Special Report: Reimbursement/Regulations Impacting Physical Therapy

Transcription

1 Special Report: Reimbursement/Regulations Impacting Physical Therapy Carole S. Galletta, PT, MPH PPTA Reimbursement Specialist West Central District meeting 11/10/15 PPTA West Central District 11/10/15 1

2 Medicare Physician Fee Schedule OP payment rates Comprehensive Care for Joint Replacement Act 39 Fairness in Copay MACRA* Therapy Cap Manual Medical Review * Medicare Access and CHIP Reauthorization Act Fraud and Abuse CMS Audit Initiatives Documenting to support medical necessity Jimmo v. Sebelius Skilled or Not? Rehab? Maintenance? Improving Medicare Post-Acute Care Transformation Act (IMPACT) PAYMENT REFORM Volume Value PPTA West Central District 11/10/15 2

3 MACRA Medicare Access and CHIP Reauthorization Act PPTA West Central District 11/10/15 3

4 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Signed into Law 4/16/2015 Repeals 1997 Sustainable Growth Rate Physician Fee Schedule (PFS) Update Creates Merit-Based Incentive Payment System (MIPS) Incentives for participation in Alternate Payment Models (APM) PPTA West Central District 11/10/15 4

5 Medicare Therapy Cap When MACRA (Medicare Access and CHIP Reauthorization Act) was signed into law on April 16, 2015, the therapy caps exceptions process for Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) services was extended through CY PPTA West Central District 11/10/15 5

6 Manual Medical Review Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) The $3,700 trigger for manual medical review (MMR) has been replaced with a system that links MMR to provider behavior and other factors. CMS will look at whether a provider has a pattern of "aberrant" billing practices, the provider's claims denial percentage, whether the provider is newly enrolled, what types of medical conditions are being treated, and whether the provider is part of a group that includes another provider who has been identified in terms of the above factors. PPTA West Central District 11/10/15 BACK 6

7 Medicare Physician Fee Schedule PPTA West Central District 11/10/15 7

8 Medicare Physician Fee Schedule 2016 Payment Rates The payment rate for physical therapy services will increase 0.5%. This is based on: The 2016 conversion factor of $35.83 which reflects the 0.5% increase and budget neutrality adjustment of 0.77% called for under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA); and The actual impact of payment rates for individual physical therapy practices will depend on the mix of services provided. PPTA West Central District 11/10/15 8

9 Proposed Rule: Comprehensive Care for Joint Replacement (CCJR) PPTA West Central District 11/10/15 9

10 Comprehensive Care for Joint Replacement (CCJR) Proposed CCJR Model focused on elective primary hip and knee replacement patients Model includes inpatient stay and post discharge care 90 days after discharge Pilot begins January 1, 2016 and lasts for 5 years All IPPS hospitals in the 75 selected MSAs must participate Proposed Metropolitan Statistical Areas (MSAs) include PA counties: Cumberland, Dauphin, Allegheny, Berks PPTA West Central District 11/10/15 10

11 Financial Arrangements/Gain Sharing Providers are still paid under fee for service (FFS) payment models as they are today (may share in savings) Hospitals may have certain financial relationships with collaborators (can share reconciliation payments and internal cost savings with collaborators) Must furnish services during episode to be collaborator PPTA West Central District 11/10/15 11

12 Collaborators May include Physicians and nonphysician practitioners Home Health Agencies Skilled Nursing Facilities Long Term Care Hospitals Physician Group Practices Inpatient Rehabilitation Facilities Independent physical and occupational therapists PPTA West Central District 11/10/15 12

13 Beneficiaries Beneficiaries may still select any provider of choice with no restrictions. May still receive any Medicare covered service with no restrictions. No copayment change PPTA West Central District 11/10/15 13

14 CCJR: Proposed Waivers Fraud and abuse law waivers will be promulgated separately by OIG and CMS Can waive the SNF 3 day rule if SNF is rated 3 stars or higher on Nursing Home Compare Can waive incident to rule for physician services to allow clinical staff of a physician to furnish home visits. (only for non HHA covered patients) Telehealth waives originating site requirements so service may be originated in patient s home BACK PPTA West Central District 11/10/15 14

15 Fraud and Abuse The institute of Medicine estimates there is $746 billion spent by Medicare on waste and abuse and $75 billion in fraud. PPTA West Central District 11/10/15 15

16 Preventing Fraud, Abuse, and Waste: A Primer for Physical Therapists Need staff education for your Compliance Program? Part of APTA's Integrity in Practice campaign, this document provides physical therapists with information on how to comply with the relevant laws and regulations by identifying risk areas that could lead to potential liability. PPTA West Central District 11/10/15 16

17 Fraud involves obtaining something of value for which you are not entitled Through intentional deception or misrepresentation of material facts. Examples of fraud include, but are not limited to: Knowingly billing for services that were never furnished Knowingly altering claim forms to receive more payment Falsifying documentation to receive payment for which you are not entitled PPTA West Central District 11/10/15 17

18 FOR IMMEDIATE RELEASE Monday, March 2, 2015 New York Catholic Nursing Chain to Pay $3.5 Million to Resolve Allegations Concerning Claims for Rehabilitation Therapy RehabCare engaged in a pattern and practice of providing high levels of therapy that were not reasonable or necessary during so-called assessment reference periods, then provided less therapy to those same patients outside the assessment reference periods PPTA West Central District 11/10/15 18

19 Spectrum Rehab/OIG audit June 2013 Overpayment of $3,112,501 in Medicare reimbursement for outpatient occupational and physical therapy services that did not comply with certain Medicare requirements. Documentation didn t support medical necessity Treatment notes didn t meet MC requirements PPTA West Central District 11/10/15 19

20 January 25, 2014 Detroit, MI Physical therapist gets 10 years for Medicare fraud, must pay $10 million A physical therapist who co-owned an Oak Park health care business involved in numerous Medicare fraud convictions was sentenced to 10 years prison Friday, according to the FBI. The therapist was accused of creating fake patient files and laundering money through multiple shell companies. Have you been audited? Ever heard of data mining? PPTA West Central District 11/10/15 20

21 Anti-kickback violation A physician assistant (PA) agreed to be excluded from participating in Federal health care programs for a period of five years under 42 U.S.C. 1320a-7(b)(7). OIG alleged that the PA knowingly and willfully received illegal remuneration in exchange for referring patients for the furnishing of items or services for which payment may be made in whole or in part under a Federal health care program. OIG further alleged that the PA referred patients to health care entities for physical therapy and home health care services in exchange for illegal kickbacks in violation of the Anti-Kickback Statute. PPTA West Central District 11/10/15 21

22 Abuse involves payment for items or services for which there is no entitlement. In contrast to fraud, abuse involves instances in which the provider has not intentionally misrepresented facts to obtain payment. Examples of abuse include: Billing services that are not medically necessary Billing for services that do not meet professional standards of practice Unbundling services and billing for them; for example billing separately for electrodes, which are considered part of the payment for electrical stimulation PPTA West Central District 11/10/15 22

23 Waste involves incurring unnecessary costs due to deficient management practices, systems, or controls. Examples include: Duplication of tests and services that were already provided Spending on services when there are less costly alternatives that would result in the same outcome Ordering unnecessary tests to guard against liability Failures of care coordination that result in hospital readmissions or complications BACK PPTA West Central District 11/10/15 23

24 Documenting to support medical necessity PPTA West Central District 11/10/15 24

25 Medically unnecessary? PPTA West Central District 11/10/15 25

26 Fact: Unsubstantiated evidence of medical necessity and skilled care are two of the most common reasons for payment denial in rehab services. PPTA West Central District 11/10/15 26

27 Medically necessary? Skilled?... or not? PPTA West Central District 11/10/15 27

28 PPTA West Central District 11/10/15 28

37 Skilled services that are not adequately documented may appear to be unskilled. PPTA West Central District 11/10/15 37

38 Historical problem with physical therapy documentation Documentation focuses on patient activities versus therapist interaction with the patient Flow sheets of exercise indicate repetitive exercise or use of equipment with no indication of skill required by therapist PPTA West Central District 11/10/15 38

39 Documentation & Medical Necessity How do you document skilled care? Identifying the skilled interaction between qualified healthcare provider and patient is an essential component of documentation PPTA West Central District 11/10/15 39

40 Skilled Therapy under Medicare Reasonable and Necessary Skill may be documented by: The clinician s descriptions of their skilled treatment, The changes made to the treatment due to a clinician s assessment of the patient s needs on a particular treatment day, or Changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task. PPTA West Central District 11/10/15 40

41 Documenting Functional Performance: A Skill-Based Model Skill can be defined as the ability to achieve a desired outcome with consistency, flexibility, and efficiency: Consistency: Ability to successfully perform a skill repeatedly over multiple trials or days Flexibility: Ability to perform a skill under a variety of environmental conditions Efficiency: Ability to perform a skill within a certain level of energy expenditure (cardiovascular and musculoskeletal). PPTA West Central District 11/10/15 41

42 Documenting Functional Performance: A Skill-Based Model Consistency: Ability to successfully perform a skill repeatedly over multiple trials or days Rate of goal achievement (# of successes/# of attempts) Number of days/week able to perform Accuracy (spatial measures of errors) Accuracy (# of errors) Documentation Example: Patient is able to ambulate 300 ft using standard cane, with occasional verbal cues for sequencing, on level surface, three consecutive trials with a 2 minute rest period between trials. PPTA West Central District 11/10/15 42

43 Documenting Functional Performance: A Skill-Based Model Flexibility: Ability to perform a skill under a variety of environmental conditions Height, surface, position of equipment Environment (e.g. open vs. closed) Ability to do two tasks at once Documentation Example: Patient safely able to climb up 6 steps of 8, w / railing (ht of steps in home); unable to carry anything in hands with this activity. Requires verbal reminders for foot placement to safely climb up 4, 10 steps (outside step at home) with railing. PPTA West Central District 11/10/15 43

44 Documenting Functional Performance: A Skill-Based Model Efficiency: Ability to perform a skill within a certain level of energy expenditure (cardiovascular and musculoskeletal). Time to complete task Distance completed Speed of Movement Heart Rate, respiratory rate, or blood pressure changes Documentation Example: Patient can walk distance of 10ft. (from bed into bathroom) in 14.2 seconds (average time/3 trials) with increased HR to 100 bpm. PPTA West Central District 11/10/15 44

45 Proposed Local Coverage Determination (LCD) Therapeutic Exercise Many therapeutic exercises may require the unique skills of a therapist to evaluate the patient s abilities, design the program, and instruct the patient or caregiver in safe completion of the special technique. However, after the teaching has been successfully completed, repetition of the exercise, and monitoring for the completion of the task, in the absence of additional skilled care, is non-covered. What does your flow sheet/daily note reflect? PPTA West Central District 11/10/15 45

46 Proposed LCD Gait Training Repetitive walk-strengthening exercises for feeble or unstable patients or to increase endurance do not require qualified professional supervision and will be denied as not reasonable and necessary. BACK PPTA West Central District 11/10/15 46

47 Act 39 Fairness in Copay PPTA West Central District 11/10/15 47

48 Copay Legislation (SB 487) Act 39 Prohibits multiple copays or depleting more than one visit for a session with the same provider Signed by the Governor 7/31/15 PPTA West Central District 11/10/15 48

49 Act 39 Summary The bill specifically prohibits a health insurance policy that is delivered, issued for delivery, renewed, extended or modified in this Commonwealth by a health care insurer from subjecting an insured to more than one copayment per visit or from depleting more than one visit for services provided by a licensed physical therapist, chiropractor or occupational therapist provider on a given date. PPTA West Central District 11/10/15 49

50 Health care insurer versus Self-insured health plans Under federal law, states are not allowed to regulate self-insured benefits plans. Pennsylvania's mandated benefits and conversion provisions do not apply to health plans in which the employer pays all benefits without the proceeds of any insurance policy. An employer's health plan is self-insured if the risk of paying claims is on the employer and not on an insurance company. Self-insured plans may contract with third-party administrators (TPAs), including insurance companies, to process benefits claims. The TPA pays the claims and then is reimbursed by the employer. PPTA West Central District 11/10/15 50

51 Act 39 does not impact self-insured plans because they are federally regulated and exempt from state law by ERISA If a patient is charged a double copay or docked for more than one visit, and it is not a self-insured plan, contact the PPTA Reimbursement Specialist. csgalletta@gmail.com BACK PPTA West Central District 11/10/15 51

52 Audit Initiatives PPTA West Central District 11/10/15 52

53 Preventing Fraud, Abuse, and Waste: A Primer for Physical Therapists Need staff education for your Compliance Program? Part of APTA's Integrity in Practice campaign, this document provides physical therapists with information on how to comply with the relevant laws and regulations by identifying risk areas that could lead to potential liability. PPTA West Central District 11/10/15 53

54 OIG 2016 Work Plan Physical therapists High use of outpatient physical therapy services We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable or were not properly documented or that the therapy services were not medically necessary. Our focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Medicare will not pay for items or services that are not reasonable and necessary. PPTA West Central District 11/10/15 54

55 OIG 2016 Work Plan SNF We will review compliance with various aspects of the skilled nursing facility (SNF) prospective payment system, including the documentation requirement in support of the claims paid by Medicare. Prior OIG reviews have found that Medicare payments for therapy greatly exceeded SNF s cost for therapy. In addition, we have found that SNFs have increasingly billed for the highest level of therapy even though key beneficiary characteristics remained largely the same. PPTA West Central District 11/10/15 55

56 CERT Comprehensive Error Rate Testing (CERT) program is to measure improper payments in the Medicare fee-for-service (FFS) program. The CERT program cannot be considered a measure of fraud. Since the CERT program uses random samples to select claims, reviewers are often unable to see provider billing patterns that indicate potential fraud when making payment determinations. CERT is designed to comply with the Improper Payments Elimination and Recovery Act of PPTA West Central District 11/10/15 56

57 ZPIC The primary goal of the Zone Program Integrity Contractors (ZPICs) is to identify cases of suspected fraud, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped. PPTA West Central District 11/10/15 57

58 Pennsylvania Benefit Integrity Support Center (PENN-BISC) ZPIC for Zone 6 which includes PA General mailing address for PENN-BISC is the following: SafeGuard Services, LLC PENN-BISC Suite Camp Hill Bypass Camp Hill, PA PPTA West Central District 11/10/15 58

59 Strategic Health Solutions, LLC 4211 South 102nd Street Omaha, NE Provider compliance Supplemental Medical Review Contractor PPTA West Central District 11/10/15 59

60 Signature Requirements Pub Medicare Program Integrity Manual Chapter 3 Updated- EFFECTIVE DATE: August 25, 2015 PPTA West Central District 11/10/15 60

61 Signature Requirements Pub Medicare Program Integrity Manual - Transmittal 604/Change Request 9225 Summary Of Changes: The purpose of this Change Request (CR) is to allow contractors to use alternate medical documentation to identify an illegible handwritten signature. PPTA West Central District 11/10/15 61

62 Signature Requirements Due to attestation or signature logs not being submitted in medical records, this CR 9225 is instructing the contractors to use other submitted medical documentation to verify a signature. The contractors shall consider evidence in a signature log, attestation statement, or other documentation submitted to determine the identity of the author of a medical record entry, if the signature is illegible. PPTA West Central District 11/10/15 62

63 Illegible signature over a typed or printed name Example : John Whigg, MD CMS Pub 108 Chapter 3 PPTA West Central District 11/10/15 63

64 Illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signatory. Example: An illegible signature appears on a prescription. The letterhead of the prescription lists (3) physicians names. One of the names is circled. CMS Pub 108 Chapter 3 PPTA West Central District 11/10/15 64

65 Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by: a signature log, or an attestation statement CMS Pub 108 Chapter 3 BACK PPTA West Central District 11/10/15 65

66 PAYMENT REFORM Volume Value Fee for Service is becoming a thing of the past! PPTA West Central District 11/10/15 66

67 Value-Based Healthcare CMS: to shift the incentives for payment from volume to value Demonstration of value must be communicated through documentation Timeline announced January, 2015: 2016: 30% of FFS payments based on value and provided through alternative payment models 2018: 50% of FFS payments based on value and provided under alternative models that base payments on quality of care PPTA West Central District 11/10/15 67

68 New Evaluation Codes will likely be implemented in 2017 Evaluation RUC Survey Analysis July: Survey closed July through August: Data analysis w/ member experts September: RUC recommendations due to AMA Evaluation Code Launch October: Recommendations presentation to the RUC July 2016: MPFS proposed rule (comment period) January 2017: Potential implementation Refinement of Intervention Codes Currently regrouping and strategizing on next steps October: CPT meeting/pmr WG meeting PPTA West Central District 11/10/15 68

69 Overview of Evaluation Coding Structure 3 levels of complexity Low complexity Moderate complexity High complexity The level of the PT evaluation dependent on clinical decision making and the nature of the condition (severity). PPTA West Central District 11/10/15 69

70 CPT Code Revisions PT Evaluation- Low Complexity History Examination Presentation Decision-Making No personal factors and/or comorbidities that impact POC Addressing 1-2 elements from any of the following: body structures and functions, activity limitations and/or participation restrictions Stable and/or uncomplicated characteristics Low complexity, use of standard patient assessment instrument and/or measurable assessment of functional outcome PPTA West Central District 11/10/15 70

71 CPT Code Revisions PT Evaluation- Moderate Complexity History Examination Presentation Decision-Making 1-2 personal factors and/or comorbidities that impact POC Addressing 3 or more of any of the following: body structures and functions, activity limitations and/or participation restrictions Evolving with changing characteristics Moderate complexity, use of standard patient assessment instrument and/or measurable assessment of functional outcome PPTA West Central District 11/10/15 71

72 CPT Code Revisions PT Evaluation- High Complexity History Examination Presentation Decision-Making 3 or more personal factors and/or comorbidities that impact POC Addressing 4 or more of any of the following: body structures and functions, activity limitations and/or participation restrictions Unstable and unpredictable characteristics High complexity, use of standard patient assessment instrument and/or measurable assessment of functional outcome PPTA West Central District 11/10/15 72

73 CPT Code Revisions PT Re-evaluation Single level Re-evaluation of established Plan of Care Examination including review of history, use of standardized tests and measures and revised POC based on standardized patient assessment instruments and/or measurable assessment of functional outcome PPTA West Central District 11/10/15 73

74 Regrouping and strategizing on next step Refinement of Intervention Codes APTA President, Sharon Dunn, PT, PhD, OCS held a town hall meeting on the future of payment reform for physical therapy services at the APTA State Policy & Payment Forum being held in Denver, CO. PPTA leadership was in attendance at this town hall meeting to share your concerns and questions You can learn more about APTA's efforts by going to: BACK PPTA West Central District 11/10/15 74

75 Skilled Rehab v. Skilled Maintenance Jimmo v. Sebelius CMS there is no Improvement Standard PPTA West Central District 11/10/15 75

76 Rehabilitative therapy v. Maintenance Therapy Care must be taken to assure that documentation justifies the necessity of the skilled services provided. PPTA West Central District 11/10/15 76

77 Rehabilitative therapy v. Maintenance Therapy In the case of rehabilitative therapy, the patient s condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained; and, there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time. PPTA West Central District 11/10/15 77

78 Rehabilitative therapy v. Maintenance Therapy In the case of maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers. BACK PPTA West Central District 11/10/15 78

79 Improving Medicare Post-Acute Care Transformation (IMPACT) Act Initiatives-Patient-Assessment-Instruments/Post- Acute-Care-Quality-Initiatives/IMPACT-Act-of and-Cross-Setting-Measures.html PPTA West Central District 11/10/15 79

80 Four separate payment systems for SNFs, HHAs, IRFs, and LTCHs Similar services provided in these settings but payments differ (wide variation in payment) Placement may not be based on clinical factors but provider available Little evidence of best setting for care Lack of common patient assessment tool PPTA West Central District 11/10/15 80

81 Post Acute care concerns Unable to compare quality across settings Current Post-Acute care payment systems encourage increased utilization of services to increase payment Wide variation in post-acute care costs and use PPTA West Central District 11/10/15 81

82 3 Conditions: IRF Payments Higher (patients similar) PPTA West Central District 11/10/15 82

83 Advancing PAC reform Payments should be based on patient needs, not site of service Payments should be better aligned with costs of care. Better coordination of care Improvements in Quality PPTA West Central District 11/10/15 83

84 Improving Medicare Post-Acute Care Transformation Act (IMPACT) Wednesday, October 21; 1:30-3pm ET LOOK FOR RECORDING To Register: Visit MLN Connects Event Registration. Legislative requirements of the IMPACT Act related to the use of standardized data, quality measures, and resource use and other measures for Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Home Health Agencies (HHAs) BACK PPTA West Central District 11/10/15 84