With nearly a third of the total Medicare population enrolled in a Medicare Advantage (MA) plan and growth expected to continue, it’s time for the public-private hybrid system to evolve and move away from excessive use of prior authorization—that’s the message being delivered to the Centers for Medicare and Medicaid Services (CMS) from a coalition of health care and consumer organizations including APTA.
In an April 10 letter to CMS Administrator Seema Verma, the Coalition to Preserve Rehabilitation (CPR) writes that MA’s uses of prior authorization “may be sources of increasing barriers to accessing needed care, particularly inpatient and outpatient rehabilitation services and devices, for beneficiaries nationwide.” The coalition argues that in many cases, prior authorization “often serves as an unnecessary delay for beneficiaries seeking medically necessary care, and often results in no cost savings to the plan.”
A major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare, but other provisions in the massive budget bill that ended the hard cap have created different challenges. Case in point: in the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.
The final budget package approved by Congress last week includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers’ negotiations around the budget deal with no opportunity for input from stakeholders. The new provisions also eliminate therapy thresholds that affect episode payment calculations.
APTA’s Physical Therapy Outcomes Registry (Registry) has been approved again by the US Centers for Medicare and Medicaid Services (CMS) as a qualified clinical data registry (QCDR). The designation for 2018 means that physical therapists (PTs) who participate in the Merit-based Incentive Payment System (MIPS) program can submit their data directly from the Registry, but the CMS approval is also an acknowledgment that APTA offers a robust, reliable system for tracking and benchmarking patient outcomes.
Although voluntary for now, PT participation in MIPS could be mandatory as early as 2019, making it important to become familiar with the system (APTA encourages eligible PTs to voluntarily participate in MIPS now).The Registry’s QCDR status will be particularly helpful for practices whose electronic health records (EHRs) do not have the capability to report directly to MIPS.
According to Heather Smith, PT, MPH, APTA’s director of quality, the value of the Registry goes well beyond MIPS data submission.
Efforts by the US Centers for Medicare and Medicaid Services (CMS) to make Medicare Advantage (MA) plans more accessible to more vulnerable beneficiaries are laudable, and provisions that would steer patients away from overuse of drugs are understandable, but CMS needs to be mindful of the unintended consequences of these and other changes, says APTA in its comments on proposed MA rules changes for 2019.
At the center of APTA’s comments are proposed changes to so-called “uniformity requirements,” out-of-pocket limits, and frequently abused drugs. Essentially CMS would like to make it easier for more vulnerable individuals to participate in MA plans by reducing cost-sharing requirements, and harder for providers and patients to overutilize certain drugs, including opioids. Both efforts are worth pursuing, APTA says in its comments to CMS.
In its push toward outcomes-based models, the US Centers for Medicare and Medicaid Services (CMS) needs to take a closer look at wound care, say authors of a new study that estimates nearly 15% of all Medicare beneficiaries experience chronic nonhealing wounds at an annual cost of nearly $32 billion. And the researchers believe those numbers are on the conservative side.
The study, recently published in Value in Health, analyzed data from Medicare’s 5% Limited Data Set during 2014 for details on claims in which wounds were the primary or secondary diagnosis. Researchers looked at costs, both in aggregate and by care setting, for 12 types of wounds: arterial ulcers, diabetic foot ulcers, diabetic infection, chronic ulcer, pressure ulcer, skin disorders, skin infection, surgical wounds, surgical infection, traumatic wound, venous ulcers, and venous infection. Here’s what they found:
In 2014, approximately 14.5% of Medicare beneficiaries were diagnosed with at least 1 type of wound or wound infection—that’s about 8.2 million patients.
Did you participate in the Physician Quality Reporting System (PQRS) in 2016? You can check on your 2016 reporting results and find out if you’re subject to any payment adjustments for 2018. But take note: if you’ve received a payment reduction notice and think the decision was made in error, you need to submit a request for review by December 1.
The Centers for Medicare and Medicaid Services (CMS) released the reporting results—known as the Annual Quality and Resource Use Reports (QRURs)—as well as the feedback reports for online viewing on September 18. The 2016 PQRS feedback report contains all detailed information used to determine your 2016 reporting results and indicates if you are subject to the 2018 PQRS negative payment adjustment.
The US Centers for Medicare and Medicaid Services (CMS) has killed a controversial proposal that would have restricted many physical therapists (PTs) from furnishing custom orthotics and prosthetics. The proposal was opposed by APTA and a host of other provider and patient advocacy organizations.
The proposed rule, issued in January, would have required PTs to be “licensed by the state [as a qualified provider of prosthetics and custom orthotics], or…certified by the American Board for Certification in Orthotics and Prosthetics…or by the Board for Orthotist/Prosthetist Certification.” The association voiced its opposition to the CMS plan, characterizing the proposal as a set of unnecessary requirements that would limit patient access to appropriate care.
APTA delivered comments to the US Centers for Medicare and Medicaid Services (CMS) that make no bones about the agency’s proposed changes to the home health payment system. The bottom line, according to the association: The plan contains “significant flaws” that “will have a harsh and dramatic effect on patient care.” And what’s more, APTA says, CMS may not have the legal authority to do what it wants to do, at least in the way it hopes to do it.
The letter from APTA provides a detailed deconstruction of a CMS proposal to radically change the payment environment for home health (HH) in ways that would directly impact patients, physical therapists (PTs), and physical therapist assistants (PTAs)—and not for the better. Those proposed changes would move episodes of care from 60 to 30 days, and would include the adoption of a new case-mix model, known as the Home Health Grouping Model (HHGM), that removes physical therapy service-use thresholds from the mix.
The US Centers for Medicare and Medicaid Services (CMS) will move away from its current practice of randomly selecting claims for audit in favor of a more targeted approach that it hopes will streamline the process and result in fewer appeals.
The program, dubbed Targeted Probe and Educate, directs Medicare administrative contractors (MACs) to select claims for items or services “that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate,” focusing only on “providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from their peers.” The program was piloted in 1 MAC jurisdiction in 2016, and expanded to 3 more in July of this year. All MAC jurisdictions will be following the procedure “later in 2017,” according to a CMS fact sheet.
The final 2018 rules for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) released by the US Centers for Medicare and Medicaid Services (CMS) don’t vary much from the proposed versions issued this spring, following through with proposals for an overall 1% payment increase, changes to reporting requirements, and updates to the list of ICD-10-CM codes the agency uses to evaluate facility compliance with the so-called “60% rule.” That rule states that 60% of an IRF’s patients must require treatment for 1 or more specified conditions.
As in the proposed rules, payment increases amounting to $80 million for IRFs and $390 million for SNFs are included, as are increased quality-reporting requirements—and consequences for noncompliance. More detail on the proposed rules appears in a PT in Motion News storypublished in May. CMS has published fact sheets on both the SNF and IRF final rules.