Title: Virginia Physical Therapy Association 2012 Annual Conference Health Care Reform
1Virginia Physical Therapy Association 2012
Annual ConferenceHealth Care Reform
- Gillian Russell, JD
- Senior Regulatory Affairs Specialist
- American Physical Therapy Association
2HCR / Goal of Integrated CareThree Part Aim
3Emerging Themes in Health Care
4Timeline of Key Health Reform Provisions
5Collaborative Care ModelsAccountable Care
Organizations(ACOs)
6What 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
7ACO Final Rulemaking
8Highlights of MSSP Final Rule
9ACO Multiple Pathways
10ACO Resources
- 116 MSSP ACOs
- 32 Pioneers
- 20 Advanced Payment
11Eligible Participants
- ACO Professionals in Group Practice Arrangements
- Networks of Individual Practices of ACO
Professionals - Partnerships or Joint Venture Arrangements
Between Hospitals and ACO Professionals - Hospitals Employing ACO Professionals
- Critical Access that bills for facility and
professional services - Federally Qualified Health Centers
- Rural Health Clinics
12ACO 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
13ACO 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
14ACO 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
15Establishing 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
16Risk 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)
17Beneficiary 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
18ACO 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
19ACOs 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
20ACO Quality Reporting Therapy Considerations
21Interim 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
22Anti-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
23Private ACO Collaborations
24(No Transcript)
25Dispelling the Myths
- 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
26Physical Therapy Considerations
27What Do ACOs Mean for PT Practice?
ACO
Physical Therapists Practicing Outside of ACO
Model
Physical Therapists Practicing Within ACO Setting
28Is an ACO Partnership Right for Your Practice?
29CMS 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
30Key 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
31Collaborative Care ModelsBundled Payments
32Section 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
33CMMI 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
34Bundling Initiative Four Proposed Models
35Relationship 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
36Definition 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
37Example 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.
38Bundling 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
39Hospital 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.
40Hospital 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)
41Hospital 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
42Additional Readmissions Measures
43APTA 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
44Collaborative Care ModelsPatient-Centered
Medical Homes(PCMHs)
45Medical 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.
46Medical 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
47Medical 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
48Patient-Centered Medical Home Functions and
Attributes
Source AHRQ Patient Centered Medical Home
Resource Center
49Harris County Hospital (Houston, TX)NCQA
distinction as PCMH
50Collaborative 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
51(No Transcript)
52HCR ImplementationHealth Insurance Exchanges
53Health 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
54State 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
55HHS 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
56Coverage 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
57Tax 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
58Exchange Development Timeline
Slide Source Avalere Health LLC presentation
Understanding State Efforts to Implement
Exchanges July 18, 2011
59Status 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.
60Significant 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
61Significant 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?
62Snapshot of State Exchanges
- Virginia http//www.healthinsurance.org/
63Essential 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
64Flexibility 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.
65Rehabilitation 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.
66Rehabilitation 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
67APTA 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
68EHB 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.
69EHB 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
70EHB 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
71EHB 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
72Virginia 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
73Virginia 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.
74Virginia 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
75Virginia 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
76Virginia 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.
77Virginia 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.
78HCR ImplementationMedicaid Expansion
79Medicaid 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.
80Impact 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
81Initial State Plans for Medicaid Expansion
82Virginia 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
83Beyond HCRMedicare Therapy Cap Updates
842012 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
852012 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.
86Therapy 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
87Therapy 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.
88Therapy 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
89Therapy 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.
90APTA 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
91CMS 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.
92CMS 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
93Beyond HCRReporting Functional Information on
Medicare Claims
94Reporting 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.
95Reporting 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
96Functional Limitation Reporting
97Functional Limitation Reporting
98MedPAC 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
99HCR InitiativesProgram Integrity
100Improper 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
101Improper 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
102Program 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
103Strategies to Reduce Improper Payments
104Provider 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
105Limited 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
106Provider 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)
107Provider 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.
108Resources 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
109Prepayment 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.
110Prepayment 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.
111Prepayment 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.
112Prepayment 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.
113Postpayment 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.
114Recovery 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
115Recovery 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. )
116Recovery 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.
117Recovery 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.
118Recovery 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.
119Recovery 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.
120Zone 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.
121Zone 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
122Contractor 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.
123Summary 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
124Risk 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
125Risk 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
126Risk 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
127Risk 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
128Risk 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
129Risk 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
130Risk 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
131Tips 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
132Appeal 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
133Questions?