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Medical Rehab

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Today, the following important notice was issued by the American Medical Rehabilitation Providers Association (AMRPA) regarding a historic appeal settlement that they, along with the FAIR Fund and the Federation of American Hospitals, reached with the Centers for Medicare and Medicaid Services (CMS) that will allow inpatient rehabilitation facilities (IRFs) to settle their pending Medicare appeals.

Today CMS, AMRPA, the FAIR Fund, and the Federation of American Hospitals announced that an agreement has been reached with CMS which will allow IRFs to settle their pending Medicare appeals. For most pending claims, providers will be able to settle their pending appeals for 69% of the net payable amount of the claim. This is the highest percentage global settlement CMS has ever agreed to. In addition, some claims, such as those denied for failing to justify the use of group therapy, can be settled at 100% of the net payable amount. Here are some of the key things AMRPA members should know:

  • The settlement is voluntary. Providers can choose whether to settle their claims or continue to exercise their appeal rights.
  • Providers choosing to settle claims will receive 69% of the net payable amount (Medicare approved amount, less any applicable deductible or co-insurance).
  • Claims denied solely on the basis of threshold of therapy time not being met (3-hour or 15-hour rule), where the claim did not undergo further review for medical necessity, will be paid at 100% of the net payable amount. Claims denied solely because justification for group therapy was not documented will also be paid at 100% of the net payable amount.
  • If participating in the settlement, providers must settle all currently pending appeals. Providers cannot choose only select claims to settle.
  • To be eligible for settlement, the claim must have been denied in full, and the denial must have been appealed on or before August 31, 2018. The appeal must also still currently be pending at any level of appeal, and appeal rights must not have been exhausted at time of settlement.

Providers should read the entire template agreement for additional important details. CMS has provided instructions for how providers can participate in the settlement on its website.

This settlement was reached due to the diligent efforts of AMRPA’s sister organization, the FAIR Fund, in collaboration with AMRPA and the Federation of American Hospitals. AMRPA would especially like to thank longtime counsel to AMRPA and the FAIR Fund, Peter Thomas and Ron Connelly of Powers Law Firm, whose dedication to the rehabilitation field led to this historic settlement.

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

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The Centers for Medicare and Medicaid Services (CMS) has issued a press release with a Request for Information (RFI) seeking new ideas from the public on how to continue progress of the Patients Over Paperwork Initiative to be published in the June 11, 2019 Federal Register. The initiative was originally launched in the fall of 2017. Since that time, CMS estimates that through regulatory reform alone, the health care system will save an estimated 40 million hours and $5.7 billion through 2021. These estimated savings come from both final and proposed rules.

This RFI invites patients and their families, the medical community, and other health care stakeholders to recommend further changes to rules, policies, and procedures that would shift more of clinicians’ time — and our health care system’s resources — from needless paperwork to high quality care that improves patient health. CMS is especially seeking innovative ideas that broaden perspectives on potential solutions to relieve burden and ways to improve:

  • Reporting and documentation requirements;
  • Coding and documentation requirements for Medicare or Medicaid payment;
  • Prior authorization procedures;
  • Policies and requirements for rural providers, clinicians, and beneficiaries;
  • Policies and requirements for dually enrolled (i.e., Medicare and Medicaid) beneficiaries;
  • Beneficiary enrollment and eligibility determination; and
  • CMS processes for issuing regulations and policies.

Comments on this initiative must be submitted by August 12, 2019. For additional information, visit the Patients over Paperwork page on the CMS website.

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The Centers for Medicare and Medicaid Services (CMS) has published a new “Outpatient Rehabilitation Therapy Services: Complying with Medicare Billing Requirements” booklet. Outpatient rehabilitation therapy services include physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services.

The booklet describes common outpatient rehabilitation therapy services Comprehensive Error Rate Testing (CERT) program errors, how CMS calculates improper payment rates, the necessary documentation to support billed Medicare Part B claims; and managing potential overpayments. Contact Melissa Dehoff, RCPA Rehabilitation Services Director, with questions.

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The Centers for Medicare and Medicaid Services (CMS) identified a typographical error in the publication of the fiscal year (FY) 2020 inpatient rehabilitation facility prospective payment system (IRF PPS) proposed rule that was published in the April 24, 2019 Federal Register. The error was in the calculation of the estimated burden for the IRF quality reporting program (QRP).

On page 17329 of the proposed rule it states, “Specifically, we believe that there will be an addition of 7.4 minutes on admission, and 11.1 minutes on discharge, for a total of 8.9 minutes of additional clinical staff time to report data per patient stay.” This sentence should have stated, “Specifically, we believe that there will be an addition of 7.8 minutes on admission, and 11.1 minutes on discharge, for a total of 18.9 minutes of additional clinical staff time to report data per patient stay.”

The final values and the overall burden proposed in the rule are correct despite these minor typographical errors. CMS will correct the figures in the final rule. A technical correction will not be issued due to the nature of the errors.

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

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The United States Senate Committee on Finance will conduct a full committee hearing (Medicare Physician Payment Reform After Two Years: Examining MACRA Implementation and the Road Ahead) on Wednesday, May 8, 2019 at 10:15 am. The purpose of the hearing will be to assess if the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 has been successful in reforming physician payments. Witnesses scheduled to present information during the hearing include individuals from: American Medical Association, American Academy of Family Physicians, American College of Surgeons, American Medical Group Association, and Brookings Institution.

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The Centers for Medicare and Medicaid Services (CMS) recently announced the Primary Cares Initiative, which includes a new set of payment models that will transform primary care to deliver better value for patients throughout the health care system. The initiative will seek to reduce administrative burdens and empower primary care providers to spend more time caring for patients while reducing overall health care costs. The initiative will be administered through the Center for Medicare and Medicaid Innovation (CMMI) under two paths: Primary Care First (PCF) and Direct Contracting (DC). The PCF payment models are focused on individual primary care providers, while the DC payment model options target a wider range of organizations that are capable of tending to larger patient populations and are experienced in handling financial risk, such as Medicaid managed care organizations, accountable care organizations, and Medicare Advantage plans.

The PCF models will be tested for five years and are currently scheduled to begin in January 2020. The DC models are expected to launch for a performance period in January 2021. CMS is seeking public comment on the DC model with comments being accepted until May 23, 2019.

Additional information is provided on the CMS website, including dates/times for webinars for interested stakeholders.

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The Centers for Medicare and Medicaid Services (CMS) released the proposed rule for the inpatient rehabilitation facility prospective payment system (IRF PPS) for fiscal year (FY) 2020.

Some of the key proposals in the rule include:

  • Net Payments: Net payments for IRF’s would increase by 2.3 percent, including a 3.0 percent market basket update, offset by a statutorily mandated cut of 0.5 percentage points for productivity, and a 0.2 percent decrease in outlier payments. This update reflects the proposed revision and rebasing of the market basket using data from 2016 as the base year instead of 2012.
  • Case-Mix Revisions: The Functional Independence Measure (FIM) and Functional Modifier items were removed from the IRF Patient Assessment Instrument (PAI) as finalized in the FY 2019 IRF PPS final rule. CMS also indicated that the FY 2020 case-mix groups (CMGs) would be based on a patient’s motor function, age, memory function, and communication function. However, in this proposed rule CMS made the decision not to include the communication and memory scores because their inclusion in the CMG definitions resulted in lower payments for patients with cognitive deficits (based on their analysis of two years of data).
  • Outlier Threshold and Cost-to-Charge Ratio: CMS proposes to update the outlier threshold amount from $9,402 for FY 2019 to $9,935 for FY 2020 to ensure outlier payments account for 3 percent of total payments, as they did for FY 2019. CMS notes that its initial analysis showed that outlier payments would be 3.2 percent and made the above proposed adjustment to maintain it at 3 percent.
  • Rehabilitation Physician Definition: CMS proposes to clarify that compliance with the regulatory definition of “rehabilitation physician” (a licensed physician with specialized training and experience in inpatient rehabilitation) will be determined by the IRF. Currently, the regulations do not specify the level or type of training or experience that are required to satisfy this criteria.
  • Proposed Changes to IRF Quality Reporting Program (QRP): CMS proposes to adopt two measures to the IRF QRP with data collection for discharges beginning October 1, 2020.
  • Transfer of Health Information to the Provider
  • Transfer of Health Information to the Patient

Transfer of Health Information is a required domain of the IMPACT Act and CMS has been developing these measures since 2016. The measures are process-based measures that assess if a “current reconciled medication list” is given to either the subsequent provider or to the patient/family/caregiver when the patient is discharged or transferred from his or her current PAC setting. CMS proposes to start collecting the measure via the IRF-PAI for discharges beginning October 1, 2020.

  • Proposed Revision to Discharge to Community Measure: CMS proposes to revise the Discharge to Community post-acute care measure to exclude baseline nursing facility (NF) residents from the measures beginning with the FY 2020 IRF QRP due to stakeholder recommendations.

CMS proposes to define baseline NF residents as those who had a long-term NF stay in the 180 days preceding their hospitalization and IRF stay.

  • Proposed Standard Patient Assessment Data Elements (SPADEs): This proposal is slated for reporting beginning in October 2020. In line with the IMPACT Act, CMS is required to develop and collect standardized patient assessment data in PAC settings. In this rule, CMS proposes to adopt ”many of” the standardized patient assessment data elements (SPADEs) it had previously proposed in the FY 2018 IRF PPS proposed rule, as well adopt new SPADEs on social determinants of health. Some proposed items, such as the Brief Interview of Mental Status (BIMS), are currently on the IRF-PAI, in which case CMS is proposing to formally adopt them as SPADEs. However, most of the proposed items would entail adding new, additional reporting elements to the IRF-PAI.
  • Proposal to Collect All-Payer IRF PAI Data: CMS proposes to expand the reporting of the IRF-PAI data to include data on all patients, regardless of their payer, beginning with patients discharged on or after October 1, 2020.

The proposed rule will be published in the April 24, 2019 edition of the Federal Register. Comments on the provisions contained in the proposed rule will be accepted until June 17, 2019. Contact Melissa Dehoff, RCPA Rehabilitation Services Director, with questions.

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2019 marks the official 18th anniversary of Sexual Assault Awareness Month (SAAM) — but did you know we can trace its history even further back?

Even before its official declaration, SAAM was about both awareness and prevention of sexual assault, harassment, and abuse. Looking at the history of the movement to end sexual violence, it’s clear why: it’s impossible to prevent an issue no one knows about, and it’s difficult to make people aware of a problem without providing a solution. The two work in tandem, and they always have. From the civil rights movement to the founding of the first rape crisis centers to national legislation and beyond, the roots of SAAM run deep.

Roots of the Movement
As long as there have been people who care about making the world a better place, there have been individuals advocating for sexual assault prevention. In the United States, movements for social change and equality began to gain traction in the 1940s and 50s with the civil rights era. Although open discussion of the realities of sexual assault and domestic violence were limited at these times, activists for equal rights began to challenge the status quo.

Sexual Assault Awareness Month is about more than awareness — the ultimate goal is prevention. Since consent is a clear, concrete example of what it takes to end sexual harassment, abuse, and assault, this year’s theme centers on empowering all of us to put consent into practice. The campaign theme, I Ask, champions the message that asking for consent is a healthy, normal, and necessary part of everyday interactions.

Sexual assault is a serious and widespread problem. Nearly one in five women in the US have experienced rape or attempted rape at some time in their lives, and one in 67 American men have experienced rape or attempted rape. When we talk about prevention, we mean stopping sexual violence before it even has a chance to happen. This means changing the social norms that allow it to exist in the first place, from individual attitudes, values, and behaviors to laws, institutions, and widespread social norms. Prevention is everyone’s responsibility: All of us can create and promote safe environments. We can intervene to stop concerning behavior, promote and model healthy attitudes and relationships, and believe survivors and assist them in finding resources.

The National Sexual Violence Resource Center (NSVRC) is the leading nonprofit in providing information and tools to prevent and respond to sexual violence. NSVRC translates research and trends into best practices that help individuals, communities, and service providers achieve real and lasting change. The center also works with the media to promote informed reporting. Every April, NSVRC leads Sexual Assault Awareness Month (SAAM), a campaign to educate and engage the public in addressing this widespread issue.

Be sure to share your sexual assault awareness programs and activities on social media, and feel free to share on the RCPA Facebook page and Twitter feed as well.

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