Will the Therapy You Need be Covered?

Will the Therapy You Need be Covered?

Currently Medicare limits payment for outpatient therapy services at an annual dollar amount, commonly called “therapy caps.” For example, payment for occupational therapy is capped at $1,920 for 2014. If a beneficiary needs more services than the capped amount covers, the therapist can help the beneficiary request an exception through an “exceptions process.” The exceptions process will expire on March 31, 2014, and we urge Congress to extend the exceptions process or, better yet, repeal the therapy caps.

Therapy caps were imposed in response to overbilling, to save costs and reduce fraud and abuse. But the cap can also encumber a beneficiary’s access to therapy. If a beneficiary needs therapy service above the cap, a beneficiary and therapist must use the exceptions process, which requires the therapist to attest that skilled therapy services are medically necessary and reasonable and provide supporting documentation. Many beneficiaries may not know about this exceptions process, and therapists may be hesitant to engage in a burdensome and time-consuming exceptions process. Even so, the process does give beneficiaries an important opportunity to access medically necessary services above the cap. We urge Congress to extend the exceptions process until we find a better way to deter overbilling, prevent fraud and abuse and facilitate beneficiary access to medically necessary therapy services. We invite you to join us in urging Congress to extend the exceptions process, and revise procedures for better access to therapy services that can improve a beneficiary’s health outcomes.

Please join us in contacting your Congress representative today!

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.