Capping Problems: Cause vs Effect

Home Blog Capping Problems: Cause vs Effect

One of the hot-button issues in the rehabilitation industry, as far as legislation is concerned, is the ongoing battle to get a full repeal of the Medicare Therapy Caps introduced as a result of the Balanced Budget Act (BBA) in 1997.  This act has caused headaches for providers and patients alike. In part-one of this two-part series, we gave a big-picture view of the Therapy Cap and what it all entailed.  In part-two, we plan on giving a little more insight into what that actually means and the effects and implications that can have on therapists and patients.

  1. Cause: Therapy patients are capped in their combined outpatient physical therapy and speech therapy services Effect: There are a lot of patients not getting the level and amount of care they need due to this cap combining physical and speech therapy. One example includes individuals who have had strokes.  Stroke patients need physical therapy to address their functional impairments, as well as speech therapy to address their communicative and swallowing impairments.  Unfortunately, due to the therapy cap, these patients are either left with a much longer recovery process because they are limited in the number of visits they are allowed or spending a substantial amount of money out of pocket they typically do not have.  Stroke patient treatment is further complicated by the Manual Medical Review process (or $3700 cap threshold).  Many RACs and MACs are denying and taking back payment to providers based on what they perceive as treatment not being medically necessary.  Providers then must fight through multiple levels of appeals which eventually lead to the ALJ level, which is on a 24 month backlog.  During this process a provider is fully liable for all treatments provided.
  2. Cause: Therapy patients with multiple episodes capped in their outpatient therapy services Effect: The old adage of “when it rains it pours” tends to have some truth to it. Individuals who find themselves requiring physical therapy for an illness or injury earlier on in the year can have a string of bad luck and find themselves in need of more physical therapy for an unrelated reason later that same year. For example, an individual has a stroke towards the beginning of the year that requires therapy, and then gets in a car accident later that year requiring additional therapy. With the current therapy, these would be viewed through the lens of one year and the expenses would be combined for the purposes of the cap.
What can you do about it? The above situations are just two of many possible scenarios and examples of the negative impact of the Medical Therapy Cap legislation.  However, you are not in a helpless situation because there are actions you can take to help. Contacting your local congress men and women to raise the awareness among the people in power is an example of something that you can do to enact positive change.  (Click here to find the information on your current representatives and their contact information.)  If you have any questions about this or any other related issues feel free to email or visit us online at