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 Providers Must Warn Patients About Therapy Caps, CMS Says

Providers must provide written warning to Medicare patients that their treatment may not be covered before treatment can begin, the Centers for Medicare & Medicaid Services (CMS) has said in a memorandum.

The American Taxpayer Relief Act took effect earlier this year. It has changed the notice requirements for Medicare recipients whose treatment may exceed therapy caps. Before the act took effect, providers had been merely “encouraged” to hand out so-called Advance Beneficiary Notice of Noncoverage (ABN) forms as a courtesy to those patients who may find themselves stuck with the bill because of Medicare restrictions.

That was then, CMS said in a Q&A style memo issued Tuesday. This is now.

“Now the provider/supplier must issue a valid, mandatory ABN  to the beneficiary before providing services above the cap when the therapy coverage exceptions process isn’t applicable,” CMS said in the memo.

Providers will also have to hand out the warning notes before they give any treatment “that is not medically reasonable and necessary regardless of the therapy cap,” CMS said.

The warnings won’t be required in those special cases where patients are allowed an exception to the therapy caps—for instance, if a patient isn’t meeting his or her goals in physical therapy, CMS said.

For more information on CMS’ clarification, click here. E-mails can be sent to

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