02/10/2018
We have been receiving lots of questions about how this is better than what we had?
This is a good and important question with some good answers. Here we go:
The $2,010 hard cap is repealed. We did not have an exceptions process in place. The baseline we had was a denial of all claims above that arbitrary limit.
The arbitrary limitation on all services above $2,010 was removed and now ALL medically necessary care can be provided and reimbursed with a small percentage subject to potential review if documentation to ensure medical necessity.
At $3,000 a limited targeted review was put in place for some claims. CMS did not get additional money to conduct reviews so while the claims potentially subject to review have increased, the number of reviews will not. The net got bigger but so did the holes.
In discussions with the review auditors- when the review was previously in place at $3,700, they were only reviewing about 5% of claims above the threshold. With those same resources, the effective rate of reviews will likely be just 1.8% of outpatient claims.
Less than 2% of claims will actually be reviewed under this policy. A sharp difference between that and denial of all claims above $2,010.
The repeal of the cap and replacement with the targeted review at $3,000 cost $6.8 billion because of the increased access to care and reimbursement that will result. That is nearly $7 billion in additional outpatient therapy reimbursment from Medicare to OT, PT and SLP because of our advocacy.
Passing this permanent repeal and replacement stops the year to year insecurity and uncertainty we have had for the past 20 years. It creates a new baseline for advocacy and dramatically reduces the cost of future changes we need to advocate to enact.
The change is not perfect by any means but it is a great improvement and provides a lot more flexibility and opportunity to continue to advocate for additional changes and improvements.
With this policy in place we no longer need to pay for changes to the hard cap at $2,010 to change any other policy. For example, advocacy to seperate SLP from PT in application of the review threshold will be much less expensive because we start from $3,000 and only need to offset the amount of claims reviewed and denied-which is a very small number compared to all claims over $2,010.
Advocacy and the legislative process is an incremental game. This change is not perfect but a great improvement and also an enormous help to all future advocacy related to any aspect of outpatient therapy.
The value of that cannot be overstated. There is more to be done and this law makes all of that more possible.
Let's take a minute, celebrate what we just accomplished and then let's get back to work. We did this together and we can continue to make meaningful changes happen as we advocate for our professions.
Thank you all again for your part to Stop the Medicare Therapy Cap.
(P.S. We are going to need a new name!)
