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| ProviderLAW Advisory | |||||
| Research Sponsored by Sun Billing & Financial Recovery, Inc. | |||||
Update on Medicare Therapy Caps | |||||
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A copy of this advisory |
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| Drafted by: ProviderLAW | |||||
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Since 1997, federal law has required the Centers for Medicare & Medicaid Services (CMS) to impose financial caps on certain types of therapy including outpatient physical, speech-language and occupational therapy services by all providers, other than hospital outpatient departments. Since then, a series of moratoria have been enacted. When the last of these moratoria expired, the caps were reinstated on January 1, 2006 at $1,740 for each cap. On February 8, 2006, however, the President signed the Deficit Reduction Act of 2005 (DRA) into law. The DRA directs CMS to create a process to allow exceptions to therapy caps for certain medically necessary services provided on or after January 1, 2006. The law mandates that if CMS does not make a decision within 10 days, the services will be deemed to be medically necessary. Recently, the CMS posted a "fact sheet" describing the exceptions process. According to this fact sheet, "until contractors are able to implement the exceptions process, they are required to accept requests for adjustment of claims for services in 2006 that were denied for exceeding the caps." Specifically, the Fact Sheet states: |
"Providers, whose claims have already been denied because of the caps, should contact their carrier to request that the claim be reopened and reviewed to determine if the beneficiary would have qualified for the exception. In addition, providers who have not yet submitted claims for services on or after January 1, 2006 that qualify for the exception, should submit these claims for payment, and refund to the beneficiary any private payments collected because of the cap." |
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"Fact Sheet: Outpatient Therapy Caps: Exceptions Process Required by the [Deficit Reduction Act]," Centers for Medicare and Medicaid Services, February 15, 2006." Providers interested in learning more about the exceptions process for therapy caps are encouraged to carefully review CMS's exception process as detailed in the CMS fact sheet. |
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