Virginia Physical Therapy Association 2012 Annual Conference Health Care Reform - PowerPoint PPT Presentation


PPT – Virginia Physical Therapy Association 2012 Annual Conference Health Care Reform PowerPoint presentation | free to view - id: 47034c-MGY0N


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Virginia Physical Therapy Association 2012 Annual Conference Health Care Reform


Virginia Physical Therapy Association 2012 Annual Conference Health Care Reform Gillian Russell, JD Senior Regulatory Affairs Specialist American Physical Therapy ... – PowerPoint PPT presentation

Number of Views:408
Avg rating:3.0/5.0
Slides: 134
Provided by: Barbara437


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Virginia Physical Therapy Association 2012 Annual Conference Health Care Reform

Virginia Physical Therapy Association 2012
Annual ConferenceHealth Care Reform
  • Gillian Russell, JD
  • Senior Regulatory Affairs Specialist
  • American Physical Therapy Association

HCR / Goal of Integrated CareThree Part Aim
Emerging Themes in Health Care
Timeline of Key Health Reform Provisions
Collaborative Care ModelsAccountable Care
What is an Accountable Care Organization
  • Networks of physicians, hospitals and other
    providers that will be incentivized to work
    together to provide quality care and lower growth
    in health care costs under Medicare FFS
  • Goal is to provide seamless, high quality care
    instead of fragmented care in the current FFS

ACO Final Rulemaking
Highlights of MSSP Final Rule
ACO Multiple Pathways
ACO Resources
  • 116 MSSP ACOs
  • 32 Pioneers
  • 20 Advanced Payment

Eligible Participants
  1. ACO Professionals in Group Practice Arrangements
  2. Networks of Individual Practices of ACO
  3. Partnerships or Joint Venture Arrangements
    Between Hospitals and ACO Professionals
  4. Hospitals Employing ACO Professionals
  5. Critical Access that bills for facility and
    professional services
  6. Federally Qualified Health Centers
  7. Rural Health Clinics

ACO Definitions
ACO Participants ACO Professionals ACO Providers/ Suppliers
Individual or Groups of ACO providers/suppliers ACO provider/supplier Enrolled in Medicare and bills Medicare FFS
Identified by Medicare-enrolled TIN Enrolled and bills Medicare FFS Has a Medicare billing number assigned to ACO participant and listed on ACO legal forms
Alone or together with other ACO participants make-up an ACO Physician Physician Assistant Nurse Practitioner Clinical Nurse Specialist PTPPS HHAs SNFs Rehabilitation Agencies
ACO Structure
  • Formal and legal structure and allows the ACO to
    receive and distribute payments for shared
  • Formal CMS application and approval process
  • Representatives from Medicare FFS beneficiaries
    and each ACO provider/ participant
  • Allows for partnering with private entities but
    ACO participants must have at least 75 percent
    control of the ACOs governing body

ACO Structure
  • Evidence-based medical practice or clinical
  • Three-year contractual commitment (remedial
    actions for removing participants for
  • 5000 yearly patient threshold
  • Participation voluntary for providers and

Establishing a Benchmark
  • Current Medicare FFS payment
  • Shared savings payments directly to the ACO
  • Benchmark developed to assess performance
  • An estimate of total Medicare FFS Parts A and B
    costs if provided absent ACO
  • Benchmark factors in patient characteristics,
    geographic location, etc.
  • Benchmark updated each year of the three-year

Risk Models
  • Minimum savings rate based on percentage of the
    benchmark that the ACO must exceed
  • ACOs must opt into one of two risk-sharing
  • One-sided Risk (up to 50 shared savings and lt10
    of benchmark)
  • Two-sided Risk Model (up to 60 shared savings
    and lt15 percent of benchmark, up to 10 shared

Beneficiary Assignment
  • Plurality test for determining beneficiary
    assignment to an ACO
  • Whether a beneficiary receives more primary care
    from that ACO than from any other provider

ACO Quality The Measures
  • Total of 33 measures (scored as 23)
  • 4 domains
  • Better care for individuals
  • Better health for population
  • 4 methods of data submission
  • Patient survey
  • Claims
  • EHR
  • Group Physician Reporting Option (GPRO)
  • Measures will be phased in from pay for reporting
    to pay for performance

ACOs and Quality
  • Quality reporting overview
  • ACOs must report and meet quality measure
    standards for the contracted three years
  • Quality reporting will include mix of measures
  • Evidence-based care process
  • Outcome
  • Patient experience
  • CMS did not include utilization measures as the
    ACO program will address this through improved
    coordinated and quality

ACO Quality Reporting Therapy Considerations
Interim Final Rule on Fraud and Abuse Waivers
  • 5 final waivers
  • ACO pre-participation
  • ACO participation
  • Shared Savings Distribution
  • Compliance with Physician Self-referral Law
  • Patient incentive
  • Applies a reasoned approach analysis
  • Existing exceptions and safe harbors still apply

Anti-trust Enforcement Policy
  • Establishes an anti-trust safety zone
  • Combined share of 30 or less of each combined
    service PSA
  • Exception for rural ACOs
  • Safety Zone designation stays in effect for
    duration of ACO agreement
  • ACOs outside of safety zones not necessarily

Private ACO Collaborations
(No Transcript)
Dispelling the Myths
  • Myth
  • Reality
  • ACOs are the same as the HMOs of the 1990s
  • ACOs will replace Medicare FFS and providers will
    be paid by the ACO
  • Patient choice is taken away
  • ACOs widen the door for POPTs
  • ACOs have significant quality, governance and
    marketing requirements
  • Providers will still submit claims to Medicare
  • Patients/ providers can receive care outside ACO
  • ACOs do not affect Stark IOAS exception but does
    pose significant issues

Physical Therapy Considerations
What Do ACOs Mean for PT Practice?
Physical Therapists Practicing Outside of ACO
Physical Therapists Practicing Within ACO Setting
Is an ACO Partnership Right for Your Practice?
CMS Resources
  • CMS Shared Savings Program
  • http//
  • CMMI Pioneer and Advanced Payment Model
  • http//

Key Points for Therapists
  • Can contract with multiple ACOs
  • ACO activity and composition will vary
  • ACOs are voluntary
  • ACO final rules do not relax Stark II IOAS
  • Know differences in MSSP, Pioneer, and Private
  • Participation in quality initiatives and
    collection of outcomes data is crucial
  • Assess interoperability of current and potential

Collaborative Care ModelsBundled Payments
Section 3023 of ACA Bundling
  • Bundling Pilot Project national, voluntary
    pilot program
  • Hospitals, physicians and post-acute care
    providers (SNFs, home health, IRFs, and LTCHS)
  • Improve patient care and cost-savings through
    bundled payment model
  • Must be established by 2013 and will last for
    five years
  • Episode of care 3 days before admission to
    hospital, through LOS, and end 30 days post
  • Based on eight selected conditions
  • Quality measures/assessment tool to be
  • Medicaid bundled payment demo to take place in
    eight states

CMMI Bundling Payment Initiative
  • Designed to encourage doctors, hospitals and
    other health care providers to coordinate care
  • Objectives
  • Support and encourage providers through three
    part aim
  • Decrease the cost of an acute episode of care and
    the associated post-acute care while improving
  • Develop and test new payment models for
    three-part aim
  • Shorten the cycle time for adoption of
    evidence-based care

Bundling Initiative Four Proposed Models
Relationship between Bundling Initiative and
Pilot Project
  • Bundled Payments for Care Improvement initiative
    is a separate activity
  • Consistent with goals of National Pilot Program
    on Payment Bundling authorized by ACA
  • Bundled initiative will help inform future work
    under the pilot project

Definition of Bundled Payments
  • Single payment made for a defined group of
  • May cover services furnished by a single entity
    or items and services furnished by several
    providers in multiple care delivery settings.
  • Single negotiated episode payment of a
    predetermined amount for all services.
  • Paid prospectively or retrospectively.

Source CMMI Website FAQs
Example Bundled Payment
  • Medicare and the provider would agree to a
    bundled payment target price for acute care
    hospital services for an inpatient stay plus
    professional services and post-acute care related
    to the principal reason for the hospitalization,
    rather than paying separately for each physician
    visit and procedure provided during the episode.

Bundling Key Focus Reduction in Hospital
  • Implementation of reduction measures in key acute
    and post acute care settings
  • Inpatient hospitals
  • Inpatient rehabilitation facilities (IRF PPS
  • Transitioning focus in home health, skilled
    nursing facilities, and LTCHs
  • Private initiatives define readmissions United
    Healthcare and Geisinger

Hospital Readmissions Reduction
  • The Patient Protection and Affordable Care Act
    (PPACA) established the Hospital Readmissions
    Reduction Program.
  • Begins in 2013, and is aimed at adjusting
    hospital payments for those institutions that
    have higher than expected readmissions.

Hospital Readmissions Reduction Program
  • Program to reduce payments for facilities
    exceeding certain rate of readmissions
  • Proposed Rule August 18, 2011
  • Implementation October 2012
  • Condition specific 30-day readmissions
  • Acute myocardial infarction (AMI)
  • Heart failure (HF)
  • Pneumonia (PN)

Hospital Readmissions Reduction Program
  • Additional conditions to be added
  • As determined by Secretary for FY2015
  • Chronic obstructive lung disease, coronary bypass
    grafting, percutaneous coronary interventions,
    other vascular procedures (as identified in 2007
    MedPAC report)
  • P4P
  • Withholdings up to 1 FY2013, 2 FY2014, and 3
    FY 2015 and beyond

Additional Readmissions Measures
APTA Readmissions Efforts
  • Increased member education regarding through a
    variety of educational sessions including
  • The Value of Physical Therapy in Reducing
    Avoidable Hospital Readmissions (audio
  • Medicare update presentations (CSM Annual
  • Coding, Payment and Practice Applications
  • Creation of new readmission page on the website
  • Submission of comments by APTA on a variety of
    payment regulations and measurement methodologies
    related to readmissions

Collaborative Care ModelsPatient-Centered
Medical Homes(PCMHs)
Medical Homes
  • Redefining primary care
  • Primary care medical home accountable for meeting
    the large majority of each patients physical and
    mental health care needs
  • Prevention and wellness, acute care, and chronic
  • Team approach physicians, nurses, physical
    therapists, pharmacists, nutritionists, social
    workers, etc.

Medical Homes Affordable Care Act
  • Sec. 2703 established person-centered health home
    for State Medicaid and other programs
  • Individuals with chronic conditions
  • PTs not specifically named in statute but can
    partner with state entities to participate
  • Sec. 3502 provides grants to eligible entities
    to establish community-based health teams to
    support primary care providers in the creation of

Medical Homes Beyond the ACA
  • CMMI Challenge Grants
  • Up to 1 billion in grants for delivering better
    health, improved care and lower costs to people
  • CMMI FQHC Advanced Primary Care Practice
  • Private Partnerships
  • Geisinger Health System
  • Group Health, Seattle
  • TransforMED National Demonstration Project

Patient-Centered Medical Home Functions and
Source AHRQ Patient Centered Medical Home
Resource Center
Harris County Hospital (Houston, TX)NCQA
distinction as PCMH
Collaborative Care Resource Center
  • Evolving resource center designed for physical
    therapists to gain a better understanding of
    where PTs fit in integrated models of care
  • Practice Applications discover lessons learned
    from colleagues currently engaging in new
    delivery models
  • Summary and analysis of federal rulemaking and
    how it impacts PT
  • http//
  • Communities Discussion Board

(No Transcript)
HCR ImplementationHealth Insurance Exchanges
Health Insurance Exchanges
  • Section 1311 of ACA establishes health insurance
  • State implementation by 2014
  • Centralized marketplace where individuals and
    small businesses can purchase coverage
  • One-stop shop web portal

State Health Insurance Exchange
  • Financially stable must be self-financing by
    January 1, 2015
  • Federal grants until then
  • VA and Federal Funding
  • September 2010 Virginia State Department of
    Medical Assistance Services received a federal
    Exchange Planning grant of 1 million.
  • VA planned to submit a Level One Establishment
    grant application in June 2012 however, the
    Governor announced in a letter to the Legislature
    in July, he decided not to submit the
  • VA is one of 9 states receiving technical
    assistance from the Robert Wood Johnson
    Foundation through the State Health Reform
    Assistance Network
  • This assistance includes help with setting up
    health insurance exchanges, expanding Medicaid to
    newly eligible populations, streamlining
    eligibility and enrollment systems, instituting
    insurance market reforms and using data to drive

HHS Rulemaking on Exchanges
  • Establishment of Exchanges and Qualified Health
    Plans (QHPs)
  • Standards Related to Reinsurance Risk, Risk
    Corridors and Risk Adjustment
  • Exchange functions in the Individual Market
    Eligibility Determinations Exchange Standards
    for Employers

Coverage under the Exchanges
  • Coverage for all individuals
  • Individual mandate All individuals must have
    insurance by 2014
  • Coverage facilitated by
  • Tax credits for premiums
  • Subsidies for out-of-pocket costs
  • Medicaid expansion
  • Qualified health plan (QHP) coverage
  • Essential Health Benefits

Tax Credits and Subsidies
Slide Source The Commonwealth Fund presentation,
Achieving and Maintaining Near Universal
Coverage Under the Affordable Care Act Key
Issues For Federal and State Policy Makers
Exchange Development Timeline
Slide Source Avalere Health LLC presentation
Understanding State Efforts to Implement
Exchanges July 18, 2011
Status of State Legislation to Establish
Exchanges, As of May 2012
State exchange in existence prior to passage of
Legislation failed/no gubernatorial action
Legislation signed into law post passage of ACA
Governors pursuing non-legislative options
Legislation signed intent to establish an
exchange, creation of study panel or
Governors working with HHS on options
Legislation passed one or both houses
Governor veto or decision not to establish
Legislation pending in one or both houses
No legislative activity to date
Source National Conference of State
Legislatures, Federal Health Reform State
Legislative Tracking Database. http//
Commonwealth Fund Analysis.
Significant State Flexibility
  • Nationwide standard for
  • Enrollment period
  • Approval for state exchanges
  • Some national standards for
  • Streamlined applications and eligibility
  • Governance structure
  • West Virginia vs. California vs. Maryland
  • Subsidiary and regional exchanges
  • SHOP Employer/Employee Choice Model

Significant State Flexibility
  • Some national standards for
  • Exchange consumer tools
  • Navigator program
  • Requirements for QHP offerings
  • Network requirements
  • States completely flexible on
  • Health plan selection process
  • Utah vs. Massachusetts
  • Network adequacy standards
  • Marketing requirements
  • Agent and broker roles
  • Waivers?

Snapshot of State Exchanges
  • Utah
  • Massachusetts
  • Virginia http//

Essential Health Benefits
  • Comprehensive set of services and items that must
    be offered in the qualified health plans within
    the Exchange, Small Business Health Options
    Program, and Medicaid expansion
  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Mental health and substance abuse services
  • Rehabilitative and habilitative services and
  • Prescription drugs
  • Laboratory services
  • Preventive and wellness services and chronic
    disease management
  • Maternity and newborn care
  • Pediatric services

Flexibility for States EHBs
  • Institute of Medicine (IOM) issued reports
    advocating for flexibility in EHB definitions
  • HHS Bulletin December 16, 2011
  • States will choose benchmark plan from the
    following health insurance plans
  • One of the three largest small group plans in the
    state by enrollment
  • One of the three largest state employee health
    plans by enrollment
  • One of the three largest federal employee health
    plan options by enrollment
  • The largest HMO plan offered in the states
    commercial market by enrollment.

Rehabilitation and Habilitation Definitions under
  • National Association of Insurance Commissioners
    (NAIC) definitions
  • Rehabilitation Services Health care services
    that help a person keep, get back or improve
    skills and functioning for daily living that have
    been lost or impaired because a person was sick,
    hurt or disabled. These services may include
    physical and occupational therapy,
    speech-language pathology and psychiatric
    rehabilitation services in a variety of inpatient
    and/or outpatient settings.
  • Habilitation Services Health care services that
    help a person keep, learn or improve skills and
    functioning for daily living. Examples include
    therapy for a child who isnt walking or talking
    at the expected age. These services may include
    physical and occupational therapy,
    speech-language pathology and other services for
    people with disabilities in a variety of
    inpatient and/or outpatient settings.

Rehabilitation and Habilitation Definitions under
  • Mosbys Medical Dictionary
  • Habilitation the process of supplying a person
    with the means to develop maximum independence in
    activities of daily living through training or
  • IOM Report
  • Congressional floor statement advocating broadly
    based interpretation for rehabilitation,
    habilitation and devices, including items and
    services used to restore functional capacity,
    minimize limitations on physical and cognitive
    functions, and maintain or prevent deterioration
    of functioning
  • Advocates for children suggest modeling medical
    necessity after EPSDT coverage rules, allowing a
    child to accommodate to a condition and reach
    his/her highest level of functioning

APTA Efforts on Exchanges/EHBs
  • Comments submitted to HHS in response to IOM
    report, Essential Health Benefits Balancing
    Coverage and Cost
  • Comments submitted to HHS in response to
    Establishment of Exchanges and Qualified Health
    Plans proposed rule
  • APTA Website created for EHB and Exchanges
  • Member education
  • State chapter advocacy tools

EHB Advocacy Principles
  • Generally, rehabilitation services may include
  • Diagnosis and management of movement dysfunction
    and human performance to enhance physical and
    functional abilities
  • Skilled interventions to address functional
    limitations, impairments and disabilities that
    diminish an individuals quality of life, health
    status, or independence in activities of daily
    living. Restoration, maintenance and promotion of
    optimal physical function and
  • Prevention and management of the onset, symptoms,
    and progression of impairments, functional
    limitations and disabilities that may result from
    disease, disorders, conditions or injuries.

EHB Advocacy Principles (cont.)
  • Rehabilitative services should be provided by
    qualified health care professionals currently
    authorized under federal law
  • No absolute limits on the provision of
    rehabilitation services
  • No restriction on the number of therapy visits in
    EHB packages without allowing exceptions
  • No limit on annual visits

EHB Advocacy Principles (cont.)
  • Devices should be a covered benefit
  • Defining medical necessity
  • Health care practitioners should determine what
    method, scope or type of treatment is medically
  • Allow latitude for treatment variations while
    balancing costs
  • Actuarial data should be utilized if certain
    limits are allowable

EHB Advocacy Principles (cont.)
  • Individual and community education and consumer
  • If states have flexibility, appropriate education
    should be provided to ensure all stakeholders are
    aware of the minimum federal requirements and how
    to obtain information regarding any additional
    state requirements
  • Planning grants and technical assistance could
    mitigate the impact of financial strain
  • Plan Rating System

Virginia Health Insurance Exchange
  • April 6, 2011 Governor Bob McDonnell (R) signed
    HB 2434 into law, declaring the states intent to
    establish a health insurance exchange
  • Based on a recommendation by the Virginia Health
    Reform Initiative Advisory Council
  • November 25, 2011 Advisory Councils exchange
    recommendations were submitted to the General
    Assembly by the Governor

Virginia Health Insurance Exchange
  • Council voted in favor of establishing a
    state-based exchange as a quasi-governmental
    agency with a governing board.
  • Council recommended the exchange follow the
    states existing conflict of interest guidelines,
    maintain administrative flexibility in hiring,
    compensation, transparency and procurement, and
    appoint 11 to 15 board members.

Virginia Small Business Health Options Program
  • Advisory Council recommended that Virginia
  • Limit the size of the SHOP exchange to employers
    with up to 50 employees in 2014
  • Maintain one administrative structure for both
    the individual and SHOP Exchange, but keep the
    risk pools separate

Virginia EHB
  • Advisory Council recommended in June 2012 that a
    subcommittee be established to consider Anthem,
    the states small-group PPO as the states
    benchmark plan.
  • The subcommittee recommended Anthem as the EHB
    benchmark plan and the Childrens Health
    Insurance Program (CHIP) dental benefit plan
    (Smiles for Children) as the pediatric dental
    supplemental plan

Virginia Information Technology
  • Focus on a significant Medicaid IT system upgrade
    and has received approval from the CMS for an
    enhanced federal match.
  • May 2012 released a Request for Proposals
    soliciting subcontractors to streamline
    eligibility and enrollment for all existing
    social service benefits, including Medicaid,
    TANF, and food stamps.
  • State officials envision eventual
    interoperability between the upgraded system and
    an exchange.

Virginia Next Steps
  • VA has declared a preference for a state-based
    exchange as opposed to a federally run exchange
  • Must submit declaration letter signed by the
    Governor and an application to HHS by Nov. 16,
  • VA has until Jan. 1, 2013 to create state-based
    exchange that HHS approves fully or conditionally.

HCR ImplementationMedicaid Expansion
Medicaid Expansion
  • Jan. 1, 2014 ACA expands Medicaid to include
    individuals between the ages of 19 up to 65
    (children, pregnant women, parents, and adults
    without dependent children) with incomes up to
    138 FPL.
  • CMS has stated that states may decide whether
    and when to expand, and if a state covers the
    expansion group, it may later drop the coverage.

Impact of SCOTUS Decision
  • Between now and 2014, states will determine
    whether to implement the ACAs Medicaid expansion
    and receive the associated enhanced federal
    matching funds
  • CMS has stated
  • States may decide whether and when to expand,
    and if a state covers the expansion group, it may
    later drop the coverage.
  • No deadline yet by which states must tell CMS of
    Medicaid expansion plans (though Exchange
    blueprint to HHS by Nov. 16)
  • Court decision does not impact reduction to DSH

Initial State Plans for Medicaid Expansion
Virginia and Medicaid Expansion
  • Gov. Bob McDonnell considering opting out of
    Medicaid expansion
  • Letter to legislators in July 2012, considering
    opting out, stating that he needs more
  • Potential repeal of law after election

Beyond HCRMedicare Therapy Cap Updates
2012 Therapy Cap
  • For 2012, the therapy cap amount is 1880 for PT
    and SLP combined and a separate 1880 cap for OT.
  • Therapy cap does not apply in outpatient
  • Medicare Advantage plans do not have to implement
    a therapy cap.
  • Exceptions process will be in effect until
    December 31, 2012.
  • If your patients exceed the therapy cap, you may
    submit the claim with a KX modifier (if services
    are medically necessary) until December 31
  • Congressional action is necessary to extend the
    exceptions process

2012 Therapy Cap Hospitals
  • The therapy cap has applied in the past to all
    outpatient therapy settings except hospitals.
  • Starting October 1, 2012 the therapy cap with an
    exceptions process will also apply to hospital
    outpatient settings. (critical access hospitals
    are exempt)
  • Hospitals would no longer be subject to the
    therapy cap after December 31, 2012 unless
    Congress extends the provision in future

Therapy Cap Exceptions
  • January 1-October 1, 2012 an automatic exception
    to the therapy cap may be made when documentation
    supports the medical necessity of the services
    beyond the cap. Providers should use the KX
  • October 1, 2012-December 31, 2012 an automatic
    exception may be made for claims between
    1880-3700 (use KX modifier)
  • October 1, 2012-December 31, 2012 Claims
    exceeding 3700 in expenditure will be subject to
    manual medical review to be paid

Therapy Cap Manual Medical Review
  • Starting October 1 for claims exceeding 3700
  • All therapy services beginning January 1, 2012
    count toward the therapy cap amount in
    calculating the 3700.
  • CMS issued guidance on manual medical review in a
    fact and question and answer document.

Therapy Cap Manual Medical Review
  • Phase I providers Subject to manual medical
    review from October 1-December 31, 2012.
  • Phase II providers Subject to manual medical
    review from November 1-December 31, 2012
  • Phase III providers Subject to manual medical
    review from December 1-December 31, 2012.
  • List of NPIs and phases to which they are
    assigned is available at
  • https//

Therapy Cap Manual Medical Review
  • If a provider does not request advanced approval
    prior to providing services over 3700, payment
    for the claims will stop and a request for
    medical records will be sent to the provider.
  • The provider will be subject to prepayment review
    for those claims and the time frame for review
    will be approximately 60 days.

APTA Resources for Therapy Cap Changes
  • http//
  • FAQ
  • Webinar
  • Podcast
  • List of links to all MACs
  • Complaint form

CMS Resources for Therapy Cap Changes
  • A transcript of a special open door forum held by
    CMS on the manual medical review process is
    available at the link below (http//
  • Questions may be emailed to therapycapreview_at_cms.

CMS Resources for Therapy Cap Changes
  • Medicare Benefit Policy Manual
  • http//
  • Medicare Claims Processing Manual, chapter 5
  • http//
  • Centers for Medicare and Medicaid Services
  • CR 6660 http//
  • CR 5871, Pub. 100-04, Transmittal 1414
  • Transmittal 2537 CR 7881 (August 31, 2012)
  • Transmittal 1117 CR 8036 http//

Beyond HCRReporting Functional Information on
Medicare Claims
Reporting Functional Information on Claim Form
  • By 2013 CMS will implement a claims based data
    collection strategy designed to collect data on
    the claim form about patient function.
  • Proposal included in 2013 physician fee schedule

Reporting Functional Information on Claim Form
  • Comment deadline September 4
  • APTA submitted extensive comments
  • Involves reporting of G codes regarding
    functional limitation accompanied by a severity
  • CMS proposes the use of tools and translation of
    the scores from those tools to determine the
    level of impairment and severity modifier
  • Final rule will be published November 1, 2012

Functional Limitation Reporting
Functional Limitation Reporting
MedPAC report
  • MedPAC must submit a report on how to improve the
    outpatient therapy benefit to Congress by June
    15, 2013.
  • MedPAC discussed outpatient therapy at March 2012
    meeting, September 7 meeting, and October 5

HCR InitiativesProgram Integrity
Improper Payments Under Medicare
  •  For fiscal year 2010, HHS reported almost 48
    billion in Medicare improper payments, (38
    percent of the total 125.4 billion estimate for
    the federal government)
  • Medicare Fee for Service error rate in 2010 was
    around 10.5 (34.3 billion)
  • Governments goal is to reduce the Medicare FFS
    improper payment rate to 8.5 by Nov 2011 and
    6.2 by Nov 2012

Improper Payment
  • Improper Payment Any payment to the wrong
    provider for the wrong services or in the wrong
  • Overpayments and underpayments
  • Didnt meet the statutory coverage requests
  • Didnt meet the Medical necessity requirements
  • Incorrectly coded
  • Didnt submit sufficient documentation

Program Integrity Efforts
  • More coordination among Agencies
  • CMS, Office of Inspector General, Department of
    Justice, FBI
  • Use of Program Safeguard Contractors, Zone
    Program Integrity Contractors (ZPICs), Recovery
    Audit Contractors, HEAT (DOJ-FBI-HHS Strike
  • HEAT is focused on Detroit, Houston, Brooklyn,
    Tampa and Baton Rouge, Dallas, Chicago
  • Increased Ability to Detect Aberrant Billing
    (collecting near real time data)
  • Increased Focus on Physical Therapy Services

Strategies to Reduce Improper Payments
Provider Enrollment
  • Enrollment Screening
  • ACA requires that HHS and OIG establish screening
    procedures for providers/suppliers
  • Level of screening varies among categories of
    providers/suppliers based on risk of fraud and
  • Screen can include
  • Licensure checks, fingerprinting, criminal
    background checks, site visits, etc.
  • Final Rule Issued Feb. 2011

Limited Moderate High
-Physician or nonphysician practitioners, occupational therapists, speech language pathologists, medical groups or clinics -Hospitals -SNFs -CORFs -Physical therapists enrolling as individuals or groups in private practice -Revalidating home health agencies -Revalidating DMEPOS suppliers -Newly Enrolling Home Health Agencies -Newly Enrolling DMEPOS suppliers
Licensure checks Site visits, Licensure checks Licensure checks, Fingerprinting, site visits
Provider Enrollment
  • Physical Therapists in Private Practice (PTPPs)
    placed in moderate risk category.
  • PTPPs must have a site visit prior to enrollment
    as of March 25, 2011.
  • PTPPs may be subject to unannounced site visits
  • PTPPs are exempt from the new 505 (raised to
    523 for 2012) enrollment fee.
  • If a PTPP also enrolls as a DMEPOS supplier
    (e.g. a hand therapist), they must meet the
    DMEPOS supplier requirements (pay enrollment fee
    of 523 high risk category for new DMEPOS

Provider Enrollment Revalidation
  • ACA established a requirement for all enrolled
    providers and suppliers to revalidate their
    enrollment information under new enrollment
    screening criteria. (applies to those providers
    and suppliers that were enrolled prior to March
    25, 2011).
  • Between now and March 23, 2015, MACs will send
    out notices to begin the revalidation process for
    each provider and supplier.
  • Providers and suppliers must wait to submit the
    revalidation only after being asked by their MAC.

Resources on Provider Enrollment
  • February 2, 2011 final rule
  • http//
  • Transmittal 371 (effective date March 25, 2011)
  • https//

Prepayment Review
  • Reviews are conducted by Medicare Administrative
    Contractors (MACs), Zone Program Integrity
    Contractors (ZPICs).
  • Small business Jobs Act of 2010 required
    predictive modeling to identify prevent improper
  • CMS contracted with Northrop Grummon to deploy
    algorithms and an analytical process that looks
    at CMS claims in real timeby beneficiary,
    provider, service origin or other patterns
  • Starting July 1, 2011 will identify problems and
    assign an alert and risk scores for claims that
    are aberrent
  • Beginning with 10 states identified by CMS as
    having the highest risk of fraud, waste, or

Prepayment Review
  • CMS identifies practices that are potentially
    fraudulent/abusive through Northrop Grummon and
    sends information to Safeguard Contractor.
  • Safeguard Contractor sends personnel to visit the
    practice and request names, addresses, birth
    dates of all employees, business contracts,
    licenses of professionals, etc. Requests that
    information be provided within 24 hours.

Prepayment Review
  • Medicare Administrative Contractors (MACs) are
    targeting providers with claims they think may
    have improper payments.
  • Request medical records via paper letter, which
    are then reviewed by clinicians (nurses,
    physical therapists, etc)
  • For prepayment review, contractors are initially
    requesting documentation on approximately 5
    claims to review for medical necessity. If they
    find a problem, will request a greater number of
    medical records.
  • If documentation does not support medical
    necessity, MAC may place the provider on 100
    prepayment review.

Prepayment Review MACs
  • Will deny payment if review and find it is not
    medically necessary
  • Provider can appeal to the MAC any denials.
  • Reviews will result in delays in payment.

Postpayment Review
  • Reviews are being conducted by Office of
    Inspector General, ZPICs, MACs, Recovery Audit
  • MACs will target certain claims will review, and
    recoup payment if found to be improperly paid.
    Provider can appeal.
  • Recovery Audit Contractors
  • PPACA expanded Medicares RAC program to Medicare
    Advantage and the prescription drug benefit

Recovery Audit Contractors (RACs)
  • RACs identify Medicare underpayments
    overpayments recover overpayments. (Part A
    B-so any provider can be subject to RAC review)
  • RACs are paid contingency fees (for overpayments
    collected for underpayments identified)
  • A Database of claims for RACs to review was
    created by CMS
  • Website

Recovery Audit Contractors (RACs)
  • Region A Diversified Collection Services, Inc.
    of Livermore, CA ( CT, DE, DC, ME, MD, MA, NH,
    NJ, NY, PA, RI and VT)
  • Region B CGI Technologies and Solutions, Inc.
    of Fairfax, VA ( IL, IN, KY, MI, MN, OH and WI)
  • Region C Connolly Consulting Associates, Inc.
    of Wilton. CT ( AL, AR, CO, FL, GA, LA, MS, NM,
    NC, OK, SC, TN, TX, VA, WV, Puerto Rico and U.S.
    Virgin Islands.)
  • Region D HealthDataInsights, Inc. of Las Vegas,
    NV (
  • AK, AZ, CA, HI, ID, IA, KS, MO, MT, ND, NE, NV,
    OR, SD, UT, WA, WY, Guam, American Samoa and
    Northern Marianas. )

Recovery Audit Contractors
  • Can reopen claims up to three years from the date
    the claim was paid.
  • RACs cannot review claims prior to October 1,
  • The RAC Program is required to follow all
    applicable Medicare regulations such as payment
    policies, reopening timeframes, and appeal rights
    for providers.
  • RACs required to have a medical director on
    staff, and to use nurses, therapists, and
    certified coders.
  • Cannot collect contingency fee if claim is being
    appealed at any level of appeal.

Recovery Audit Contractors
  • RACs choose issues to review based on data mining
    techniques, OIG and GAO reports and experience of
  • Two types of review
  • Automated (no medical record)
  • Complex (medical records)
  • New Issues for review will be posted on RACs

Recovery Audit Contractors
  • RACs will send request for medical records.
  • If provider does not submit requested record in
    45 days, the service will be denied.
  • Records may be submitted via mailed paper copy,
    fax, or mailed CD/DVD
  • CMS has established medical record limits.

Recovery Audit Contractors
  • Medical Record Request Limits
  • Inpatient hospital, IRF, SNF, hospice 10 of avg
    monthly Medicare claims (max of 45 days) per NPI
  • Other Part A Billers (outpatient hospital, home
    health)1 of avg monthly Medicare services (max
    of 200) per 45 days per NPI
  • Physicians, Physical therapists in private
  • Solo practitioner 10 medical records per 45
    days per NPI
  • Partnership of 2-5 individuals 20 medical
    records per 45 days per NPI
  • Group of 6-15 individuals30 medical records per
    45 days per NPI
  • Large Group (16 individuals)50 medical records
    per 45 days per NPI.

Zone Program Integrity Contractors
  • ZPICs combine data from a number of different
    sources to create a platform for complex data
  • ZPICs were started by CMS by combining Program
    Safeguard Contractors (PSCs) and Medicare
    Prescription Drug Integrity Control (MEDIC)
  • Use data to look for overpayments, and also to
    look for potential fraud.
  • ZPIC auditors refer all identified overpayments
    to the a MAC, who subsequently sends the provider
    a demand letter for recoupment may conduct site
    visits, refer cases to OIG, FBI, etc.

Zone 1 CA, NV, American Samoa, Guam, HI and the Mariana Islands Safeguard Services
Zone 2 AK, WA, OR, MT, ID, WY, UT, AZ, ND, SD, NE, KS, IA, MO AdvanceMed
Zone 3 MN, WI, IL, IN, MI, OH and KY PSC
Zone 4 CO, NM, OK and TX Health Integrity, LLC
Zone 5 AL, AR, GA, LA, MS, NC, SC, TN, VA and WV AdvanceMed
Zone 6 PA, NY, MD, DC, DE and ME, MA, NJ, CT, RI, NH and VT PSC
Zone 7  FL, PR and VI Safeguard Services
Contractor Review
  • ACA included provisions for CMS to evaluate
    contractors receiving Medicare Integrity Program
    and Medicaid Integrity Program funding every 3
  • ACA requires these contractors to provide
    performance statistics to HHS and its OIG upon
  • Contractors must competitively bid for the
    contract therefore, they are under pressure to
    keep their rates of improper payment low.

Summary of Reviewers
  • Medical Review Units at MACs
  • Prepay and postpay, automated and complex)
  • Targeted claims selected
  • To stop future incorrect payments
  • Recovery Audit Contractors
  • Postpay, automated and complex
  • Detect and correct past improper payments
  • CERT
  • Postpay only, complex only
  • Randomly Selected

Risk Areas for Physical Therapists In Outpatient
  • Missing Certifications on plan of care
  • Billing for services furnished by Aides/Techs
  • Providing inadequate supervision
  • Billing for one-on-one codes instead of group
  • Billing for co-treatment
  • Failing to comply with the 8 minute rule
  • Failing to comply with CCI edits
  • Submitting claims for services that provider
    knows are not reasonable and necessary

Risk Areas for Physical Therapists In Outpatient
  • Code Gaming
  • Unbundling (hot pack, dressings)
  • Upcoding (E-Stim)
  • Billing for not medically necessary services
    without an ABN
  • Billing for maintenance care
  • Billing for excessive duration and frequency of
  • Billing for services not furnished
  • Billing for student services
  • Documentation deficits or fraudulent
    modifications post denial or request for records

Risk Areas for Physical Therapists in Outpatient
  • Signatures not legible (physician on plan of care
    or PT)
  • Used a stamped signature
  • Plan of care not signed by the physician
  • Plan of care not recertified
  • Duration/frequency not in compliance with that
    identified in Local Coverage Decision
  • Documentation is insufficient
  • Services not medically necessary

Risk Areas for Physical Therapists
  • Frequent use of the KX modifier (aberrent from
    the norm)
  • In a private practice setting, the billing is
    going under one PT provider number rather than
    each separate PT enrolling.
  • Collecting cash from the patient with no ABN

Risk Areas for Physical Therapists in Post-Acute
Care Settings
  • Home Health
  • Documenting medical necessity
  • Incomplete documentation (lack of measurable
    goals or rationale for number of therapy visits
  • Supervision and use of PTAs
  • Overlap of services between acute and post acute
  • Establishment and management of maintenance
  • Timely submission of claims and request for
  • Evidence to support patient homebound status

Risk Areas for Physical Therapists in Post-Acute
Care Settings
  • Skilled Nursing Facilities
  • Documenting medical necessity and justification
    for modes of therapy
  • Use of different modes of therapy (individual,
    concurrent, and group therapy)
  • Adherence to MDS scheduled assessment periods
  • Use of physical therapy aides and students
  • Use and documentation of modalities

Risk Areas for Physical Therapists in Post-Acute
Care Settings
  • Inpatient Rehabilitation Facilities
  • Adherence to three hour rule (intensive therapy
  • Distinction of skilled versus unskilled therapy
  • Use of different modes of therapy (individual,
    concurrent, and group therapy)
  • Use of physical therapy aides
  • Completion of preadmission screening and post
    admission evaluation
  • Physician involvement
  • Interdisciplinary team meetings

Tips on How to Protect Yourself
  • Be familiar with Medicare coverage criteria (keep
    a copy of applicable Local and National Coverage
  • Know how access key Medicare reference documents
    (Medicare Benefits Policy and Claims Processing
  • Sign up for Medicare contractor list servs and
    email alerts for Open Door Forums and other
    educational outreach opportunities
  • Conduct periodic self audits

Appeal Rights
  • You have an appeal right when your
    carrier/intermediary/MAC determines an
    overpayment occurred on prepayment or postpayment
  • Five levels of appealeach level has different
  • Redetermination
  • Reconsideration
  • Administrative Law Judge
  • Medicare Appeals Council
  • Federal District Court