Welcome back to Part II of our series on the Final CMS Rule. In Part I, we explored the nitty-gritty details, including the sobering reality that by 2025, the total impact on physical therapists — considering both the cumulative conversion factor cuts and inflation — will be approximately 13.93% (that’s 10.33% cumulative conversion factor cut plus 3.6% inflation increase). All of this is happening during unprecedented inflation and shortages, creating significant practice challenges for freestanding healthcare providers of all types. It’s like trying to run a marathon with a piano on your back.
However, the timing couldn’t be better, thanks to the upcoming change in the federal political landscape due to the recent election — one that has promised to kill regulations faster than you can say “bureaucratic red tape.” We have a unique opportunity, particularly to take advantage of Trump’s “Ten Rules Out for Every Rule In.” Whether we’ll be writing to appointee Dr. Oz, who apparently will work for RFK Jr., remains to be seen (talk about strange bedfellows). But our readers were not shy about suggesting which rules to deep-six!
In no particular order, here are the top rules to kill, including those sent to me:
1. Eliminate Every Superimposed CMS Rule
Over the years, CMS has added rules that, in effect, trump (pardon the pun — couldn’t resist) existing regulations. Because it’s the federal government’s rulebook, they have the authority to overrule state regulations. It’s like a game of rock-paper-scissors, but CMS always picks dynamite.
• Delegation Restrictions: CMS generally does not allow a physical therapist to operate within their own state practice act. Typically, a physical therapist can delegate tasks to support personnel — but not under Medicare. Any support staff other than a PTA that so much as breathes near a patient is deemed ineligible for payment.
• “One-on-One Care” Definition: CMS takes absurdity further by defining physical therapist care as exclusively “one-on-one care,” meaning direct, individual attention without simultaneous treatment of another patient — even if that second patient is within your state practice act’s constraints. So, forget multitasking; CMS wants you to be the epitome of monogamy in patient care.
• The Infamous 8-Minute Rule: This gem dictates that healthcare providers must provide at least eight minutes of direct, face-to-face patient care to bill for one unit of a timed service. Anything less than that doesn’t qualify as billable time, regardless of the skill and advanced competencies required. So if you manage to cure someone in seven minutes, tough luck — you get nothing.
Yep, all of these must go.
2. Eliminate Plan of Care (POC) Requirements
• Current Requirement: Therapists must establish a detailed POC that requires physician certification and periodic recertification. Effectively, CMS is the only entity that requires this redundant documentation, which is already covered in any evaluation note. It’s like asking for a receipt after you’ve already paid the bill and framed the invoice.
• Impact: Eliminating this requirement would reduce paperwork and potential delays in care due to administrative processes. While some relief on the tracking of these POCs was finalized in the current rule, it only helps in small doses — POCs should be eliminated permanently from the lexicon of physical therapy. Let’s send them the way of the dodo.
3. Eliminate Mandatory Goal Writing
Current regulations often require detailed, standardized goal-setting documentation, which can be time-consuming and may not always contribute to patient outcomes. Because nothing says “patient care” like spending an hour crafting the perfect SMART goal while your patient waits.
• Insight from Clinicians: A blog post in the Journal of Orthopaedic & Sports Physical Therapy highlights the need to reevaluate documentation practices to prioritize meaningful patient engagement over exhaustive paperwork. In other words, less typing, more helping.
4. Eliminate PT Student Supervision Restrictions for Medicare Patients
• Current Challenge: Strict Medicare regulations limit the involvement of physical therapy (PT) students in treating Medicare beneficiaries unless under direct supervision, which can restrict hands-on learning opportunities. It’s like teaching someone to swim without letting them get in the pool.
• Proposed Solution: Modify supervision requirements to allow PT students to participate more fully under appropriate oversight. This change would enhance their educational experience without compromising patient care. After all, today’s students are tomorrow’s therapists — if we ever let them learn.
5. Remove the Medicare Therapy Threshold
Background: Previously known as the therapy cap, the Medicare threshold requires additional documentation and justification for services exceeding a certain dollar amount. It’s like hitting a spending limit on your credit card but with more paperwork and less fun.
Rule Kill Proposal: Eliminate the threshold to reduce unnecessary administrative tasks. Less time on paperwork means more time helping patients — what a novel concept!
6. Implement General Supervision for PTAs in Outpatient Settings
• Current State: Physical Therapist Assistants (PTAs) often require direct supervision, which can limit their ability to provide services independently. It’s like having a driver’s license but needing someone in the passenger seat at all times.
• Proposed Change: Implement general supervision permanently, as was temporarily allowed during the COVID-19 Public Health Emergency.
• Benefits:
• Allows PTAs to serve patients more flexibly, particularly in underserved areas.
• Enables clinics to utilize their staff more effectively, improving patient throughput.
• Frees up therapists to focus on more complex cases while PTAs handle routine care.
In other words, let’s trust these competent professionals to do their jobs without someone constantly looking over their shoulder.
7. Eliminate the Merit-based Incentive Payment System (MIPS)
MIPS aims to tie payments to quality and value but has become a bureaucratic quagmire.
• The Problem: It’s burdensome due to complex reporting requirements, is poorly adopted, and hasn’t been shown to add anything but process to an already overly processed system. Too much paperwork in patient care? Shocking!
• Proposal: Eliminate MIPS entirely. Practices have generally assessed the cost-benefit analysis and concluded it doesn’t justify the administrative effort. Every year brings edits, confusing changes, and often “can kicking,” further frustrating providers.
It’s time to acknowledge that MIPS is the New Coke of healthcare — an experiment that didn’t pan out.
Conclusion
If we can get all these rules killed, we might just Make Physical Therapy Great Again. Or at least make it slightly less burdened by bureaucratic nonsense.
Look forward to the discussion!
@physicaltherapy
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