Symmetry is pleased to report good news for patients insured by Medicare. The United States Congress has (finally) passed legislation that eliminates the “hard therapy cap” on Physical Therapy / Speech Therapy services. This means that therapy services can now be provided to patients beyond the 2018 benefit limit of $2010, as long as the services are certified as medically necessary by the treating practitioner. The way that Symmetry describes the concept of medical necessity to patients is that treatment is expected to provide a benefit to patients via improvement in their physical level of function. If we observe deficits in function that we expect to respond positively to physical therapy, then we can provide care. Once a normal level of function is achieved, Medicare’s expectation is that patients will continue with independent activity until such time as their functional status changes to a point that further care is indicated. Medicare does not provide a benefit for “maintenance care” that does not require the specialty skills of a licensed therapist. That said, Medicare does recognize that medically necessary care may include intermittent or periodic therapy performed by a skilled and licensed practitioner to prevent decline in physical function. An example of this circumstance would be the periodic provision of care for patients that are doing well overall, but that also have ongoing chronic conditions such as diabetes or degenerative arthritis that respond well to periodic manual therapy or functional exercise adjustments as part of an ongoing health management strategy.
The legislation that was recently passed is actually a permanent fix to the hard therapy cap situation. For the last number of years, annual Congressional action has been required to prevent the implementation of a hard cap such as that enacted earlier this year. It has been typical for there to be a scramble of phone calls, letter writing, and other appeals to Congress towards the end of each calendar year to encourage each temporary fix to the therapy cap problem. Now, as in the past, a specific benefit amount for Physical Therapy / Speech Therapy services will be announced each year by the Centers for Medicare Services. But because of the current legislation, the process by which services can continue to be provided in excess of this amount when medically necessary will remain permanently as described above. This fix should reduce the uncertainty experienced by both patients and providers each year about whether or not medically necessary care will be available and reimbursed.
If you’ve read this far, hopefully you’ve gotten the gist of how Medicare’s benefit for therapy services works. If it’s possible to absorb a bit more information about the ins and outs of Medicare policy, it is worth reading a bit further about another provision to this legislation. In addition to setting an annual “base” benefit amount for Physical Therapy / Speech Therapy services, the Centers for Medicare Services also specifies a “threshold” amount after which it is possible to “trigger” what is called a “targeted medical review” of all therapy services provided to a patient within any given calendar year. For 2018 this threshold amount is $3000. (This is a reduction from past years, where the threshold amount has been $3700.) A targeted medical review can be thought of as a type of audit, during which Medicare representatives sample a number of cases to make sure that medical providers are honestly assessing patients’ needs for services and are providing care accordingly. This process is meant to discourage health care providers from overbilling Medicare for unneeded care. What this policy means for patients, is that from time to time therapists will perform reevaluation procedures and will discuss therapy prognosis, plans, and expectations with each patient to make sure that the treatment being provided is continuing to meet patients’ needs and to be providing a tangible health benefit. This is something that Symmetry does for all patients – regardless of the type of insurance that they carry – as it is a “best practice” that ensures quality care. In the past, if a Medicare audit was triggered, it would mean that an auditor would have a specified period of time in which to review the case. After this time, specific parameters might be issued about how much additional care would be pre-authorized within a particular time frame. Whether or not this process was altered within the current legislation is unclear. Further information is expected in coming months as the American Physical Therapy Association has a chance to more thoroughly review the final legislation’s documentation.
We realize that the process of navigating and understanding Medicare policy is complicated. If you have questions about this information or how it might affect your personal situation, please feel free to contact us at Symmetry. We do our best to stay current with Medicare policy, and to help our patients get the most out of their health care benefits.