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Finance SGR Package Replaces Therapy Caps With Prior Authorization

The below excerpts were taken from an article posted on InsideHealthPolicy.com on
December 10, 2013.

The Senate Finance Committee proposes to repeal Medicare therapy caps and institute a new medical review process in its place as part of the extenders package tied to the committee's
replacement of the flawed Medicare physician payment formula, released Tuesday (Dec. 10). Providers say including a repeal of the caps -- which Congress has overridden 10 times since the caps were enacted -- in the package to repeal the Sustainable Growth Rate is a good starting point, though one therapy advocate said they would like to see the language in the proposal tightened up before it is passed to better mirror congressional intent. Senate Finance and House Ways & Means plan to each mark up their respective SGR packages shortly.
 The Ways & Means package, also released Tuesday, does not include extenders. Mandy Frohlich, the senior director of government affairs at the American Physical Therapy Association, said she expects therapy caps to come up at the Ways & Means mark-up. Providers are still reviewing the Finance package, but said the direction the committee takes is a good start, and some provider advocates said Finance's approach is very thoughtful. The Therapy Caps Coalition, which includes therapy and chronic disease lobbyists, and other stakeholders have been pushing lawmakers to add a long-term Medicare payment alternative to the therapy caps to alleviate the uncertainty of renewing the exceptions process every year.

 The Finance Committee's newly unveiled bill proposes to immediately repeal the cap, which is currently set at $1,900 a year for occupational therapy and $1,900 for a year for physical
therapy and speech pathology, but keep the $3,700 threshold for manual medical
reviews through the end of 2014. Starting in January 2015, HHS would start a new medical review program with prior authorization. The program would look to review therapy providers using appropriate factors, a committee summary says, which could include those new to the Medicare program, with higher billing patterns than peers, and a high percentage of claim denials. The committee also suggests those with questionable billing practices, such as billing medically unlikely amounts in a day, also could be reviewed.


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