The Medicare Cap: Just a Private Practice Problem?

No, no it’s not.

But that’s a question that’s come up, and here’s why:

Hospital outpatient therapy services were not originally included in the therapy cap when it was created 20 years ago. Any therapy services rendered within the hospital system were not subject to the roughly $2,000 cap. However, when the exceptions process was enacted in 2012, hospital OP then became subject to the cap.

Fast forward to January 1, 2018. The exceptions process expires, leaving a hard cap of $2,010 in place for PT/SLP and OT services. However, because the exceptions process is no longer in place, hospital OP is no longer subject to the hard cap.

Does that remove the incentive to advocate?

No, no it doesn’t.

It’s an access issue.

Think about it. You’re a PT in an OP private practice–let’s say you’re a neuro PT. Your patient is approaching the cap. You know that if they don’t get therapy services, they will regress. But they can’t afford to pay out of pocket. You do what you have to do to make sure the patient gets the care they need, and you refer them to hospital outpatient services. The waitlist to get in for an evaluation is 2 weeks long. The PT in the hospital setting can’t see your notes, so you do the best you can to prep the patient about what to tell them.

You’re the hospital OP neuro PT. Your schedule is booked out 3 weeks. You know these patients need care, and you know that some of them are driving 30+ miles to get to you because they can’t afford to go to the private practice in their hometown. You’re trying to accommodate different schedules, book them when they’re in for a check up, but it’s hard. You also realize that your patient population is becoming more complex–documentation is taking longer and you need more assistance from aides for patient safety. You’d like to follow up with the private practice PTs who have been seeing some of these patients, so you bring dinner, stay late, and live on the phone.

You’re the hospital inpatient PT. The next patient on your schedule is observation status. You ask the OT to triage for you to help determine if you should go see the patient so that you don’t cut into their Medicare part B dollars. You don’t know if they have access to hospital OP services, or if they’ll need to go to a private practice, but you’ll make sure that you don’t charge them unnecessarily. (Patients under observation status do not qualify to use their Medicare A dollars; thus, they use Med B dollars, drawing from the cap. They also don’t qualify for a stay in a skilled nursing facility under Med A.)

Hold up, let’s just bring on more staff.

Bring on the PRN staff! Hire more PTs! That could work but….Christa Trumbull, our graphics designer and rural generalist PT in Nebraska, explains the difficulty affecting some areas:

“We’ve been trying to hire some PRN for months and can’t get anyone. We also would love to hire more full time help, but no one wants to live three hours from nowhere if they aren’t from here or married to someone from here.”


No matter what setting you’re in, this affects you.

Your patient now has to drive an hour to get to therapy. That’s not an after work visit, that’s a day they have to take off.

Your patient now has a different therapist, when they spent 10 visits building the therapeutic relationship with another.  

Your patient can’t see a specialist PT because the hospital system doesn’t have one, but they’ll hit the cap if they go outside.

Your patient gets to you more deconditioned than when they started because the earliest evaluation on your schedule was two weeks from their release date from the hospital.

We rely on each other as a whole system to make sure that we can serve the needs of the area in which we live. We all care about the needs of our patients. We’re all in this boat together.

Therapy can’t wait.

These patients would be better served by faster, local access to therapy services. But these PTs are stuck between a rock and a hard place, and it’s not just about the bottom line. It’s about patient care.

Congress can’t either.

As Justin Elliott, VP of Government Affairs for the APTA says, “Every day hurts.” Congress must vote on a spending bill by February 8th. We have to ensure that leadership gets the Medicare permanent fix legislation attached to the spending bill.

So let’s #StopTheCap.

In order to make sure Congress understands the impact this is having on their constituents, APTA is urging therapists to get patients on video stating how the hard cap affects them.

Are you in home health? Skilled nursing? Have more stories? Share them in the comments below!

Ever wonder if passing the permanent fix legislation is just a dream? We did, too. Check out the editorial here.