It Ain’t Over ’til It’s Over: Why Our Fight for Therapy Cap Reform Must Go On

I’m a firm believer in celebrating milestones. During my years as a practicing physical therapist, it was key to keeping my patients engaged in care. Now, as an advocate for the physical therapy profession, I find that taking a moment to celebrate victories is still just as important. For one thing, taking the time to appreciate how far you’ve come is a great way to maintain momentum. Furthermore, savoring your victories can reinforce your confidence and help you push on to the next goal. That’s why I think it’s important for physical therapists—heck, all rehab therapists—to take a moment and celebrate the milestone we achieved this past February. I’m talking, of course, about the repeal of Medicare’s hard cap on therapy services. As you undoubtedly know by now, on February 9, Congress passed the Bipartisan Budget Act of 2018, and buried deep within all that legalese was language that removed the hard caps on services for PTs, OTs, and SLPs. But, while this is certainly a win for rehab therapists and Medicare beneficiaries alike, it is merely one battle in a much larger fight to improve patient access to healthcare services—specifically, rehab therapy services.

Granted, we’ve been talking about therapy cap reform for so long that it’s tempting to call it a day and close the book on this epic saga for the foreseeable future. We all know it’s been an exhausting fight, but the simple—and perhaps harsh—truth is that it’s not over. Instead of putting up our dukes for the Nth time, however, maybe we should take this auspicious moment to ponder alternatives. After all, our professional associations—and the providers they represent—still have a lot of work to do.

There’s still a limit on therapy services.

First and foremost, it’s important to note that this repeal does not remove the limit on therapy services—at least not entirely. Rather, it removes the threat of capping a patient’s services at a certain dollar amount—a threat that briefly became a reality earlier this year. Previously, CMS would establish an annual hard cap amount within its final rule, leaving Congress to scramble at the end of each year to enact an exceptions process. This meant claims exceeding the cap amount could still be paid as long as the provider applied the KX modifier and the services met Medicare’s definition of medical necessity. As of 2015, any claims that exceeded the secondary threshold of $3,700 were subject to a targeted manual review process. So yes, patients could still access therapy care—even beyond the $3,700 threshold—but there were a couple problems:

  1. Medicare’s definition of medical necessity is a bit murky, especially as it applies to maintenance care coverage; and
  2. PTs who frequently exceeded the cap were vulnerable to Medicare audits.

With the passage of February’s Balanced Budget Act, the cap is technically gone—emphasis on “technically.” The somewhat disappointing truth is that the Medicare claims process for therapy services still functions much the same as it did before: there’s still a $2,010 threshold for therapy services—beyond which providers must apply the KX modifier in order to receive reimbursement—and there’s still a targeted manual review process that goes into effect beyond a secondary threshold. However, that second-tier threshold has been lowered to $3,000—a change that has many therapists feeling a bit uneasy.

There’s a future payment reduction on services provided by PTAs and OTAs.

The budget bill also includes a payment reduction to services furnished by physical therapist assistants and occupational therapy assistants. Starting on January 1, 2020, any services furnished either in full or in part by a therapist assistant will be reimbursed at 85% of the amount that would normally be reimbursed had the service been performed by a therapist. The APTA has vehemently opposed this change and will continue to fight against it. “That pending payment differential under Medicare is somewhat comparable to that between physician assistants and physicians, but it was added to the budget bill late and without warning,” the APTA stated. “It wasn’t part of the 2017 bipartisan agreement legislators reached, nor was it part of any discussions or negotiations on Capitol Hill since then.”

Congress maintains that this reduction is intended to cover the eventual costs incurred by removing the threat of a hard cap—to essentially “balance things out.” But from where I’m standing, Congress’s failure to dedicate the necessary resources to rehab therapy patients is just further proof that our lawmakers do not view PTs, OTs, and SLPs as being any more valuable than they did previously. So, our work is still cut out for us on the value perception front.

Even without the hard cap, patients still have limited access to therapy services.

Let’s look at this change objectively: Medicare will still pay claims beyond $2,010 as long as the services meet Medicare’s definition of medical necessity and the KX modifier is applied appropriately—and that’s great news for patients and providers. And while it’s true that CMS will conduct targeted reviews starting at $3,000, they will only review claims from providers with a history of aberrant billing practices. Furthermore, CMS did not receive any additional funding for targeted reviews, which could imply that the agency will be more selective about which claims undergo review.

That said, by requiring providers to jump through hoops, Congress has still left unnecessary barriers in the way of patients who need care. On top of that, by singling out providers whose patients frequently exceed the therapy cap and holding the threat of an audit over their heads, CMS has put undue pressure on therapists to stay under the cap—which means Medicare beneficiaries may not receive the full breadth of care they need.

The conversation must start right now.

So, where do we go from here, and what needs to change? There are some therapists calling for continued therapy cap advocacy (as they should be), but there aren’t many active, widely known, public-facing campaigns to move this effort forward. But even though the therapy community is struggling to pivot its advocacy strategy, therapists aren’t blind. They see that the targeted review threshold is $700 lower and that PTAs and OTAs have a looming payment differential, so it’s easy to understand why many folks in the rehab therapy community feel like this repeal isn’t a win. In fact, based on some of the more heated rhetoric I’ve seen, some actually place the blame on the APTA because of the association’s push for this change.

I don’t exactly agree with that assessment. While the APTA proposed lowering the targeted review threshold to $3,000, it did not support the payment differential for therapist assistants. Furthermore, while this isn’t the change PTs—or the APTA, for that matter—were hoping for, it’s a start. And it’s moving us in the right direction.

Plus, in the midst of all this change, we still have the Medicare Access to Rehabilitation Services Act of 2017—the bill that proposes a full repeal of the Medicare therapy cap in favor of a general targeted review process—awaiting committee review. This bill has been sitting on the docket since February 2017 with little-to-no movement. But even if the bill in its current iteration fails to become law, it could serve as a jumping-off point for future efforts to repeal the cap.

Progress won’t happen unless there’s advocacy at all levels.

In a sea of big fish, the APTA exists to make sure physical therapists have a seat at the legislative table. With that in mind, I believe that making your voice heard within the association is the answer—or, at the very least, a start. And I don’t mean in the form of Internet comments or social media post tirades, because let’s face it: hurling reactionary insults from behind the keyboard has never successfully pushed a legislative agenda forward. PTs need to walk the walk, not simply talk the talk. So, get involved with your local APTA chapters. Be a part of the actual conversation—not just the social media maelstrom.

Here are a few ways you can get involved:

  • Join the APTA and stay up to date on advocacy efforts.
  • Be an active member of PTeam, APTA’s advocacy team.
  • Donate to the PT PAC to support more relationship-building with members of Congress.
  • Contact—and keep an open dialogue with—your congressional representatives about removing all barriers to therapy care.
  • Visit this APTA action page to stay current on the advocacy efforts impacting our industry.

Trying to push legislation forward feels a bit like marching through quicksand. The legislative process is slow, and it always has been. But there’s strength in numbers, and if physical therapists at every level of the profession can band together as one united front, I know we’ll have the power to propel our profession upward and onward. After all, repealing the hard cap was a hard-won victory that’s brought us a little closer to better access to health services for all—and that’s certainly a win worth celebrating.


About the Author

Heidi Jannenga PT, DPT, ATC/L is the president and co-founder of WebPT, the leading practice management solution for physical, occupational, and speech therapists. Heidi leads WebPT’s product vision, company culture, and branding efforts, while advocating for the physical therapy profession on a national scale. She co-founded WebPT after recognizing the need for a more sophisticated industry-specific EMR platform and has since guided the company through exponential growth, while garnering national recognition. Heidi brings with her more than 15 years of experience as a physical therapist and multi-clinic site director as well as a passion for healthcare innovation, entrepreneurship, and leadership.

An active member of the sports and private practice sections of the APTA, Heidi advocates for independent rehab therapy businesses, speaks as a subject-matter expert at industry conferences and events, and participates in local and national technology, entrepreneurship, and women-in-leadership seminars. In 2014, Heidi was appointed to the PT-PAC Board of Trustees. She also serves as a mentor to physical therapy students and local entrepreneurs and leverages her platform to promote the importance of diversity, company culture, and overall business acumen for private practice rehab therapy professionals.

Heidi was a collegiate basketball player at the University of California, Davis, and remains a lifelong fan of the Aggies. She graduated with a bachelor’s degree in biological sciences and exercise physiology, went on to earn her master’s degree in physical therapy at the Institute of Physical Therapy in St. Augustine, Florida, and obtained her doctorate of physical therapy through Evidence in Motion. When she’s not enjoying time with her daughter Ava, Heidi is perfecting her Spanish, practicing yoga, or hiking one of her favorite Phoenix trails.

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