Medicare Compliance & Reimbursement

But therapists still hoping for yet another moratorium next year. 

Unless and until Congress declares otherwise, the oft-postponed Medicare therapy caps are in effect.

For the period from Sept. 1 through Dec. 31, beneficiaries face a combined $1,590 limit on outpatient physical therapy and speech language pathology, and a separate $1,590 limit for occupational therapy. Those limits will also apply over all twelve months of 2004.

The caps were included in the Balanced Budget Act of 1997 but never went into effect due to repeated postponements by Congress and then the Centers for Medicare & Medicaid Services. They were finally slated to be implemented on July 1 of this year, but CMS agreed to push that back to Sept. 1 when the Medicare Rights Center and others sued, complaining of inadequate notice to beneficiaries.

On Sept. 29, a federal district judge gave CMS the go-ahead to implement the caps, turning aside plaintiffs' complaints that the agency still had not notified enough beneficiaries. However, in a ruling delivered from the bench, the judge left the door open for individual beneficiaries to challenge coverage denials if they were not notified of the caps, according to the Fort Lauderdale Sun-Sentinel.

"The ball is now in Congress' court," said Medicare Rights Center President Robert Hayes. He noted that 49 senators and a majority of representatives sponsor legislation to repeal the caps altogether.

In addition, congressional Medicare conferees have tentatively agreed to delay the caps until 2005, but the question there is how long that bill itself will be delayed.

Cap Moratorium in January?

But all is not lost for rehab providers - the cap may be rolled back in early 2004.

"There may be another year-long moratorium," Hayes says, referring to a provision in the Congressional prescription drug benefits bill that may also halt the therapy cap in 2004.

"Ultimately the pressure will be so overwhelming on the president that he'll make sure the bill goes through," predicts Hayes.

But Edo Banach, deputy general counsel at the MRC, isn't quite as confident. "There is only a moratorium in January if the prescription benefits bill passes," he says. "The other option would be for Congress to pass legislation to do away with the therapy cap completely," he suggests, "but as of now that measure hasn't gone anywhere."

Hayes believes the rehab community can use the prescription drug/therapy cap combination to their advantage. "Therapists don't have to promote what might appear to be their self-interest," he says, adding that this might be a 'cleaner' advocacy position. "All they have to do is promote the drug bill, which is going to be good for their patients."