Outpatient therapy and the importance of understanding the CMS therapy cap

For several years, the Centers for Medicare and Medicaid Services (CMS) has instituted a therapy cap that serves as the determining factor in what Medicare identifies as the annual allowable cost for outpatient therapy services. In 2014, CMS upheld the ruling to continue the cap despite legislation that would have challenged it. It continued with the therapy services cap for 2014 of $1,940 for both physical therapy (PT) and speech therapy (ST) combined, and an additional $1,940 for occupational therapy (OT) services.

What does this mean to the consumer?

It means that it is beneficial to ask questions on how your therapy provider manages your services relative to the CMS-mandated capitation. Will you incur costs? Will your selected provider work with you to provide service if it is necessary and challenge the $1,940 limit? Will they provide services past that amount?

CMS did provide an option to provide treatment above the cap up to $3,700 PT/ST combined total and $3,700 OT, with the knowledge that any charges in excess of this are subject to a manual medical review of the charges and services provided.

As a consumer, you are your best advocate. The more you know about your benefits, you will be able to make more informed decisions as you select your provider.

Janelle Jaszczak is the director of Rehabilitation at Life Care Center of Coeur d'Alene.