Review of Texas Medicaid Acute Care Therapy Programs

Transcription

1 Review of Texas Medicaid Acute Care Therapy Programs Interim Report Research Questions 1-4 Submitted to: Strategic Decision Support Texas Health and Human Services Commission Revision 1.0 Prepared by: Sean Gregory 1,2, MBA, MS, PhD Robert Ohsfeldt 1,2, PhD Andrea Lorden 1, MPH, PhD Obi Nwaiwu 1, MBBS, MPH 1 Department of Health Policy & Management School of Public Health 2 Department of Pediatrics College of Medicine Health Sciences Center Texas A&M University 1

2 CHAPTER 1. INTRODUCTION AND BACKGROUND Senate Bill 1, 83 rd Legislature, Regular Session, 2013 (Article II, Health and Human Services Commission, Rider 51 1 ) directs the Health and Human Services Commission (HHSC) to reduce Medicaid funding and contain costs. Specifically, there is a mandated "reduction of $200,000,000 in general revenue funds and $284,730,974 in federal funds in fiscal year 2014 and $200,000,000 in general revenue funds and $276,871,722 in federal funds in fiscal year 2015, a biennial total of $400,000,000 in general revenue funds and $561,602,696 in Federal Funds 1 ". Rider 51, parts state: (1) Phase down Medicaid rates which are above Medicare rates, with separate consideration for an accurate and appropriate evaluation of the service delivery model when developing the rate for Medicaid rates for pediatric therapy services that have no equivalent Medicare service. (2) Develop a more appropriate fee schedule for therapy services, requiring providers to submit the National Provider Identification (NPI) on each claim. Rider 51 cost savings associated with Medicaid acute care therapies (fee-for-service [FFS] and managed care [MC]) totaled $36.8 million in general revenue funds and $51.7 million in federal funds for the biennium. Currently, Texas Medicaid FFS reimbursement rates for acute care therapy for children are higher than those of Medicare and Medicaid rates in other states. Medicaid does not typically reimburse at a rate higher than that of Medicare for the same service but it is unclear if Medicare rates are an appropriate point of comparison for therapy services provided to children. HHSC has proposed FFS rate reductions, based on provider type and delivery model (i.e., services provided in an office/clinic setting versus services provided in the client s home). Effective September 1, 2013, the following FFS rate reductions apply: 1.5% reduction for services provided in client's home by a home health agency (HHA) or independent provider 2.5% reduction for services provided in a comprehensive outpatient rehabilitation facility (CORF)/outpatient rehabilitation facility (ORF) 4.0% reduction for services in an office or clinic by an independent provider It is unknown whether the September 1, 2013 FFS payment rates are unreasonable or required due to the payer mix, utilization patterns, or cost of services. Senator Williams and Representative Pitts of the Senate Finance Committee and Committee on Appropriations, respectively, requested that "HHSC review the rates mid-year and make further adjustments or policy changes as needed in order to achieve overall budgeted savings while ensuring quality Medicaid services are provided 2." The legislators also encourage HHSC to explore other cost saving options that would maintain quality of care and increase efficiency of Medicaid acute care therapy services such as standardizing rates, increasing service consistency, encouraging service provision in appropriate settings, improving the quality of care, and achieving efficiencies through managed care therapy utilization. 1 S.B. 1, 83 rd Legislature, Regular Session, 2013 (Article II, Health and Human Services Commission, Rider 51 2 Letter from Tommy Williams, Senate Finance Committee, and Jim Pitts, Committee on Appropriations, to Dr. Kyle Janek, Executive Commissioner Health and Human Services Commission. August 21,

3 The September 1, 2013, rate reductions are estimated to produce savings of $18.1 million in general revenue and $25.4 million in federal funds for the biennium. Legislative intent includes an expectation that additional acute care therapy savings of $18.7 million in general revenue and $26.3 million in federal funds will be achieved during the biennium so that the entire cost savings assumed in Rider 51 for acute care therapies is achieved. A study is needed to understand how Medicaid FFS in Texas compares to other payers regarding pediatric acute care therapy (occupational, physical, speech) in terms of authorization policies, rates, and utilization patterns. Understanding the landscape of pediatric acute care therapy services will inform decision-making regarding authorization policies and rate adjustments. A. PURPOSE OF THE STUDY The proposed study will examine the authorization process, rate structure, and utilization patterns of pediatric acute care therapy (occupational, physical, speech) in Texas. Comparisons will be made according to payer type, and service delivery model (see Table 1). These comparisons should illustrate how Texas Medicaid FFS compares to Texas Medicaid MC, Texas Medicare, private insurers in Texas, and other states' Medicaid in terms of authorization processes, rate structures, and utilization patterns. Additionally, this study will describe the Medicaid clients receiving acute care therapy services and analyze the effectiveness of various service delivery models. Results of this study should identify pros and cons of the current Texas Medicaid pediatric acute care therapy authorization process and rate structure and inform recommendations for policy and/or rate changes to achieve the remaining required cost savings for the biennium. Therapy type Payer types Service delivery models Table 1. Medicaid Rate Comparisons Occupational Physical Speech Medicaid fee-for-service (FFS) in Texas Medicaid managed care (MC) in Texas Medicaid in other states Medicare in Texas Private insurance in Texas (one or two selected large insurance companies, i.e., Blue Cross Blue Shield, United) Comprehensive outpatient rehabilitation facility (CORF)/ Outpatient rehabilitation facility (ORF) Home health agency (HHA) Independent provider - clinic or office setting Independent provider - client's home A. Key Study Questions Study Arm 1: Pediatric Acute Care Therapy Authorization Process, Rate Structure and Utilization Patterns The aim of Study Arm 1 is to illustrate how Texas Medicaid FFS compares to Texas Medicaid MC, Texas Medicare, private insurers in Texas, and other states' Medicaid in terms of authorization processes, rates, and utilization patterns. 1. Authorization Process Research Question 1: How does the authorization process for pediatric acute care therapy compare among payer types? (For Texas, use authorization process as of January 1, 2014.) a. Compare Texas' prior authorization, utilization review, authorization periods, allowed number of therapy hours per day, and evaluation and re-evaluation policies to other payers. Conduct a comparative case study analysis to examine the typical client requiring services for each payer type. Payer types must include 3

4 Medicaid FFS and MC in Texas, private insurance in Texas, and Medicaid in other states (Medicare not necessary). This analysis must include a separate case study for physical therapy, occupational therapy, and speech therapy for each service delivery model. b. Develop a best practice model for authorization and assessment processes to determine the need for and level of services for each patient including when a patient should be eligible for in-home services. This analysis will illustrate how similar or dissimilar authorization processes are among payer types to inform considerations and possible adjustments necessary for one-to-one comparisons of rates among different payers. Additionally, this comparison will inform the development of a best practice model for the pediatric acute care therapy authorization process. 2. Rate Structure Research Question 2: How do payment rates for pediatric acute care therapy compare among payer types? (For Texas, use rates as of September 1, 2013.) a. Compare rates for selected pediatric acute care therapy procedure codes billed per treatment by payer type, and service delivery model. i. Include average travel time to provide services in a client s home, if applicable. b. Compare rates for selected pediatric acute care therapy procedure codes billed per specific amounts of time (i.e., per 15 minutes). i. Include average amount of time spent providing therapy (all settings) and travel time to provide services in a client s home, if applicable. c. Compare costs of pediatric acute care therapeutic services by therapy type, location (STAR service delivery areas in Texas, statewide for comparison states), and service delivery model. (Costs measured in terms of therapist salary or other proxy measure.) d. Compare differences between costs and reimbursement rates of pediatric acute care therapeutic services by therapy type, location, payer type, and service delivery model. (Costs measured in terms of therapist salary or other proxy measure.) These analyses will allow for a "head-to-head" comparison of rates among payer types and to determine any under- or over-payments relative to the cost of providing the service. 3. Utilization Patterns Research Question 3: How do utilization patterns for pediatric acute care therapy compare among payer types? (Compare fiscal year (FY) 2010 through 2012 or 2013, depending on data availability.) a. Compare utilization patterns among therapeutic providers by therapy type, location (STAR service delivery areas in Texas, statewide in comparison states), payer type, and service delivery model. b. Describe payer mix among providers in Texas offering pediatric therapeutic services by STAR service delivery area, payer type, and service delivery model. These analyses will allow for an assessment of the impact of potential rate cuts on providers, based on utilization patterns and payer mix. For example, a provider whose patient base is 5 percent Medicaid clients will be impacted less than a provider whose patient base is 80 percent Medicaid clients. 4. Impact of Future Rate Reductions 4

5 Research Question 4: What would be the impact of additional rate reductions on providers in Texas based on payer mix and utilization patterns? (Reductions based on September 1, 2013 rates.) a. Rate reductions may be from 1 to 5 percent. This analysis will determine if certain providers will be disproportionately affected by additional rate cuts due to the payer mix of their practices and/or utilization patterns. The report is organized into four subsequent chapters, one for each research question. The chapters are inclusive of the methods, results, conclusions and limitations regarding each research question. Some methods are repeated in each of the chapters such that each chapter can serve as a stand-alone response to the research question posited within. 5

6 CHAPTER 2. PEDIATRIC ACUTE CARE THERAPY AUTHORIZATION PROCESS The first research question will examine whether the authorization process for pediatric acute care therapy differs among payer types. Specifically, for physical therapy, occupational therapy, and speech therapy we will: Compare Texas' prior authorization, documentation requirements, utilization review, authorization periods, allowed number of therapy hours per day, prescription of services, and evaluation and reevaluation policies to the Medicaid programs in Florida, California, Minnesota, and Arizona and private insurance in Texas. Conduct a comparative case study analysis to examine the typical client requiring services in Texas Medicaid Managed Care and Fee-for-service, Medicaid programs in Florida, California, Minnesota, and Arizona, and private insurance in Texas. This analysis will illustrate how similar or dissimilar authorization processes are among payer types to inform considerations and possible adjustments necessary for one-to-one comparisons of rates among different payers. Additionally, this comparison will inform the development of a best practice model for the pediatric acute care therapy authorization process. A. POLICY COMPARISON In order to determine whether the Texas Medicaid policies differ from the Medicaid programs of other states or private insurance in Texas we examined program policies related to the prior authorization process, documentation requirements, utilization review, authorization periods, allowed number of therapy hours per day, prescription of services, and evaluation and re-evaluation. 1. Methods To address whether Texas Medicaid policies differ from the Medicaid programs of other states or private insurance in Texas we selected four states that had a Medicaid population that would represent a broad range of Medicaid programs that are shifting beneficiaries from fee-for-service to Medicaid Managed Care: Florida, California, Minnesota, and Arizona. These states represent varying degrees of Medicaid Managed Care concentration, and varying durations since these policy changes have occurred and are presented according to their duration in Medicaid Managed Care, and the sophistication of the Medicaid Managed Care market structure. We believe these large, populous, and demographically diverse states (save for Minnesota), serve as reasonable comparators for HHSC to evaluate contemporary practices in prior authorization, utilization review, authorization periods, allowed number of therapy hours per day, and evaluation and re-evaluation processes. Data for this analysis was gathered from each states Medicaid website with particular emphasis on their prior authorization, utilization reviews, authorization periods, allowed number of therapy hours per day, and evaluation and re-evaluation policies for pediatric acute care therapy (occupational, physical, speech). Tables 2-7 summarize policies from each state and Texas private insurance for the different therapy types. 2. Results In the subsections that follow, state-specific findings will be identified and discussed. In some circumstances there is no state-specific guidelines or policies for the given subsection, therefore not all comparison states are detailed in each subsection. Prior Authorization Policies We compared the prior authorization policies in Texas, Florida, California, Minnesota, Arizona and Texas private insurance. With the exception of Minnesota, most states require prior authorization for occupational 6

7 and speech therapy services. See Table 2 for a summary of services by state that require or do not require a prior authorization. Texas. Prior authorization is required for all occupational therapy, physical therapy, and speech therapy services, in both FFS and MC programs, except for: therapy services provided in an inpatient setting, evaluations or re-evaluations, services provided through the School Health and Related Services (SHARS), or Early Childhood Intervention (ECI) programs. A Request for Initial Outpatient Therapy (Form TP-1) or Request for Extension of Outpatient Therapy (2 Pages) (Form TP-2) must be submitted to the Texas Medicaid & Healthcare Partnership (TMHP) prior to the start of care for the current acute episode of therapy. Florida. Physical, occupational therapy, and speech-language pathology services require prior authorization for reimbursement. Therapy services for recipients who are members of a Medicaid Health Maintenance Organization (HMO) and recipients who are members of a Medicaid Provider Service Network (PSN) are exempt from prior authorization by the Quality Improvement Organization (QIO), also referred to as the External Quality Review Organization (EQRO). Arizona. Prior authorization is required for covered occupational therapy, speech therapy and audiology services, but not required for covered physical therapy services. Covered services include medically necessary therapy services provided to all members who are receiving inpatient care at a hospital (or a nursing facility) when services are ordered by the member's PCP or attending physician for FFS members, and provided by or under the direct supervision of a licensed therapist. Outpatient Occupational and Speech Therapy services are covered only for members receiving Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services, KidsCare members and Arizona Long Term Care System (ALTCS) members. Outpatient Physical Therapy services are covered for EPSDT and KidsCare members, and limited to 15 outpatient visits per contract year for adult members (21 years of age and older) of ALTCS who are not Medicare eligible. California. Treatment Authorization Requests (TARs) for occupational therapy, physical therapy, and speech therapy for Medi-Cal-only recipients is required and must be submitted to the San Francisco Medi- Cal Field Office. Prior authorization approval by the Medi-Cal field office is limited to services that: 1) Are necessary to prevent or substantially reduce an anticipated hospital stay; 2) Continue a plan of treatment initiated in the hospital; 3) Are recognized as a logical component of post hospital care. Minnesota. Unlike Texas, Florida, Arizona and California, the Minnesota Health Care Programs (MHCP) suspended prior authorization requirements effective July 1, 2013 for outpatient rehabilitative and therapeutic services (physical therapy, occupational therapy and speech-language pathology). Rehabilitative and therapy services are subject to post-payment review and may result in a particular provider being required to request authorization for certain services. However, prior authorization is still required for outof-state provider, or if a health service meets one of the following conditions: The health service could be considered, under some circumstances 3, to be of questionable medical necessity 3 No specific example was given. We interpret this comment in the Minnesota guidelines to refer to a situation where there is a debate on the benefit of OT, PT, or ST on the medical condition. In other words, where evidence of effectiveness and/or appropriateness still lacks. 7

8 Use of the health service requires monitoring to control the expenditure of Minnesota Health Care Programs (MHCP) funds A less costly, appropriate alternative health service is available The health service is investigative or experimental The health service is newly developed or modified The health service is of a continuing nature and requires monitoring to prevent its continuation when it ceases to be beneficial The health service is comparable to a service provided in a skilled nursing facility or hospital but is provided in a recipient's home The health service could be considered cosmetic Texas Private Insurance (BlueCross BlueShield of Texas.). Initial evaluation for Therapy Services does not require prior authorization. However, after initial evaluation, therapy visits, continuation of services, and re-evaluations must be authorized prior to services being rendered. An evaluation is needed before implementing any treatment. The evaluation is essential to: 1) determine if acute care therapeutic services are medically necessary 2) gather baseline data 3) establish a treatment plan 4) develop goals based on the data The re-evaluation is a more comprehensive assessment that is indicated when there are new clinical findings, a rapid change in the individual's status, or failure to respond to therapy interventions. 8

9 Table 2. Prior Authorization Requirements by State State Prior Authorization Required Prior Authorization Not Required Texas Occupational therapy Therapy services provided in an inpatient Physical therapy setting, Speech therapy Evaluations or re-evaluations, Services provided through the School Health and Related Services (SHARS), or Early Childhood Intervention (ECI) programs Florida Occupational therapy Physical therapy Speech-language pathology services Arizona Occupational therapy Speech therapy audiology services California Occupational therapy Physical therapy Speech therapy Members of a Medicaid Health Maintenance Organization (HMO) Members of a Medicaid Provider Service Network (PSN) Physical therapy services None Minnesota Texas Private Insurance Services that are: experimental newly developed or modified require monitoring comparable to a service provided in a skilled nursing facility or hospital but is provided in a recipient's home of questionable medical necessity considered cosmetic The following therapy visits after initial evaluation: Occupational therapy Physical therapy Speech therapy Continuation of services Re-evaluations of therapy Occupational therapy Physical therapy Speech therapy Initial evaluation for Therapy Services 9

10 Documentation Requirements Each state s Medicaid program in our sample requires documentation to establish medical necessity of therapy, treatment plan, achievable goal for each therapy, and the scope and duration of therapy. In addition, there are documentation requirements for the therapy providers to establish the basic credentials needed for these providers. Minimum documentation requirements include: Signature of the prescribing practitioner Name, address, telephone and identification number of the prescribing practitioner Date of prescription Medical condition necessitating the service(s) (diagnosis) Specific services (for example, evaluation, treatments, and modalities) prescribed Frequency of services Duration of medical necessity for services Specific dates and length of treatment should be identified if possible. Anticipated medical outcome as a result of the therapy (therapeutic goals) Date of progress review (when applicable) Age of the client at the time of evaluation Functional limitations Mental status and ability to comprehend Related medical conditions Delay in achievement of developmental milestones in a child or impairment of normal achievement in an adult Two states (Texas and Florida) have additional documentation requirements. In addition to the information listed above, Texas requires: For an extension of outpatient therapy, the new request must document all progress made from the beginning of the previous treatment period The number of sessions per week must be supported by documentation supporting the medical necessity for the frequency requested. When requesting prior authorization for group occupational therapy, the provider must submit documentation supporting the group process as being medically necessary and beneficial to the client. A procedural modifier when submitting claims for services. Florida also requires a copy of the documentation demonstrating the recipient has been examined or received medical consultation by the ordering or attending physician before initiating services and every 180 days thereafter. Utilization Review Remarkably, there were no findings in the literature search, or the inspection of state Medicaid program websites regarding specific utilization review (UR) process and procedures for Acute Therapy Services. Through discussion with state Medicaid officials it was noted that typically UR responsibilities have been transferred, albeit not explicitly, to the Medicaid Managed Care Organizations via the fixed capitation for beneficiaries. It is assumed that the Medicaid Managed Care Organizations perform these medical management policies and procedures to manage the risk and utilization in their respective risk pools. All states required Medicaid Managed Care Organizations to cover Acute Therapy Services, and use the same authorization and pre-authorization processes. Texas Private Insurance. In the BlueCross BlueShield of Texas, nurses utilize Clinical Guidelines, Medical Policies, Milliman Guidelines, and plan benefits to determine whether or not coverage of a request can be approved. The nurses 10

11 review for only medical necessity. They do not initiate denial. The request will be authorized if it meets criteria, and referred to a Peer Clinical Reviewer (PCR) if it does not meet criteria. The PCR reviews the cases that are not able to be approved by the nurse and can deny service for lack of medical necessity. In Chapter 4 we will examine whether the expansion of Medicaid Managed Care in Texas impact overall utilization (e.g. spending and number of units.). Authorization Periods In Texas, Florida, California, and Arizona, a request for pediatric acute care therapeutic services may be authorized for varying lengths of time within a patients eligibility period, but no longer than 180 days duration. A new request must be submitted if therapy is required for a longer duration 4. The therapist must review the plan of care every 180 days or prior to the end of the authorization period and make necessary revisions. Texas. When group therapy is authorized, weekly therapy limits cannot be exceeded. If a provider discontinues therapy with a client and a new provider begins therapy during an existing authorization period, submission of a new plan of care and documentation of the last therapy visit with the previous provider is required along with a letter from the client, or responsible adult, stating the date therapy ended with the previous provider. California. Occupational, physical, and speech therapy services rendered in an outpatient setting in California are limited to a maximum of two services per month subject to the availability of Medi-Service reservations. This limitation does not apply to occupational therapy services rendered in a certified rehabilitation center or Nursing Facility (NF) Level A or B. Minnesota. If authorization is required, the date of the order/prescription must not be more than 30 days from the requested start of care. Such conditions requiring authorization are listed in Table 4 below. However, authorization can be submitted for ongoing service by re-evaluating and including summary of statements since therapy started and treatment notes with verification of units provided since last authorization. The plan of care should be documented every 60 days. Minnesota does not require prior authorization except health services meets the some criteria listed above (e.g. if the provider is an out-of-state provider) Texas Private Insurance. For Texas private insurance, authorization periods for services depends on the benefit plans for the individual. Benefits are limited to 75 visits (standard option) or 50 visits (basic option) per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria are met. Allowed Number of Therapy Hours per Day In all 5 states, one unit of service is defined as 15 minutes of therapy service. Texas limits the number of allowed therapy hours, for OT and PT, to two hours (eight units) per day per therapy type. ST treatments are limited to one hour (four units) per day. Florida has a lower limit on the allowed number of therapy hours per day (maximum of four units per day for all therapy types combined) with an additional limit of 14 units of service per week for each therapy type. In California, similar to the private insurance in Texas, no specific limit was set on the allowed number of therapy hours per day. This depends on the individual child s medicals need and the plan of care. 4 Minnesota does not require prior authorization except for health services that meets the criteria listed above e.g if the provider is an out-of-state provider. These are typically the conditions noted in the Prior Authorization discussion for Minnesota. 11

12 Texas. Procedure codes may be billed in multiple quantities (i.e., 15 minutes each) are limited to two hours (eight units) per day for individual, group, or a combination of individual and group therapy, per therapy type (two hrs. of OT and two hrs. of PT). Each 15 minutes equals one unit. All 15-minute increment procedure codes are based on the actual amount of billable time associated with the service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units must be rounded up or down to the nearest quarter hour. The documentation retained in the client s file must include the billable start time, billable stop time, total billable minutes, and activity that was performed. For some procedures, related to occupational and physical therapy, there is a limit of one procedure per day while some procedures, related to speech therapy, are limited to two procedures per day. These services are billed on a per service provider basis versus by unit of time. Florida. For all therapy types combined, recipients may receive four units of therapy service per day. In addition, there is a limit of 14 units of service per week for each therapy discipline. California. The number of hours of therapy per day authorized for the individual child will depend upon the child s otherwise level of institutional care and upon the child s medical need, as demonstrated by the plan of care. The cost to the Medi-Cal program for community care cannot exceed the cost to the Medi-Cal program for the equivalent institutional level of care. Authorization of hours for Pediatric Day Health Care (PDHC) may be substituted for hours authorized for in-home nursing care services; but at no time shall the total number of hours for both in-home nursing care services and PDHC services should not exceed the number of hours allowed under CCR, Title 22, Section 51340(m). BlueCross BlueShield of Texas. OT or PT therapy session can vary from fifteen minutes to four hours per day, while speech language pathology treatment session is usually defined as thirty minutes to one hour of speech therapy on any given day, depending on the age and diagnosis and ability to sustain attention for therapy. Treatment sessions lasting more than one hour per day are rare in outpatient settings but may be medically appropriate for inpatient acute settings, day treatment programs, and select outpatient situations. If this is the case, sessions must be supported in the treatment plan and based on an individual's medical condition. Prescription of Services For all states in our sample and the BlueCross Blue Shield of Texas, a prescription requirement is needed before providers are reimbursed. In order to be reimbursed by Medicaid, all therapy services, including evaluations, must be prescribed by the recipient s primary care provider, an advanced registered nurse practitioner, a designated physician assistant, or a designated physician specialist. A prescription is considered current when it is signed and dated on or no later than 60 days before the start of therapy. Evaluation and Re-Evaluation Initial evaluations are used to determine the baseline functional status of an individual and to identify the need for therapeutic services to address the recipient s decreased functional abilities, capabilities, and activity level. Re-evaluations are done at varying intervals depending on the state. Re-evaluations document the progress made since the onset of therapy and modifies or redirects the intervention, if necessary. Most states limit evaluations to once every 180 days, and re-evaluations to once every 30 days. Florida limits reevaluations to once in 150 days. For BlueCross BlueShield of Texas, no calendar day limit is set on reevaluations. A reevaluation is generally indicated when there are new clinical findings, a rapid change in the individual's status, or failure to respond to therapy interventions. Texas. Physical therapy, occupational therapy, and speech therapy do not require prior authorization for evaluations and re-evaluations. Evaluations are limited to once every 180 calendar days by any provider. 12

13 Re-evaluations are limited once per 30 calendar days by any provider. An evaluation or re-evaluation performed on the same day as therapy from a different therapy type must be performed at distinctly separate times to be considered for reimbursement. If a therapy evaluation or re-evaluation procedure code and similar therapy procedure codes are billed for the same date of service by any provider, the similar therapy evaluation or re-evaluation will be denied. Procedural modifiers are not required for evaluations and reevaluations. California. California Medi-Cal does not require prior authorization for initial and six month re-evaluations for occupational therapy (billed under HCPCS code X4108) and speech therapy (billed under HCPCS code 4308). However, California does require that the recipient be eligible for Medi-Cal in the month the service is performed. In contrast, all physical therapy services (including initial and six-month re-evaluations) require prior authorization. Florida. Medicaid reimburses one initial evaluation per recipient, per discipline, per year. A recipient who has received therapy services within the previous 180 days and whose diagnosis has not changed is not eligible for an initial evaluation and must receive a re-evaluation. Medicaid reimburses one re-evaluation per recipient, per discipline, every 150 days, beginning 150 days after the initial evaluation. Re-evaluations rendered within 150 days of a previous evaluation are not reimbursable by Medicaid. Therapy visits performed on the same day as evaluations are not reimbursable. Medicaid reimburses the following Medicaid enrolled providers for evaluations: 1) Licensed physical and occupational therapists; 2) Licensed and provisionally licensed speech-language pathologists; and 3)Home health agencies that employ or contract with licensed physical and occupational therapists and speech-language pathologists. Reimbursement for writing the initial plan of care is included in the reimbursement for the evaluation. Medicaid does not reimburse for evaluations performed by therapy assistants or students. Medicaid does not accept the co-signatures by therapy assistants or students as documentation for authorization of Medicaid services. Texas Private Insurance. Initial evaluation for Therapy Services does not require prior authorization. Therapy visits following the initial evaluation and continuation of services must be authorized prior to services being rendered. Re-evaluations of therapy must be authorized prior to services being rendered. An evaluation is needed before implementing any treatment. The evaluation must include: 1) Prior functional level, if acquired condition; 2) Specific standardized and non-standardized tests, assessments, and tools; 3) Analytic interpretation and synthesis of all data, including a summary of the baseline findings in written report(s); 4) Objective, measurable, and functional descriptions of an individual's deficits using comparable and consistent methods; 4) Summary of clinical reasoning and consideration of contextual factors with recommendations; 5) Plan of care with specific treatment techniques or activities to be used in treatment sessions that should be updated as the individual's condition changes; 6) Frequency and duration of treatment plan; 7) Functional, measurable, and time-framed long-term and short-term goals based on appropriate and relevant evaluation data; 8) Rehabilitation prognosis; and 9) Discharge plan that is initiated at the start of treatment. B. COMPARATIVE CASE STUDY ANALYSIS In order to determine whether the Texas Medicaid policies differ from the Medicaid programs of other states we conducted a comparative case study analysis to examine the typical client requiring services in Texas Medicaid Managed Care and Fee-for-service, Medicaid programs in Florida, California, Minnesota, and Arizona and private insurance in Texas. The details of the case study analysis for each of the five states and Texas private insurance are summarized below in Tables 3-8. Tables are arranged such that the columns represent therapy types, if the state has 13

14 unique policies and/or processes by therapy type. This is the case for Minnesota, Arizona and California. Florida and Texas private insurance has standard processes across all three therapy types, and Texas differs by service modality, CORF/ORF versus other modalities. Starting within a specific column, the use case for each of the therapy types by state can be examined. The process flow begins with pre-authorization, proceeds to authorization, coding, re-authorization billing and documentation processes, indicating patient, provider and payer requirements throughout the Acute Therapy Episode. 14

15 Table 3. Use Case: State of Texas Medicaid Prior authorization Texas OT, PT, & ST (Comprehensive Care Program) A current written order by a physician based on medical necessity A prescription is considered current when it is signed and dated on or no later than 60 days before the start of therapy Texas OT, PT, & ST (CORF or ORF) A current written order by a physician based on medical necessity A prescription is considered current when it is signed and dated on or no later than 60 days before the start of therapy A Request for Initial Outpatient Therapy (Form TP-1) or Request for Extension of Outpatient Therapy (2 Pages) (Form TP-2) must be submitted to TMHP prior to the start of care for the current episode of therapy The most recent evaluation and treatment plan. To establish medical necessity, the written treatment plan must include the following: 1) The age of the client at the time of evaluation 2) Diagnosis 3) Description of specific therapy being prescribed 4) Specific treatment goals related to the client's individual needs. Therapy goals may include improving function, maintenance of function, or slowing of the deterioration of function A Request for Initial Outpatient Therapy (Form TP-1) or Request for Extension of Outpatient Therapy (2 Pages) (Form TP-2) must be submitted to TMHP prior to the start of care for the current episode of therapy The most recent evaluation and treatment plan. To establish medical necessity, the written treatment plan must include the following: 1) The age of the client at the time of evaluation 2) Diagnosis 3) Description of specific therapy being prescribed 4) Specific treatment goals related to the client s individual needs. Therapy goals may include improving function, maintenance of function, or slowing of the deterioration of function For an initial request, anticipated measurable progress toward goals, the prognosis, and the client's gross motor skills in years or months For a new request for additional therapy, documentation of all progress made from the beginning of the previous treatment period Duration and frequency of therapy Requested date of service For an initial request, anticipated measurable progress toward goals, the prognosis, and the client s gross motor skills in years or months For a new request for additional therapy, documentation of all progress made from the beginning of the previous treatment period Duration and frequency of therapy Requested date of service The number of sessions per week must be supported by documentation supporting the medical necessity for the frequency requested When requesting prior authorization for group occupational therapy, the provider must submit documentation supporting the group process as being medically necessary and beneficial to the client. When group therapy is authorized, weekly therapy limits will not be exceeded 15 The number of sessions per week must be supported by documentation supporting the medical necessity for the frequency requested When requesting prior authorization for group occupational therapy, the provider must submit documentation supporting the group process as being medically necessary and beneficial to the client. When group therapy is authorized, weekly therapy limits will not be exceeded

16 Authorization periods Texas OT, PT, & ST (Comprehensive Care Program) An advanced practice registered nurse (APRN) or a physician assistant may sign all documentation related to the provision therapy services on behalf of the client's physician when the physician delegates this authority to the APRN or physician assistant A request for services may be prior authorized for no longer than 180 days duration. A new request must be submitted if therapy is required for a longer duration. A procedural modifier is required when submitting claims for services. Providers must use modifier GO for OT services, GP for PT services, and GN for ST services. Procedural modifiers are not required for evaluations and reevaluations. Texas OT, PT, & ST (CORF or ORF) An advanced practice registered nurse (APRN) or a physician assistant may sign all documentation related to the provision therapy services on behalf of the client s physician when the physician delegates this authority to the APRN or physician assistant A request for services may be prior authorized for no longer than 180 days duration. A new request must be submitted if therapy is required for a longer duration A procedural modifier is required when submitting claims for services. Providers must use modifier GO for OT services, GP for PT services, and GN for ST services. Procedural modifiers are not required for evaluations and reevaluations. If a provider discontinues therapy with a client and a new provider begins therapy during an existing authorization period, submission of a new plan of care and documentation of the last therapy visit with the previous provider is required along with a letter from the client, or responsible adult, stating the date therapy ended with the previous provider If a provider discontinues therapy with a client and a new provider begins therapy during an existing authorization period, submission of a new plan of care and documentation of the last therapy visit with the previous provider is required along with a letter from the client, or responsible adult, stating the date therapy ended with the previous provider Evaluation and re-evaluation Prior authorization is not required for evaluations and reevaluations. Evaluations are limited to once every 180 calendar days any provider. Reevaluations are limited once per 30 calendar days, any provider Prior authorization is not required for evaluations and reevaluations. Evaluations are limited to once every 180 calendar days, any provider. Reevaluations are limited once per 30 calendar days, any provider An evaluation or reevaluation performed on the same day as therapy from a different therapy type must be performed at distinctly separate times to be considered for reimbursement. If a therapy evaluation or reevaluation procedure code and like therapy procedure codes are billed for the same date of service by any provider, the like therapy evaluation or reevaluation will be denied An evaluation or reevaluation performed on the same day as therapy from a different therapy type must be performed at distinctly separate times to be considered for reimbursement If a therapy evaluation or reevaluation procedure code and like therapy procedure codes are billed for the same date of service by any provider, the like therapy evaluation or reevaluation will be denied 16

17 Texas OT, PT, & ST (Comprehensive Care Program) Texas OT, PT, & ST (CORF or ORF) Allowed number of therapy hours per day Occupational and Physical therapy evaluation or reevaluation will be denied as part of the following therapy procedure codes billed with Modifiers GO and GP respectively: S8990. Speech therapy evaluation and reevaluations will be denied when billed on the same date of service by any provider, as procedure codes and with modifier GN Procedure codes that may be billed in multiple quantities (i.e., 15 minutes each) are limited to two hours (eight units) per day individual, group, or a combination of individual and group therapy, per therapy type (two hrs. of OT and two hrs. of PT). Each 15 minutes equals one unit. Speech therapy treatment codes 92507, 92508, and are payable in 15-minute increments at a maximum of four units (one hour) per day. Occupational therapy evaluation or reevaluation and Physical therapy evaluation or reevaluation will be denied as part of the following therapy procedure codes billed with Modifier GO or GP respectively. Speech therapy evaluation and reevaluations will be denied when billed on the same date of service by any provider as procedure code and with modifier GN. Procedure codes that may be billed in multiple quantities (i.e., 15 minutes each) are limited to two hours (eight units) per day of individual, group, or a combination of individual and group therapy, per therapy type (two hrs. of OT and two hrs. of PT). Each 15 minutes equals one unit. Speech therapy treatment codes 92507, 92508, and are payable in 15-minute increments at a maximum of eight units (two hours) per day. The following procedure codes are billed in 15-minute increments: S8990 The following procedure codes are billed in 15-minute increments: S8990 All 15-minute increment procedure codes are based on the actual amount of billable time associated with the service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units must be rounded up or down to the nearest quarter hour All 15-minute increment procedure codes are based on the actual amount of billable time associated with the service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units must be rounded up or down to the nearest quarter hour The documentation retained in the client s file must include the billable start time, billable stop time, total billable minutes, and activity that was performed The documentation retained in the client s file must include the billable start time, billable stop time, total billable minutes, and activity that was performed To calculate billing units, count the total number of billable minutes for the calendar day for the client, and divide by 15 to convert to billable units of service. If the total billable minutes are not evenly divisible by 15, minutes greater than 7 are converted to 1 unit and 7 or fewer minutes are converted to 0 unit To calculate billing units, count the total number of billable minutes for the calendar day for the client, and divide by 15 to convert to billable units of service. If the total billable minutes are not evenly divisible by 15, minutes greater than 7 are converted to 1 unit and 7 or fewer minutes are converted to 0 unit 17

18 Texas OT, PT, & ST (Comprehensive Care Program) Texas OT, PT, & ST (CORF or ORF) The following procedure codes (97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97150) are limited to once per day, for each therapy type (OT and PT). Speech procedure codes and are limited to two procedures per day, for different procedures, billed by the same provider or provider group. If procedure code is billed with an office visit on the same date of service by the same provider, the office visit will be denied. Procedure code will be denied if billed on the same date of service by the same provider as procedure code Electrical stimulation therapy (procedure code 97032) may be considered with documentation of medical necessity. Procedure code will be denied if billed on the same date of service by the same provider as procedure code Electrical stimulation therapy may be considered with documentation of medical necessity 18

19 Table 4. Use Case: State of Florida Medicaid Prior authorization Authorization periods Approval process Approved Request Florida Physical, occupational therapy, and speech-language pathology services require prior authorization for reimbursement. The request must be submitted to the Medicaid Quality Improvement Organization (QIO) via its Web-based Internet system. All required documentation to support the request must be submitted directly to the QIO at the time of the request For initial service requests, it is recommended that the therapy services provider submit the request to the QIO at least ten business days prior to the start of care. For subsequent authorization requests (continued stay requests), the therapy services provider must submit the request to the QIO at least ten business days prior to the new certification period The earliest effective date of the authorization is the date the request is received by the Medicaid QIO When requesting prior authorization, each therapy provider is responsible for informing the QIO of other therapy providers also providing services to the recipient To be reimbursed by Medicaid, all therapy services, including evaluations, must be prescribed by the recipient s primary care provider, an advanced registered nurse practitioner (ARNP), a designated physician assistant (PA), or a designated physician specialist Minimum requirements for each prescription request: 1) Recipient s name, address, date of birth, and Medicaid ID number 2) Recipient s diagnosis or diagnoses contributing to the need for therapy 3) Therapy provider s Medicaid provider number, name and address 4) Procedure code(s), with modifier(s) if applicable, matching the services reflected in the plan of care 5) Units of service requested 6) Duration and frequency of the therapy treatment period 7) Summary of the recipient s current health status, including diagnosis(es) 8) Planned dates and times of service 9) Ordering provider s Medicaid provider number, National Provider Identifier, or Florida medical license number, name, and address 10) Signature of the prescribing provider 11) Date of prescription 12) Specific type of evaluation or service requested 13) The complete evaluation and plan of care, reviewed, signed and dated by the primary care provider, ARNP or PA designee, or designated physician specialist 14) Patient condition summaries that substantiate medical necessity and the need for requested services, such as a hospital discharge summary (if services are being requested as a result of a hospitalization), physician or nurse progress notes, or history and physical 15) A copy of the documentation demonstrating the recipient has been examined or received medical consultation by the ordering or attending physician before initiating services and every 180 days thereafter The QIO will authorize service up to a 180 day period If the prescription has not been received before the service is rendered, Medicaid will not reimburse for the service Prescriptions to evaluate recipients are valid for up to 60 days The QIO will review each prior authorization request and approve, deny or request additional information to support the request Prior authorization requests for therapy services that appear to deviate from treatment norms, established standards of care, or utilization norms may be subject to a more intensified review by the QIO prior to rendering a determination When the request is approved, the approval will contain a prior authorization number for billing and reference An approved request is not a guarantee that Medicaid will reimburse the services The provider and recipient must be eligible on the date of service, and the service must not have exceeded any applicable service limits 19

20 Recipients Exempt from Prior Authorization Evaluations and Reevaluations Plan of Care Requirements Plan of Care Approval Recipients who are members of a Medicaid Health Maintenance Organization (HMO); and,recipients who are members of a Medicaid Provider Service Network (PSN). Medicaid reimburses one initial evaluation per recipient, per discipline, per year A recipient who has received therapy services within the previous 180 days and whose diagnosis has not changed is not eligible for an initial evaluation and must receive a re-evaluation Medicaid reimburses one re-evaluation per recipient, per discipline, every 150 days, beginning 150 days after the initial evaluation Re-evaluations rendered within 150 days of a previous evaluation are not reimbursable by Medicaid Therapy visits performed on the same day as evaluations are not reimbursable Medicaid reimburses the following Medicaid enrolled providers for evaluations: 1) Licensed physical and occupational therapists 2) Licensed and provisionally licensed speech-language pathologists Home health agencies that employ or contract with licensed physical and occupational therapists and speechlanguage pathologists Reimbursement for writing the initial plan of care is included in the reimbursement for the evaluation Medicaid does not reimburse for evaluations performed by therapy assistants or students. Medicaid does not accept the co-signatures by therapy assistants or students as documentation for authorization of Medicaid services After the therapist or speech-language pathologist performs the initial evaluation of a recipient, and before providing services, the therapist or speech language pathologist must write an initial plan of care for the recipient based on the results of the initial evaluation If any amendments to the plan of care are necessary, those amendments must be made by the therapist and must be reviewed, approved and signed by the primary care provider before service is provided The therapist must review the plan of care every 180 days or prior to the end of the authorization period and make necessary revisions The therapist and the primary care provider, ARNP or PA designee, or designated physician specialist who prescribed the therapy must retain a copy of the plan of care in his or her records for the recipient The plan of care may suffice as a prescription if the signed plan of care indicates that the plan of care is to serve as a prescription and all prescription requirements are met The plan of care must be reviewed, signed and dated by the therapist and by the primary care provider, ARNP or PA designee, or designated physician specialist who prescribed the therapy The prescriber s signature indicates approval of the plan of care The prescriber must review, certify, and sign the renewed plan of care, based on the recipient s re-evaluation, before the end of the authorization period If the plan of care has not been signed and approved before the service is rendered, Medicaid will not reimburse for the service 20