Virginia Physical Therapy Association 2012 Annual Conference Health Care Reform

1
Virginia Physical Therapy Association 2012
Annual ConferenceHealth Care Reform

• Gillian Russell, JD
• Senior Regulatory Affairs Specialist
• American Physical Therapy Association

2
HCR / Goal of Integrated CareThree Part Aim
3
Emerging Themes in Health Care
4
Timeline of Key Health Reform Provisions
5
Collaborative Care ModelsAccountable Care
Organizations(ACOs)
6
What is an Accountable Care Organization
(ACO)?

• 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
  model

7
ACO Final Rulemaking
8
Highlights of MSSP Final Rule
9
ACO Multiple Pathways
10
ACO Resources

• 116 MSSP ACOs
• 32 Pioneers
• 20 Advanced Payment

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Eligible Participants

1. ACO Professionals in Group Practice Arrangements
2. Networks of Individual Practices of ACO
   Professionals
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

12
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
13
ACO Structure

• Formal and legal structure and allows the ACO to
  receive and distribute payments for shared
  savings
• 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

14
ACO Structure

• Evidence-based medical practice or clinical
  guidelines
• Three-year contractual commitment (remedial
  actions for removing participants for
  non-compliance)
• 5000 yearly patient threshold
• Participation voluntary for providers and
  patients

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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
  period

16
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
  models
• 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
  losses)

17
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

18
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

19
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

20
ACO Quality Reporting Therapy Considerations
21
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

22
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
  unlawful

23
Private ACO Collaborations
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(No Transcript)
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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

26
Physical Therapy Considerations
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What Do ACOs Mean for PT Practice?
ACO
Physical Therapists Practicing Outside of ACO
Model
Physical Therapists Practicing Within ACO Setting
28
Is an ACO Partnership Right for Your Practice?
29
CMS Resources

• CMS Shared Savings Program
• http//www.cms.gov/Medicare/Medicare-Fee-for-Serv
  ice-Payment/sharedsavingsprogram/index.html?redire
  ct/sharedsavingsprogram/
• CMMI Pioneer and Advanced Payment Model
• http//innovations.cms.gov/initiatives/ACO/index.
  html

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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
  exception
• Know differences in MSSP, Pioneer, and Private
  ACOs
• Participation in quality initiatives and
  collection of outcomes data is crucial
• Assess interoperability of current and potential
  EMRs

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Collaborative Care ModelsBundled Payments
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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
  discharge
• Based on eight selected conditions
• Quality measures/assessment tool to be
  established
• Medicaid bundled payment demo to take place in
  eight states

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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
  quality
• Develop and test new payment models for
  three-part aim
• Shorten the cycle time for adoption of
  evidence-based care

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Bundling Initiative Four Proposed Models
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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

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Definition of Bundled Payments

• Single payment made for a defined group of
  services.
• 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
37
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.

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Bundling Key Focus Reduction in Hospital
Readmissions

• Implementation of reduction measures in key acute
  and post acute care settings
• Inpatient hospitals
• Inpatient rehabilitation facilities (IRF PPS
  2012)
• Transitioning focus in home health, skilled
  nursing facilities, and LTCHs
• Private initiatives define readmissions United
  Healthcare and Geisinger

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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.

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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)

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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

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Additional Readmissions Measures
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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
  conference)
• Medicare update presentations (CSM Annual
  Conference)
• Coding, Payment and Practice Applications
  Seminars
• Creation of new readmission page on the website
  http//www.apta.org/HospitalReadmissions/
• Submission of comments by APTA on a variety of
  payment regulations and measurement methodologies
  related to readmissions

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Collaborative Care ModelsPatient-Centered
Medical Homes(PCMHs)
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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
  care
• Team approach physicians, nurses, physical
  therapists, pharmacists, nutritionists, social
  workers, etc.

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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
  PCMHs

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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

48
Patient-Centered Medical Home Functions and
Attributes
Source AHRQ Patient Centered Medical Home
Resource Center
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Harris County Hospital (Houston, TX)NCQA
distinction as PCMH
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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//www.apta.org/CollaborativeCare/
• Communities Discussion Board

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(No Transcript)
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HCR ImplementationHealth Insurance Exchanges
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Health Insurance Exchanges

• Section 1311 of ACA establishes health insurance
  exchanges
• State implementation by 2014
• Centralized marketplace where individuals and
  small businesses can purchase coverage
• One-stop shop web portal

54
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
  application.
• 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
  decisions

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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

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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

57
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
58
Exchange Development Timeline
Slide Source Avalere Health LLC presentation
Understanding State Efforts to Implement
Exchanges July 18, 2011
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Status of State Legislation to Establish
Exchanges, As of May 2012
NH
WA
ME
VT
MT
ND
AK
MN
OR
NY
ID
WI
MA
SD
RI
WY
MI
CT
PA
IA
NJ
OH
NE
NV
DE
IN
IL
MD
UT
WV
IA
VA
CO
DC
CA
KS
MO
KY
IL
WV
NC
VA
TN
SC
OK
AZ
AR
NM
GA
AL
MS
LA
HI
TX
FL
State exchange in existence prior to passage of
ACA
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
appropriation
Governors working with HHS on options
Legislation passed one or both houses
Governor veto or decision not to establish
exchange
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//www.ncsl.org
/default.aspx?TabId22122 Politico.com
Commonwealth Fund Analysis.
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Significant State Flexibility

• Nationwide standard for
• Enrollment period
• Approval for state exchanges
• Some national standards for
• Streamlined applications and eligibility
  decisions
• Governance structure
• West Virginia vs. California vs. Maryland
• Subsidiary and regional exchanges
• SHOP Employer/Employee Choice Model

61
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?

62
Snapshot of State Exchanges

• Utah

• Massachusetts

• Virginia http//www.healthinsurance.org/

63
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
  devices
• Prescription drugs
• Laboratory services
• Preventive and wellness services and chronic
  disease management
• Maternity and newborn care
• Pediatric services

64
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.

65
Rehabilitation and Habilitation Definitions under
EHBs

• 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.

66
Rehabilitation and Habilitation Definitions under
EHBs

• 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
  treatment.
• 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

67
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

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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.

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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

70
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
  necessary
• Allow latitude for treatment variations while
  balancing costs
• Actuarial data should be utilized if certain
  limits are allowable

71
EHB Advocacy Principles (cont.)

• Individual and community education and consumer
  choice
• 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

72
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

73
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.

74
Virginia Small Business Health Options Program
(SHOP)

• 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

75
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

76
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.

77
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,
  2012
• VA has until Jan. 1, 2013 to create state-based
  exchange that HHS approves fully or conditionally.

78
HCR ImplementationMedicaid Expansion
79
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.

80
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
  payments

81
Initial State Plans for Medicaid Expansion
82
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
  information
• Potential repeal of law after election

83
Beyond HCRMedicare Therapy Cap Updates
84
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
  hospitals.
• 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

85
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
  legislation.

86
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
  modifier.
• 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

87
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.

88
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//data.cms.gov/dataset/Therapy-Provider-Phas
  e-Information/ucun-6i4t

89
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.

90
APTA Resources for Therapy Cap Changes

• http//www.apta.org/Payment/Medicare/TherapyCap/20
  12/Changes/
• FAQ
• Webinar
• Podcast
• List of links to all MACs
• Complaint form

91
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//www.cms.gov/O
  utreach-and-Education/Outreach/OpenDoorForums/Down
  loads/080712TherapyClaimsSODFAnnouncementTranscrip
  tAudio.pdf)
• Questions may be emailed to therapycapreview_at_cms.
  hhs.gov.

92
CMS Resources for Therapy Cap Changes

• Medicare Benefit Policy Manual
• http//www.cms.gov/Regulations-and-Guidance/Guidan
  ce/Manuals/downloads/bp102c15.pdf
• Medicare Claims Processing Manual, chapter 5
• http//www.cms.gov/Regulations-and-Guidance/Guidan
  ce/Manuals/downloads/clm104c05.pdf
• Centers for Medicare and Medicaid Services
• www.cms.hhs.gov
• CR 6660 http//www.cms.hhs.gov/transmittals/downl
  oads/R1860CP.pdf
• CR 5871, Pub. 100-04, Transmittal 1414
• Transmittal 2537 CR 7881 (August 31, 2012)
  http//www.cms.gov/Regulations-and-Guidance/Guidan
  ce/Transmittals/2012-Transmittals-Items/R2537CP.ht
  ml
• Transmittal 1117 CR 8036 http//www.cms.gov/Regul
  ations-and-Guidance/Guidance/Transmittals/2012-Tra
  nsmittals-Items/R1117OTN.html

93
Beyond HCRReporting Functional Information on
Medicare Claims
94
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
  rule.

95
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
  modifier.
• CMS proposes the use of tools and translation of
  the scores from those tools to determine the
  level of impairment and severity modifier
  reported.
• Final rule will be published November 1, 2012

96
Functional Limitation Reporting
97
Functional Limitation Reporting
98
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
  meeting

99
HCR InitiativesProgram Integrity
100
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

101
Improper Payment

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

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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
  Forces)
• 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

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Strategies to Reduce Improper Payments
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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
  abuse
• Screen can include
• Licensure checks, fingerprinting, criminal
  background checks, site visits, etc.
• Final Rule Issued Feb. 2011

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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
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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
  suppliers)

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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.
  

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Resources on Provider Enrollment

• February 2, 2011 final rule
• http//edocket.access.gpo.gov/2011/pdf/2011-1686.p
  df
• Transmittal 371 (effective date March 25, 2011)
• https//www.cms.gov/transmittals/downloads/R371PI.
  pdf

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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
  payments
• 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
  abuse.

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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.

111
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.

112
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.

113
Postpayment Review

• Reviews are being conducted by Office of
  Inspector General, ZPICs, MACs, Recovery Audit
  Contractors
• 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
  program.

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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 www.cms.hhs.gov/RAC

115
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. )

116
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,
  2007
• 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.

117
Recovery Audit Contractors

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

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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.

119
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
  practice
• 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.

120
Zone Program Integrity Contractors

• ZPICs combine data from a number of different
  sources to create a platform for complex data
  analysis. 
• ZPICs were started by CMS by combining Program
  Safeguard Contractors (PSCs) and Medicare
  Prescription Drug Integrity Control (MEDIC)
  contracts. 
• 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.

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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
122
Contractor Review

• ACA included provisions for CMS to evaluate
  contractors receiving Medicare Integrity Program
  and Medicaid Integrity Program funding every 3
  years.
• ACA requires these contractors to provide
  performance statistics to HHS and its OIG upon
  request.
• Contractors must competitively bid for the
  contract therefore, they are under pressure to
  keep their rates of improper payment low.

123
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

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Risk Areas for Physical Therapists In Outpatient
Settings

• 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
  therapy
• 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

125
Risk Areas for Physical Therapists In Outpatient
Settings

• 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
  services
• Billing for services not furnished
• Billing for student services
• Documentation deficits or fraudulent
  modifications post denial or request for records

126
Risk Areas for Physical Therapists in Outpatient
Settings

• 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

127
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

128
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
  furnished)
• Supervision and use of PTAs
• Overlap of services between acute and post acute
  care
• Establishment and management of maintenance
  therapy
• Timely submission of claims and request for
  documentation
• Evidence to support patient homebound status

129
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

130
Risk Areas for Physical Therapists in Post-Acute
Care Settings

• Inpatient Rehabilitation Facilities
• Adherence to three hour rule (intensive therapy
  requirements)
• 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

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Tips on How to Protect Yourself

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

132
Appeal Rights

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

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Questions?