Therapy cap may return to the back burner

Physical therapists continue to seek repeal

A May 22 meeting between rehab advocates and the Centers for Medicare & Medicaid Services (CMS) may result in further delay in implementation of the $1,590 Medicare outpatient therapy cap.

The Program Memorandum CMS released earlier in May to address implementation of the cap failed to alleviate the rehab field’s concerns about potential administrative and patient notification problems. CMS officials indicated at the meeting that they may be willing to move the implementation date back from July 1 to Oct. 1. Starting in October, the Medicare Summary Notice that beneficiaries receive monthly will alert them to how close they are to exceeding the cap. If the cap were to be implemented in July, for three months beneficiaries would only be notified when they have already exceeded the cap.

Dave Mason, vice president for government affairs at the American Physical Therapy Association (APTA) in Alexandria, VA, says the program memorandum clarifies a few of the issues, but a lot of uncertainty remains. "I don’t think it addresses all of the billing problems," Mason says. "And while it clarified some details regarding notices to beneficiaries, it still seems very likely that hundreds of people will probably not be aware that the cap is in place until they’ve exceeded $1,590 in services."

Peter Clendenin, executive vice president of the National Association for the Support of Long Term Care in Alexandria, VA, says the meeting with CMS went well and a follow-up meeting will be scheduled. "CMS has displayed a spirit of cooperation in working with us to make the implementation as least harsh as possible," he says.

APTA is pushing ahead with plans to urge Congress to pass legislation that would repeal the cap entirely. An APTA grass-roots team scheduled a June 19 rally on Capitol Hill. APTA hoped to register at least 500 therapists to visit each member of Congress to ask that they support direct access and the repeal of the therapy cap, says Michael Matlack, assistant director for grass-roots and political affairs.

"I think if they pass anything, it probably won’t be until September. That’s unfortunate because it could mean that we’ll be under the cap for at least a couple months," Matlack says. "The whole thing is just terrible."

Co-sponsors of the legislation introduced in March to repeal the cap have increased to 131 in the House and 28 in the Senate. "Most members of Congress are not against it. There’s not a vocal opposition," Matlack says. "We just have to get them to focus and act on the issue. They didn’t pass one thing last year, not just for physical therapists, but for anybody in health care. Fortunately, the war is basically over. We’ll just have to see how it goes for this year."

Besides encouraging Congress to pass the legislation, therapists also should be researching avenues of appeal in case their patients exceed the cap, says Tom Howell, a physical therapist with the Physical Therapy Clinic of Boise (ID). Therapists should check with their local carrier or fiscal intermediary to see if there is an appeal process, he says.

"I think it is important to note that your patients and your clinics can appeal a claim denied due to the caps. I think every practitioner should appeal," Howell says. "For instance, if you have a Medicare beneficiary that you’ve been seeing for 15 years and who doesn’t want to travel to a hospital outpatient department for their PT, is this a case that should be appealed
if their future therapy claims go over $1,590? I think the answer is yes."

Howell says appeals will document the arbitrary and hurtful nature of the cap. "If a beneficiary lives close to your clinic and the nearest hospital outpatient department is 30 miles away, is this justification to appeal? Again, I think it is. The more we can, on paper, show how these caps hurt, the more we can show to CMS and to Congress that they have to be eliminated."

Need More Information?
  • Dave Mason, Vice President for Government Affairs, APTA, 1111 N. Fairfax St., Alexandria, VA 22314. Telephone: (703) 684-2782.
  • Peter Clendenin, Executive Vice President, National Association for the Support of Long Term Care, 1321 Duke St., Suite 304, Alexandria, VA 22315. Telephone: (703) 549-8500. E-mail:
  • Michael Matlack, Assistant Director for Grass-roots and Political Affairs, American Physical Therapy Association, 1111 N. Fairfax St., Alexandria, VA 22314. Telephone: (703) 684-2782.
  • Tom Howell, PT, Physical Therapy Clinic of Boise, Boise, ID. E-mail: