Guest Columns

Is the failed therapy cap repeal for the best?

Tara Roberts
Tara Roberts

The recent battle over the SGR passage with the Cardin Amendment brought forth glaring differences in outpatient therapy providers and their priorities. While I, along with the entire therapy world, dream of the day that the arbitrary therapy caps are repealed, the SGR “doc fix” bill simply was not the right time. 

Don't get me wrong: The passage of the Cardin Amendment would have meant putting to bed a fight that has lasted for too many years and also would have been done without a “pay for.” I watched Sen. Cardin on C-Span passionately plead the case for permanent repeal and I wanted to be there to shout “Amen!”  

The problem is the question of what was the greater good? For long-term care, where the bulk of outpatient Part B services are billed, it was imperative to pass the SGR repeal swiftly to ensure that doctors and therapists who bill via the fee schedule did not suffer a 21% reduction in payment. Claims would have had to be billed to Centers for Medicare & Medicaid Services under the expired SGR, with a much delayed extension or much delayed SGR passage, would have created a billing fiasco. Beneficiaries would have been scared. Upon deeper inspection of the Cardin amendment, the therapy world may have gotten more than they desired when it comes to Manual Medial Review revision, with hinting at a jump to an expedited pre-auth process.

Many therapists and therapy organizations immediately went for the throat of those senators who did not vote for the passage of the amendment. While I also was disappointed, I also have an appreciation for the political process that had to happen to pass SGR cleanly, swiftly and with the opportunity to move forward. The near 60-vote coup on the amendment is a clear indication that there is more than enough support for therapy cap repeal. SGR just wasn't the right vehicle.   

Our jobs now are to continue to advocate for the permanent repeal of the therapy caps. This will be done by reaching out to those senators who did vote “yes” — thanking them for their support and need for continued support. We also have to reach out to those senators who voted  “no,” and remind them they have an opportunity to redeem themselves and support any future potential legislation that could include a repeal to the therapy cap.   

Those of us who are mourning the loss of the opportunity of the passage of the Cardin Amendment need to turn that energy into grassroots advocacy through the summer and fall to make sure therapy does not end up as the "pay for." What irony would it be that we finally get our therapy cap repeal, but end up paying for the repeal in its entirety?

Many advocacy groups and long-term care providers are celebrating SGR's permanent reform. The buzz is wearing off, though. Now we settle into the after-party, which is what we should expect in this reform.

One big question: Will medical review transition from simply a mandated review process to a meaningful review process?

We know a few things for sure:

  • No more RAC MMR oversight!
  • No more “all claims over the threshold” MUST be reviewed.
  • There isn't a lot of funding given to CMS for reviews under the “doc fix."

There are specific directions for the Secretary on MMR, including:

  1. Focus reviews based on a provider's denial rates 
  2. Reviews based on provider billing practices — i.e. claims that appear to be aberrant or significantly different than other providers. (A note that this is how we were reviewed in the past. It's not a bad idea).
  3. New providers will be under the microscope
  4. Any provider linked to another provider that is under review will be at risk
  5. Claims can be reviewed based on a certain type of medical condition or what we typically think of as their diagnosis. (What could this be? The LTC side of me says likely dementia or psych diagnosis. Maybe this will present an opportunity to reinforce the importance of therapy for whatever diagnosis or condition they choose to target)

There are also some other silver linings like the hint given that back-logged 2014 Part B claims that have not been pulled for review under the old MMR system may be covered under the newly passed SGR bill.

Our advocacy efforts need to focus on shaping this interpretation and rollout. Advocacy never sleeps!

Tara Roberts, PT, is the Vice President of Rehabilitation and Wound Care Services at Nexion Health.

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