. They even suggest that they ‘indicate on their Medicare claim for services above the therapy cap limit that your therapy services are medically reasonable and necessary’. I am not making this up. Next, we send them to the billing departments for attestation statements to be attached to the bill.  (Crazy conjecture but that is what the revised educational document suggests!)


  • Most vulnerable diagnoses and age populations require services at times that are above the CAP limit – any exceptions process that isn’t AUTOMATIC based on some reasonable conditions is EXPENSIVE to understand and navigate.
  • Tracking limits whether alone (OT) or combined (PT & SLP) is difficult. The time to specifically pinpoint the line of service and all subsequent lines thereafter to utilize the modifier is most often a best guess.
  • Providers feel ‘at risk’ when offering services above the CAP even when needed because they cannot provide an ABN unless they are NOT medically necessary services – this is tough because ‘who decides that ultimately’?
  • Exceptions process is too lengthy to keep the beneficiaries’ best interest in mind.
  • Correct coding; billing, rebilling and sending documentation for review to contractors all comes at a cost.
  • Secretarial and professional administrative cost.
  • Congressional costs associated with reimplementation/education and the human hours of conssituents and providers arguing ineffectiveness as a full sweeping policy.
  • Whatever the perceived ‘real costs’, these add insult to injury for a great number of providers appropriately delegating care.

Use data to data mine infractions and penalize those inappropriately billing rather than an entire nation. Put a CAP to the CAPs process that has tried to successfully manage costs since 1972 and supposedly hasn’t worked definitively yet! Let’s move on – even silver cap guns have been outlawed since 1972!





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