Brain Injury

0 52

Yesterday, the US Department of Health and Human Services (HHS) announced a new payment model for emergency ambulance services that aims to allow Medicare fee-for-service (FFS) beneficiaries to receive the most appropriate level of care, at the right time and place, with the potential for lower out-of-pocket costs.

Beginning in early 2020, the new model – Emergency Triage, Treat, and Transport (ET3) Model – will make it possible for participating ambulance suppliers and providers to partner with qualified health care practitioners to deliver treatment in place (either on-the-scene or through telehealth), and with alternative destination sites (such as primary care doctors’ offices or urgent-care clinics), to provide care for Medicare beneficiaries following a medical emergency for which they have accessed 911 services. In doing so, the model seeks to engage health care providers across the care continuum to more appropriately and effectively meet beneficiaries’ needs. Additionally, the model will encourage development of medical triage lines for low-acuity 911 calls in regions where participating ambulance suppliers and providers operate. The ET3 Model will have a five-year performance period, extending through 2025.

Currently, Medicare primarily pays for unscheduled, emergency ground ambulance services when beneficiaries are transported to a hospital emergency department (ED), creating an incentive to transport all beneficiaries to the hospital even when an alternative treatment option may be more appropriate. To counter this incentive, the ET3 Model will test two new ambulance payments, while continuing to pay for emergency transport for a Medicare beneficiary to a hospital ED or other destination covered under current regulations:

  • Payment for treatment in place with a qualified health care practitioner, either on-the-scene or connected using telehealth; and
  • Payment for unscheduled, emergency transport of Medicare beneficiaries to alternative destinations (such as 24-hour care clinics) other than destinations covered under current regulations (such as hospital EDs).

The ET3 Model encourages high-quality provision of care by enabling participating ambulance suppliers and providers to earn up to a five percent payment adjustment in later years of the model based on their achievement of key quality measures. The quality measurement strategy will aim to avoid adding more burden to participants, including minimizing any new reporting requirements. Qualified health care practitioners or alternative destination sites that partner with participating ambulance suppliers and providers would receive payment as usual under Medicare for any services rendered.

The model will use a phased approach through multiple application rounds to maximize participation in regions across the country. In an effort to ensure access to model interventions across all individuals in a region, CMS will encourage ET3 Model participants to partner with other payers, including state Medicaid agencies.

Contact Melissa Dehoff, RCPA Director of Rehabilitation Services, with questions.

0 21

On February 11, 2019, the Office of Long-Term Living (OLTL) released Bulletin 59-19-03, Hearings and Appeals. The bulletin provides the responsibilities of Service Coordination Entities (SCEs) with respect to the notice and fair hearing requirements. Also included with the bulletin are the following attachments:

  1. MA 561 – Notice of Service Determination and the Right to Appeal
  2. MA 562 – Decision to Withdraw an Appeal Request
  3. MS 561 – MA 561 Form Instructions for Service Coordinators
  4. Bureau of Hearings and Appeals Agency Appeal Cover Sheet
  5. Bureau of Hearings and Appeals Agency Appeal Cover Sheet Instructions
  6. OHA 147 – Bureau of Hearings and Appeals Agency Expedited Information Sheet
  7. BHA Regions Chart

The bulletin is updated to reflect expedited appeals requirements that were established by the Medicaid Eligibility Final Rule and can be found in 42 CFR Part 431.224. The SCEs are responsible to understand the rights and procedures set forth in the state regulations and federal regulations. The bulletin highlights the many requirements of the SCEs.

OLTL has scheduled a webinar for Monday, February 25, 2019 at 2:00 pm to answer questions SCEs may have in relation to this bulletin. Please register here. After registering, you will receive a confirmation email containing information about joining the webinar. Contact Melissa Dehoff, RCPA Director of Rehabilitation Services, with questions.

0 93

The Pennsylvania Department of Health (DOH) published a notice in the January 26, 2019 Pennsylvania Bulletin indicating that effectively immediately, they will begin accepting applications to the Head Injury Program (HIP) for individuals 18 years of age and older.

The HIP, administered in the Bureau of Family Health (BFH), through the Emergency Medical Services Act of 1985, funds short-term intensive brain injury rehabilitation for residents in this Commonwealth who have sustained a traumatic brain injury.

To provide these services, the HIP contracts with specialized brain injury providers who offer therapies such as physical, occupational, speech, and cognitive therapies, along with assistive community integration and psychological services. Rehabilitation services can be received in a residential setting as outpatient services or as home-based and community-based services depending on the need of the individual.

To obtain an application, contact the HIP at 717-772-2763 or the Brain Injury Helpline at 866-412-4755.

0 35

Today, the Office of Long-Term Living (OLTL) issued a survey to all residential habilitation providers to obtain information regarding 2017 utilization and the definition of a day unit. The link to the survey is below and all residential habilitation providers are strongly encouraged to complete it.

This issue is one that the brain injury providers have been asking OLTL to address and change for years. Fewer responses to this survey will prevent Mercer from having sufficient data to estimate the cost associated with making the change to the service definition that the Centers for Medicare and Medicaid Services (CMS) requires when requesting an amendment.

The responses to the survey are due by February 22, 2019. Please do not delay and respond today!

Please contact Mike Penney at OLTL if you have any issues completing the survey.

RCPA partnered with the Pennsylvania Client Assistance Program, PA APSE, and PAR to send a letter to OVR Acting Executive Director Ryan Hyde, Labor and Industry Secretary Jerry Oleksiak, Governor’s Secretary of Legislative Affairs Will Danowski, and Governor’s Secretary of Policy Meg Snead, expressing our serious concern regarding the January 10 memo, as well as actions taken by various OVR district offices, affecting funding of Pre-Employment Transition Services (PETS) in calendar year 2019.

Many providers of PETS services have reported the loss of funding for programs that were in place or about to launch at the beginning of 2019. This action has had a negative impact on a large number of students across the Commonwealth, as well as schools, teachers, families, and providers of services who have invested time and resources.

View a copy of the letter and impact statements. Contact RCPA IDD Division Director Carol Ferenz with questions.

0 124

The next Community HealthChoices (CHC) Third Thursday webinar has been scheduled for January 17, 2019, 1:30 pm – 3:00 pm. Some of the agenda topics to be included during this webinar include updates from Deputy Secretary Kevin Hancock on the initial CHC implementation efforts in the Southeast; and Randy Nolen will lead a discussion on launch indicators and Operations Reports data. In addition, the Office of Long-Term Living (OLTL) Chief Medical Officer, Dr. Lawrence Appel, will present on quality activities and performance measures in the Southwest from the first year of CHC.

To participate in the webinar, participants need to register. After participants register, a confirmation email will be sent containing information about joining the webinar.

Questions should be directed to the OLTL Bureau of Policy and Regulatory Management at 717-857-3280.

0 69

The Office of Long-Term Living (OLTL) issued a billing clarification for Cognitive Rehabilitation Therapy (CRT) Procedure Code 97127 SE.

This procedure code can be billed by either billing each date of service separately per claim or by billing each date of service on separate detail lines of a date spanned claim.


Billing each date of service separately per claim:

Would mean billing each date of service for each recipient for this procedure code individually. Each date is recognized as a new claim and will have a different ICN.

Billing each date of service on separate detail lines of a date spanned claim:

Would mean span dating the dates of service from one date to another date. At the bottom of the claims each date of service is a different line or number. This will show each day on a different line in the detail section of the claim.

Providers should continue to use the SE modifier per the OLTL fee schedule.

Questions regarding this clarification should be directed to the OLTL Provider Inquiry Unit via email or 800-932-0939.

0 115

The Community Relations Manager for the Pennsylvania Independent Enrollment Broker (IEB) program (aka Maximus) has provided a map of Outreach Coordinators on the team and their coverage areas. This information was requested during the December 19, 2018 RCPA Physical Disabilities and Aging Division meeting.

Please Note: Jennifer Borgess in the North Central Region (shown in green on the map) is leaving the PA IEB (her last day will be January 4, 2019). Until a replacement is found for this region, if someone in that region reaches out to the PA IEB, please copy Joan Landis (Community Relations Manager) and Jahd Burns (her team supervisor) to ensure the issue is addressed by someone. Once a new coordinator in that area is hired and trained to take over this region, an updated map will be issued.

Contact Melissa Dehoff, RCPA Rehabilitation Services Director, with questions.