A bipartisan group of five members of the U.S. House of Representatives has joined APTA and other groups in criticism of a plan to reduce Medicare payment to providers when therapy services are delivered at least in part by a PTA or occupational therapy assistant. In a letter sent to HHS Secretary Xavier Becerra, the lawmakers warn that the system will be particularly harmful for providers in rural and underserved areas, and offer possible solutions to avoid the worst of the damage.

The letter from Reps. Brian Higgins, D-N.Y., Blaine Luetkemeyer, R-Mo., Paul Tonko, D-N.Y., Ann McLane-Kuster, D-N.H., and John Joyce, R-Pa., targets the U.S. Centers for Medicare & Medicaid Services plan to impose a 15% payment differential associated with a therapy code modifier indicating that a service was delivered "in whole or in part" by a PTA or OTA. The differential coding was required by federal law. CMS intends to impose reduced payments related to that differential beginning in 2022.

"The payment reduction puts at risk the financial viability of physical and occupational therapy businesses in rural and underserved areas," the letter states. "Absent action by the Centers for Medicare and Medicaid Services, the therapy assistant payment reduction will exacerbate the growing problem of limited access to medical care throughout much of rural America."

A Path Forward?
The lawmakers offer two possible ways for CMS to blunt the harm of the cuts for providers in rural areas, should the agency decide that it can't outright exempt providers in those areas from the cuts.

One approach, they write, would be to create "a class-specific geographic index" for therapy services furnished by PTAs and OTAs in those areas that would offset the cuts. A second approach would be to establish "incentive payments" for certain relative value unit data collected from providers in targeted areas, again designing the payments in a way that would help providers recoup funds lost to the cut.

Another Needed Fix: Supervision Requirements
Should CMS decide that it can't or won't do anything to stop or offset the planned payment cuts, then the very least the agency could do would be to introduce more flexibility in private practice supervision requirements, the legislators write.

Specifically, the letter asks CMS to consider amending supervision requirements to allow for general supervision of PTAs and OTAs instead of current requirements that all supervision be direct (requiring the supervising PT or OT to be in the office and immediately available). Medicare currently allows for general supervision in all areas except private practice.

Although the direct supervision requirements have been allowed to be met virtually during the pandemic, once the public health emergency ends, private practitioners in rural areas will once more be stuck with a potentially onerous in-person supervision requirement at the same time they're facing significant cuts to payment, thanks to the differential. Authors of the letter to CMS believe the combination of cuts and supervision burden may push many provider businesses to the breaking point.

For APTA, a Years-Long Fight
"We're grateful that Representatives Higgins, Luetkemeyer, Tonko, McLane-Kuster, and Joyce have urged HHS to take action," said Justin Elliott, APTA vice president of governmental affairs. "They understand what APTA and other organizations have been saying since this plan was unveiled without warning back in early 2018 — that this differential system will be a barrier to patient access to care, particularly in areas that are already experiencing difficulties in obtaining needed health services."

Since its 11th-hour inclusion in the Bipartisan Budget Act of 2018, APTA, the American Occupational Therapy Association, and other stakeholder organizations have been advocating against implementation of the differential and providing critiques of the needlessly complicated systems CMS devised to pin down exactly what it meant by services furnished "in whole or part" by a PTA or OTA. The final version of the policy is clearer about how a "de minimis" standard will be applied — set at 10% or more of the service delivered by a PTA or OTA — when the agency did back away from parts of the plan that APTA and AOTA viewed as particularly confusing.

Elliott is hopeful that CMS will consider the mitigation options offered by the legislators.

"The letter outlines some helpful options to HHS that we believe could help in mitigating the impact of the differential," Elliott said. "We understand that CMS is bound by law to impose a differential, but that doesn't mean all options, such as exempting rural areas or eliminating the direct supervision requirement, are off the table."

APTA staff continues to monitor the issue, advocate for the profession, and share opportunities for grassroots efforts. If you want to get an even closer look at APTA's advocacy efforts and connect with other members interested in working for change, join the APTA Advocacy Network.