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Therapy Cap Exceptions Process in Limbo Until Senate Returns

Written by: Mediware on Monday, April 6, 2015 Posted in: Outpatient Rehab

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On April 1, CMS released a special edition of ‘MedLearn Matters Connect’ that outlined several issues/items in addition to the Medicare Physician Fee Schedule adjustment that expired March 31, 2015.

Providers at every turn are in limbo with a list of issues left up in the air by the Senate’s lack of action. What items were left unsolved? CMS listed SGR, exceptions to the outpatient Therapy Caps, add-on payments for ambulance services, payments for low volume hospitals and payments for Medicare-dependent hospitals affected by the Senate’s decision to leave Washington prior to voting on extensions.

When Therapy Caps extensions are not in effect, beneficiaries essentially have services capped to the limits posted by CMS annually ‘without exception’. Does that mean it won’t be extended and made retroactive in a couple of weeks? No one knows! For this reason, it’s necessary for all outpatient therapy service providers to review the amount of services and charges to the beneficiaries they are now treating. CMS states they will only consider the present exceptions process and payment, for dates of service through March 31, 2015.

In the meantime, what should therapy providers do?

Review all patient billing for this fiscal year (January 1st to present), and determine if the patient will exceed the 2015 assigned value of $1,940 for PT and SLP combined and OT separately.

If you determine that the patient service cannot be held until the Senate returns to take action on April 13th, it would be to the patient’s and provider’s best interest to issue an Advance Beneficiary Notice of probable non-payment stating the lack of the extensions process as the cause for why CMS may not pay.

This of course would be balanced with a heavy description in the medical record as to why the treatment is reasonable and necessary for the condition being treated. The beneficiary should select OPTION #1 on the ABN stating that they also want you to bill Medicare for an official decision on payment which is sent to the beneficiary via a Medicare Summary Notice (MSN). The beneficiary acknowledges that if CMS denies and does not pay, they are responsible for payment but they can still appeal to Medicare for a final decision.

Although we all know this comes with risk, it is hard to meet the patient’s best interest unless this alternative ABN step is taken; a step that relieves some risk to both the beneficiary and the provider.

The Senate returns for business as usual on April 13th; let’s just hope that ‘as usual’ isn’t more of the same ol’ disregard for lack of action as they review Senate bill 810 related to H.R. 2 that was passed by the House of Representatives prior to leaving for spring break.

The President has stated he is ready and waiting to sign off on the bipartisan agreement. Many therapists have been lobbying to axe the Caps and extension process altogether since the most at-risk patients are harmed by this legislation. Which decision will prevail? Only time will tell!

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