November 1, 2021 | Net Health

2 min read

New Legislation Could Delay PTA/OTA Payment Differential – Reach Out to Your Representative

The Bipartisan Budget Act of 2018 (BBA) included a provision that requires CMS to implement a Medicare payment differential on January 1, 2022, for care provided “in-whole or in-part” by a physical therapy assistant (PTA) or occupational therapist assistant (OTA). Since the law was passed, CMS and stakeholders have worked together to develop regulations around this policy. One of which is the definition of “in part”; CMS regulations state that the payment differential is to be triggered when more than 10% of the therapy service is furnished by the PTA or OTA. This threshold is also referred to as a “de minimis” standard.

Currently, effective January 1, 2022, outpatient therapy services provided, in whole or in part, by therapist assistants will be reimbursed at 85% of the Medicare Physician Fee Schedule. The impending Medicare payment differential for therapy services furnished by a PTA or OTA is coming at the same time as CMS’ planned 3.75% reduction to the conversion factor will be implemented, and the 2% Medicare sequester moratorium will expire—all on January 1, 2022. However, practices and facilities are still trying to recover from the impacts of the pandemic. Lawmakers are beginning to realize that this trajectory is simply not sustainable.

Representatives Bobby Rush (D-IL-1) and Jason Smith (R-MO-8) recently introduced the bipartisan Stabilizing Medicare Access to Rehabilitation and Therapy (SMART) Act (H.R.5536). This legislation seeks to delay the implementation of the 15% therapy assistant differential by one year—pushing it back from January 1, 2022 to January 1, 2023.  With respect to patients in underserved and rural communities and the therapy assistants who live and work there, the bill goes further; PTAs and OTAs who provide care in rural or medically underserved areas would be exempted from the 15% differential altogether. This secondary effort seeks to ensure access to care in the types of communities in which PTAs and OTAs play more significant roles.  

The bill also addresses the therapist assistant supervision standard. Current Medicare rules require direct supervision of therapist assistants in outpatient clinical settings, while in all other settings, the standard is general supervision. Should H.R.5536 be enacted, it would remove Medicare’s direct supervision requirement and allow for general supervision in most outpatient settings. The level of supervision would then be determined at the state level; currently, 44 states allow for general supervision of PTAs in all setting types.

 If this bill would help your bottom line or reduce your administrative burdens, reach out to your Representative and ask them to cosponsor the SMART Act (H.R.5536).

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