Brain Injury

The Department of Human Services (DHS) has published a notice that includes proposed changes to the Medical Assistance Fee Schedule for the Aging, COMMCARE, Independence, and OBRA Waivers in the Pennsylvania Bulletin.

The Office of Long-Term Living (OLTL) is proposing to add the following employment services to three of its waivers listed below:

  • COMMCARE waiver – Benefits Counseling, Career Assessment, Employment Skills Development, Job Coaching Intensive, and Follow-along and Job Finding.
  • Independence waiver – Benefits Counseling, Career Assessment, Employment Skills Development, Job Coaching Intensive, and Follow-along and Job Finding.
  • OBRA waiver – Benefits Counseling, Career Assessment, Employment Skills Development, Job Coaching Intensive, and Follow-along and Job Finding.

DHS has developed Medical Assistance (MA) fee schedule rates for the additional services added to these waivers. The proposed MA Fee schedule rates are available for review.

Comments regarding the notice and the proposed MA fee schedule rates will be accepted until Monday, October 3, 2016, and should be sent to: Department of Human Services, Office of Long-Term Living, Bureau of Policy and Regulatory Management, Attn: HCBS Rates, PO Box 8025, Harrisburg, PA 17105-8025. Comments can also be sent via email.

Register now for RCPA on the Move, the 2016 annual conference. Early bird registration ends on Friday, September 2. The conference theme is focused on helping RCPA members move forward by developing opportunities and innovations to lead the way for Pennsylvania.

An interactive registration brochure has been prepared for download to provide essential information on the go. The conference website is available with information about all scheduled activities and details about workshops, exhibitors, and other events. Online registration is available both directly from this link and through the conference website.

  • Remember to make your hotel reservations before the room block expires on Monday, September 5.
  • Attendees will find the final agenda, workshops, and handouts through the conference website, and be able to access the RCPA mobile app, on or about September 16.

Mark your calendars for September 27–30 and join the Conference Committee, Board of Directors, and staff at the Hershey Lodge. Questions about the conference may be directed to Sarah Eyster, conference coordinator, or Tieanna Lloyd, conference registrar.

The Departments of Human Services (DHS) and Aging just announced their selection of three managed care organizations (MCOs) for Community HealthChoices (CHC). CHC will coordinate physical health and long-term services and supports (LTSS) to individuals who are dually eligible for Medicare and Medicaid, older Pennsylvanians, and individuals with disabilities.

Through a review of a request for proposals, the following MCOs have been selected to proceed with negotiations to deliver services statewide in Pennsylvania beginning in 2017:

  • AmeriHealth Caritas
  • Pennsylvania Health and Wellness (Centene)
  • UPMC for You

CHC will roll out in three phases. Persons eligible for CHC are individuals aged 21 or older who have both Medicare and Medicaid, or who receive long-term services and supports through Medicaid because they need help with everyday activities of daily living.

An RCPA Info was issued on August 18, 2016 regarding a project that was announced by the Centers for Medicare and Medicaid Services (CMS) specific to the development and maintenance of a post-acute care (PAC) cross-setting standardized assessment data. Originally, the comment deadline on this project was set for August 26, 2016. Due to concerns voiced to CMS regarding a two-week comment period, the deadline has now changed. The comment period on this project has now been extended to Monday, September 12, 2016.

On August 15, 2016, the Centers for Medicare and Medicaid Services (CMS) posted to their public comment page, Development and Maintenance of Post-Acute Care (PAC) Cross-Setting Standardized Assessment Data, with a request for comment deadline of August 26, 2016.

This project involves CMS contracting with RAND to develop standardized assessment-based data items to meet the requirements as set forth under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, Section 2(a). Development of standardized data items includes conducting environmental scans of the evidence, data item conceptualization, drafting data item specifications, convening technical expert panels, and feasibility piloting.

The Centers for Medicare & Medicaid Services (CMS) seeks comments from stakeholders on data items that meet the IMPACT Act domains of: cognitive function and mental status; special services, treatments, and interventions; medical conditions and co-morbidities; and impairments. In addition to general comments, CMS is specifically interested in public feedback regarding the topics below:

  • Potential for improving quality: includes consideration of the data element’s ability to improve care transitions through meaningful exchange of data between providers; improve person-centered care and care planning; be used for quality comparisons; and support clinical decision-making and care coordination;
  • Validity: includes consideration of the data element’s proven or likely inter-rater reliability (i.e., consensus in ratings by two or more assessors) and validity (i.e., whether it captures the patient attribute being assessed);
  • Feasibility for use in PAC: includes consideration of the data element’s potential to be standardized and made interoperable across settings; clinical appropriateness; and relevance to the work flow across settings; and
  • Utility for describing case mix: includes whether the data element could be used with different payment models, and whether it measures differences in patient severity levels related to resource needs.

Comments may be submitted on the entire set of data elements or specific to individual data elements and should be sent via email or to:

RAND Corporation
1200 South Hayes Street
Arlington, VA 22202-5050
Attn: Barbara Hennessey, W7E

The Centers for Medicare and Medicaid Services (CMS) released the fiscal year (FY) 2017 inpatient rehabilitation facility (IRF) prospective payment system (PPS) final rule in today’s Federal Register.

The majority of the final rule focuses on changes in the IRF Quality Reporting Program (QRP), pursuant primarily to the requirements of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. The rule continues to address implementation of the IMPACT Act requirements regarding resource use and quality measures, adding five new measures to the IRF QRP. Four measures will begin October 1, 2016, and are collected from Medicare claims data, so no additional reporting action from providers is required. These four measures include:

  • Discharge to Community – Post-Acute Care (PAC) IRF QRP (claims-based);
  • Medicare Spending Per Beneficiary (MSPB) – PAC IRF QRP (claims-based);
  • Potentially Preventable 30 Day Post-Discharge Readmission Measure for IRFs (claims-based); and
  • Potentially Preventable Within Stay Readmission Measure for IRFs (claims-based).

The remaining measure, Drug Regimen Review Conducted with Follow-up for Identified Issues, will begin October 1, 2018, and will require additional items on the IRF Patient Assessment Instrument (IRF PAI).

Other key provisions included in the final rule:

Standard Payment Rate
The standard payment rate conversion factor will increase in FY 2017 to $15,708, compared to the proposed amount of $15,674. This amount is the result of a 2.7 percent rehabilitation-specific market basket increase, minus a productivity adjustment of 0.3 percent and a 0.75 percent ACA adjustment. The FY 2016 standard payment rate conversion factor was $15,478.

CMS used the rehabilitation market basket for the first time. It was adopted last year. The standard payment update also accounts for budget neutrality factors for the wage index and labor related share of 0.9992 and for the CMG weight revisions of 0.9992 plus changes to the outlier threshold. Table 5 in the rule (not reproduced here) displays the FY 2017 payment rates.

Update to the CMG Weights, Lengths of Stay, and Comorbidities
CMS updated the Case Mix Group (CMG) weights using FY 2014 cost report data and the FY 2015 claims data as well as the average lengths of stay (ALOS) per CMG. Approximately 99.5 percent of the cases affected by the change in weights would be changed by less than 5 percent.

Outlier Threshold
CMS updates the outlier threshold amount to $7,984 from $8,658 for FY 2016 in order to maintain the outlier payments at three percent of total IRF payments in FY 2017. The national cost-to-charge ratio ceiling for FY 2017 is 1.29; the ceiling for rural IRFs is 0.522 and 0.421 for urban IRFs.

ICD-10-CM Presumptive Compliance Coding Changes
Unfortunately, CMS did not address the problems with the ICD-10-CM codes which eliminated certain key diagnoses from being allowed for consideration in calculating a provider’s presumptive compliance in meeting the 60 percent rule. The largest set of affected codes fall into the area of brain injury under IGCs 2.21 and 2.22.

CMS did, however, comment that IRFs are permitted to use “D” as an eligible seventh character for traumatic brain injury diagnosis codes on both the claim and the IRF PAI. However, for the reasons indicated in the FY 2015 IRF PPS final rule effective with discharges occurring on or after October 1, 2015, ICD-10-CM codes with the seventh character extension of “D” are not included in the ICD-10-CM versions of the “List of Comorbidities,” “ICD-10-CM Codes That Meet Presumptive Compliance Criteria,” or “Impairment Group Codes That Meet Presumptive Compliance Criteria.”

The payment changes to the rule will apply to IRF discharges on or after October 1, 2016 and before September 30, 2017. The quality reporting requirements are effective for discharges on or after October 1, 2106.

A more complete analysis of the rule will be forthcoming and reviewed/discussed extensively at the upcoming RCPA Outpatient Rehabilitation Committee meeting on Thursday, August 18, 2016, and the Medical Rehab Committee meeting on Thursday, September 8, 2016.

The Centers for Medicare and Medicaid Services (CMS) published a proposed rule in the August 2, 2016 Federal Register that proposes to implement three new Medicare Parts A and B episode payment models under section 1115A of the Social Security Act, which are meant to improve quality and lower cost. The proposed rule includes a new mandatory bundled payment model for cardiac care in 98 geographical markets for patients who have a heart attack or undergo bypass surgery. The rule would also extend the existing bundled payment model for hip and knee replacements – the Comprehensive Care for Joint Replacement model – to include hip and femur surgeries. Also proposed are new incentive payments designed to increase the use of cardiac rehabilitation. Additionally, new pathways are outlined for physicians participating in bundled payment models to qualify for payment incentives under the proposed Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act (MACRA). CMS issued a fact sheet to provide more detailed information on the key provisions of this proposed rule. Comments are due by October 3, 2016.

Conference registration brochure is here!

Registration for RCPA on the Move, the 2016 annual conference, is open. There are multiple ways to register and significant discounts available to those registering by September 2. The conference theme is focused on moving RCPA members forward in developing opportunities and innovations to lead the way for Pennsylvania.

The robust conference agenda brings ample opportunities to learn and dialogue, with stellar speakers to offer a variety of stimulating and timely information. This event features more than 60 workshops; a keynote; five stimulating and thought-provoking plenaries; a vibrant Exhibit Hall; networking events; time to interact with colleagues; and opportunities for creative thinking to inspire passion and drive change.

An interactive registration brochure has been prepared for download to provide essential information on the go. Links in the brochure are internal to the document as well as external to the conference website to provide additional information. The conference website is available with complete information about all scheduled activities and details about workshops, exhibitors, and other events. Online registration is available both directly from the link and through the conference website.

Mark your calendar for September 27–30 and join the Conference Committee, Board of Directors, and staff at the Hershey Lodge. Questions about the conference may be directed to Sarah Eyster, conference coordinator, or Tieanna Lloyd, conference registrar.

In an effort to reduce the large backlog of Medicare coverage and payment appeals, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would revise the procedures the Department of Health and Human Services (HHS) would follow at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations. This proposed rule covers items and services provided to Medicare beneficiaries, enrollees in Medicare Advantage and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, the proposed rule would revise procedures that HHS would follow at CMS and the Medicare Appeals Council levels of appeal for certain matters affecting the ALJ level. As of April 2016, the Office of Medicare Hearings and Appeals (OMHA) had over 750,000 pending appeals, while OMHA’s adjudication capacity was 77,000 appeals per year, with an additional adjudication capacity of 15,000 appeals per year expected by the end of the current fiscal year. The proposed rule includes provisions to expand the pool of available OMHA adjudicators and improve the efficiency of the appeals process by streamlining the processes so less time is spent by adjudicators and parties on repetitive issues and procedural matters. The proposed rule was published in the July 5, 2016 Federal Register. Comments are due by Monday, August 29, 2016.