Extension of therapy caps exceptions process hinges on healthcare reform passage

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Whether or not you are a fan of healthcare reform, here's one reason Congress should pass it: It would extend the therapy caps exceptions process.

It has been a week since the exceptions process for Medicare Part B therapy caps expired. While there may not be cause for alarm yet, each day that goes by causes residents and nursing homes more consternation.

“I think they'll [Congress] get to it early this month, but we're sort of hanging out there until that gets done,” said Peter Clendenin, executive vice president for the National Association for the Support of Long Term Care.

The Senate bill would extend the exceptions process for one year, while the House bill would extend it for two.

Providers have been here before, he noted. There have been other instances in the last 10 years that Congress has failed to act to extend the exceptions process before the expiration, Clendenin said. Fortunately, this time, the expiration has occurred at the beginning of the year. That means that residents started fresh with their annual allowance for therapy on Jan. 1. The spending limits are $1,860 for combined speech and physical therapy, and $1,860 for occupational therapy. But that is not much consolation, Clendenin said.

What happens?

When a resident exhausts the therapy benefit, it causes a problem for the resident who needs the therapy and the nursing home, which provides it, he explained. Often the options are limited. The facility could tell the resident he or she must pay privately; it could continue to provide the therapy with the expectation it will be reimbursed when the bill passes; or it could suspend therapy. None is a good alternative.

There is also the option of sending a resident to a hospital outpatient facility where there is no limit on the therapy. (Hospitals are not subject to the therapy caps rule.) But that also is not ideal because it entails transporting a resident, who may be frail. The resident who most likely would feel the impact of the cap would be someone who suffered a high-acuity event, such as a stroke or hip or knee replacement, and needs intensive, short-term therapy.

So it seems that the best option is for Congress (OK, Democrats) to pull together one more time and pass its bill. As each day passes, the health needs of residents are depending on it. 

Another therapy challenge

You may have heard some talk regarding a change to Medicare Part A concurrent therapy rule. If not, you will. This therapy topic promises to become a major concern facing long-term care rehab providers as the year continues.

As of Oct. 1, the Centers for Medicare & Medicaid Services wants to allocate therapy minutes between two residents. In other words, if a therapist is working with two residents, the number of minutes would be based on the amount of time a therapist spends with each. Currently, the number of minutes a therapist spends with two residents is based on the resident's time.

As an example, if a therapist is working with two residents for a total of 60 minutes, under the new rule, each resident would be credited with 30 minutes. The current rule allows each to be credited with 60.

Clendenin sees the new rule as a way to discourage the use of concurrent therapy. The result of such a change is that the therapist would have to spend twice as long with a resident for him or her to reach a certain Resource Utilization Group (RUG) category. These new rules could affect placement of residents in RUG categories and, by extension, payment to nursing homes.

Stay tuned for more on this issue.


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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Marty Stempniak.