Support the Exception to the Moratorium of the Exception Process Part I

Don’t laugh. History has demonstrated that we will be asked to support such lunacy in a few years.  I would rather support the elimination of the month of Feb, deep sixing pennies, or forgetting about daylight savings time.

History bears repeating:

-there was a medicare cap for everybody but hospitals

-there was a moratorium of the cap

-there were several legislative extensions to the moratorium of the cap

-during this entire time we were told there would be an alternative to the cap

-the moratorium ended and the cap was put in place

-PT’s cap is combined with speech but OT has its own cap (wish I was kidding)

-But.  An exception process to the cap was put in place. If you put altzheimer’s as an additional diagnosis, you could see the patient with no cap (just like a hospital can on all patients)

-The exception process expires in 31 Dec 2007

-We are asked to support legislation that extends the exception process up to 2 years while an alternative is being developed

-In the words of Yogi, “It’s deja vu all over again”

What about the long planned alternative?  What about the fact PT is 1.5% of the medicare budget-why all the fuss?  Why don’t we fight for eliminating the cap rather than extending moratoriums, exceptions processes, and the like? Why are we spending a disproportionate amount of time, resources, and money on 1.5% of the CMS budget?  Why is there no cap on primary care, pharmacy, MRI’s, lab, and surgery? 

-All this and there is a writer’s strike that is delaying my beloved 24

Thoughts?

Larry@physicaltherapist.com

Comments

[Michelle]

I concur, Larry!!!

Random related thought... What if like dental, and even veterinary insurance, 'PT insurance' became available? I'm sure those patient's with $30 to 100 co-pays may have interest since the current scheme is intended to discourage appropriate management. Would we have more control over rules?

While I know insurance is not the answer, fighting fire with fire may be the only way. ~ MJ

[cj]

What about some help from the art world to drive our point?!

This is GREAT!! Follow the suggested links, including those to YouTube ("Selling Sickness"), and to http://www.panexa.com/. (Can someone start a new thread with this--if nothing else, it's good comic relief?)

http://www.pbs.org/kcet/wiredscience/story/81-art_tackles_big_pharma_.html#comments

How about teaming up with psychology, dietitians/nutritionists, social work in some way to take on 'the system'?

[Selena Horner]

If CMS had a goal of reducing their costs and the cap and the exception process was the final, brilliant idea... Did it actually work?

I don't know how much it costs to process a claim, but I do know that there had to have been some increased costs with the exception process - initially the review process and then the cost of claim denials and then resubmissions with the KX modifier tagged to all lines. And then, if the subscriber didn't meet the exception rules and the subscriber wanted more services... the increased cost of a physician visit to receive a referral to continue care AND an unnecessary physical therapy evaluation by a whole different physical therapist in a hospital system.

If the cap continues with no exception process, what exactly are the legalities of that? A federal program is basically allowing only hospitals full control of care provided to their subscribers. Where exactly is the evidence that care provided by physical therapists in a hospital setting is both substantially better and more cost-effective than care provided by physical therapists providing Part B care in any other practice locations?

I would think that the big ticket items in the diagnostic arena would more effectively reduce costs. Very frequently, because of our society, diagnostic tests are not ordered because of clinical reasons as much as protection from legal ramifications by the patient or the patient's family.

[Sean Sadler]

I've never understood how a collective profession (Therapy) with 1.5%
of the CMS budget could have risen to the top of CMS' attention to
warrant placing the cap to begin with. I would be curious to see if,
in the late 90's, the Chiropractors were behind a lobbying effort to
institute the cap. Someone must have waved a flag.

The irony is that before the cap went into place originally at
$1,500, private practice owners were already limited to $900.
Instituting the cap, placed the payment model on the Physician Fee
Schedule and increased the private practice cap to $1,500 which was
great for them, but cut everyone else. Just some rambling thoughts.

[Rick]

Yup...Larry’s on target.
The great tragedy of the cap fiasco is that while patients in need are denied physical therapy services the system actually facilitates the squandering of precious healthcare dollars on unnecessary and costly services driven by self-referral.
May 2006 Department of Health & Human Services,
Office of the Inspector General
To: CMS
Based on a simple random sample of 70 physical therapy line items billed by physicians and rendered in the first 6 months of2002, we found that 91 percent of physical therapy billed by physicians and allowed by Medicare during the first 6 months of 2002 did not meet program requirements, resulting in $136 million in improper payments. In addition, we analyzed Medicare claims data from 2002 to 2004 and identified aberrances in physicians billing patterns and unusually high volumes of claims.

Were it not for the fact that this is a federal program influenced by political might it would make no sense at all.

[DG]

LARRY, ( I couldn’t send this from work due to it being blocked by all the Filters)

(in response to your EIM post on 13 Nov)

Thanks for laying out the govt. lunacy. I could go bald pulling out my hair over it!

You already know the answer to your questions: The GOLDEN Rule, 'he (MD's/Lobbyists) who has the Gold, makes the rules'.

More idiocrity: because 2 people are “offended” by the phrase “under God” in the Pledge of allegiance, 8 to 11 states have removed it!

Now, just heard today 15 Nov; the state of UTAH (Mormon America) who used to mark places with crosses where state troopers were killed, will stop that practice because of a few people who are “offended” by them.

Give me a Break !!