Therapy Cap
CMS Announces Therapy Cap Exception Procedures
Exceptions Process
CMS has established an exceptions process for the therapy caps that is effective retroactively to January 1, 2006. Providers, whose claims have already been denied because of the caps, should contact their carrier to request that the claim be reopened and reviewed to determine if the beneficiary would have qualified for the exception. In addition, providers who have not yet submitted claims for services on or after January 1, 2006 that qualify for the exception, should submit these claims for payment, and refund to the beneficiary any private payments collected because of the cap.
The exceptions process allows for two types of exceptions to caps for medically necessary services:
Automatic Exceptions: Automatic exceptions for certain conditions or complexities are allowed without a written request. A request to the contractor for an exception is not required when services related to these conditions and complexities are appropriately provided and documented. We anticipate that the majority of beneficiaries who require services in excess of the caps will qualify for automatic exceptions.
Manual Exceptions: Manual exceptions require submission of a written request by the beneficiary or provider and medical review by the contractor responsible for processing the claims. If the patient does not have a condition or complexity that allows automatic exception, but is believed to require medically necessary services exceeding the caps--the provider/supplier or beneficiary may fax a letter requesting up to 15 treatment days of service beyond the cap. A treatment day is a day on which one or more services are provided. The request must include certain documentation, including a justification for the request. Contractors will make a decision on the number of treatment days they determine are medically necessary within 10 business days. These requests for cap exceptions should be submitted prior to the date the cap is expected to be surpassed to avoid placing the beneficiary at risk of incurring the costs of treatment if the request is denied.
As with any new CMS claim process we will be working through the system to ensure that this is easy to use for both the patient and the practitioner.
For more information regarding automatic and manual exceptions, please refer to the CMS fact sheet which can be found here: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1782
On February 8, 2006, President Bush signed the “Deficit Reduction Act of 2005” into law, stating that “the Act reduces unnecessary spending of taxpayer dollars,” and reflects “a commitment to fiscal responsibility.” As you probably remember, the Senate approved the FY 2006 Budget Reconciliation Conference Report in December before winter recess. The House, however, was forced to vote again on the bill after the Senate made minor changes to the language. The House finally passed the FY 2006 Budget Reconciliation on February 1, with a 216 to 214 vote, largely along party lines.
The bill contains a legislative victory for the therapy community, as provisions implement a program that allows exceptions to the outpatient therapy cap for 2006. The bill:
- Creates a process (by the Secretary of Health and Human Services) in which beneficiaries enrolled in Medicare may request an exemption from the $1,740 (approximate) dollar limitation for outpatient therapy services.
- Services deemed medically necessary will be reimbursed.
- The approval is passive. If the Secretary does not respond that the service is not medically necessary within 10 business days of receiving the request, the care can be provided.
- Implements clinically appropriate code edits to identify and eliminate improper payments for therapy services.
Shortly after the President signed the “Deficit Reduction Act” into law, the Centers for Medicare and Medicaid (CMS) released a fact sheet establishing the therapy cap exception process. This process can be viewed on the CMS website here: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1782
While this outcome is a victory for the therapy community, a permanent fix will still be needed in 2007. Fortunately, two members of Congress, one member of the House and one from the Senate, have taken up the call to permanently fix the therapy cap. Last year, both H.R. 1125, introduced by Representative English (R-PA) and S.1024, introduced by Senator Ensign (R-NV), sought to repeal the Medicare caps on outpatient rehabilitation therapy. This year Representative English and Senator Ensign have reintroduced this legislation as H.R. 916 and S.438 with the same goal in mind. Although the Budget Reconciliation has postponed the $1,740 cap, a permanent fix remains a priority for ASHT.
ASHT's Position: Support the legislation and repeal the cap.
For more information about H.R. 916 and S.438 please CLICK HERE.
Reconciliation Bill Passes by Slim Margin
The House, on February 1, passed the FY 2006 Budget Reconciliation bill with a 216 to 214 vote, largely along party lines. This was the second time the House has voted on this bill, as the Senate made minor changes to the language which forced the House to take up the legislation again. The bill now goes to the President’s desk to be signed into law, which is essentially guaranteed.
As you may remember, the FY 2006 Budget Reconciliation contains a legislative victory for the therapy community, as provisions implement a program that fixes the outpatient therapy cap for 2006. The Budget Reconciliation’s one-year therapy cap fix includes several important provisions. First, the legislation allows those patients who reach the $1,760 cap on therapy services to request for additional services. In the appeals process, a patient, or someone on behalf of the patient, must appeal to the Secretary of Health and Human Services for additional medically necessary services. In the event that the Secretary does not respond in 10 business days, it may be assumed that the Secretary has approved of the request to exceed the $1,760 cap on therapy services. In addition to this short-term fix, the Reconciliation calls on Medicare to establish clinically appropriate code edits to identify and eliminate improper payments for therapy services.
The ASHT government relations team will update you as more information becomes available and will alert you when the Center for Medicare and Medicaid Services (CMS) has established the procedure for exemption from the therapy cap. We are currently in contact with CMS to ensure the process will be the least disruptive for your patients and your practice. We will also post an update to the ASHT Web site. |
