Policy Areas

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On May 3, 2016, the Centers for Medicare and Medicaid Services (CMS) issued an update to the additional documentation request (ADR) limits for Medicare institutional providers under the Medicare fee-for-service (FFS) recovery audit program, which will allow recovery audit contractors (RACs) to request more documents from providers who have high claims denial rates.

For example, a provider with a 0 to 3 percent denial rate will receive no additional RAC document requests for three 45-day review cycles, while providers with denial rates between 91 percent and 100 percent could potentially receive RAC document requests of up to 5 percent of their paid claims. A baseline annual ADR limit is established for each provider based on the number of Medicare claims paid in a previous 12-month period. Using the baseline annual ADR limit, which is one-half of one percent (0.5%) of the provider’s total number of paid Medicare claims from a previous 12-month period, an ADR cycle limit is also established. After three 45-day ADR cycles, CMS will calculate (or recalculate) a provider’s denial rate, which will then be used to identify a provider’s corresponding “Adjusted” ADR limit. Recovery auditors may choose to either conduct reviews of a provider based on their adjusted ADR limit (with a shorter look-back period of six months) or their baseline annual ADR limit (with a longer look-back period of three years).

Questions concerning this update can be submitted via email.

Dear Colleagues:

We are excited to announce that we have received 14 responses to the recent request for proposal (RFP) issued for Community Health Choices (CHC). This vital program will allow the departments of Human Services and Aging to serve more Pennsylvanians in their communities and allow consumers to have an active voice in the services they receive.

The Centers for Medicare and Medicaid Services (CMS) released a final rule in the May 4, 2016 Federal Register that updates health care facilities’ fire protection guidelines to improve protections from fire for Medicare beneficiaries in facilities.

The new guidelines apply to hospitals; long-term care (LTC) facilities; critical access hospitals; inpatient hospice facilities; programs for all-inclusive care for the elderly; religious non-medical health care institutions; ambulatory surgical centers (ASCs); and intermediate care facilities for individuals with intellectual disabilities (ICF-IID). This rule adopts updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the Life Safety Code, as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code.

Some of the main provisions in the final rule include:

  • Health care facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within twelve years after the rule’s effective date;
  • Health care facilities are required to have a fire watch or building evacuation if their sprinkler system is out of service for more than ten hours;
  • The provisions offer LTC facilities greater flexibility in what they can place in corridors;
  • Fireplaces will be permitted in smoke compartments without a one hour fire wall rating;
  • Cooking facilities now may have an opening to the hallway corridor;
  • For ASCs, all doors to hazardous areas must be self-closing or must close automatically; and
  • Expanded sprinkler requirements for ICF-IIDs.

Health care providers affected by this rule must comply with all regulations within 60 days of the May 4, 2016 publication date, unless otherwise specified in the final rule.

The conversion from ICD 9/DSM 4-TR to ICD 10/DSM 5 has come and gone. Many RCPA members are reporting claims denials for billing codes related to the Schizophrenia NOS and PTSD NOS. The reason is that the DSM 5 only offers the Schizophrenia NOS code but the ICD 10 offers seven other choices for Schizophrenia and similarly for PTSD. Clinicians are using the DSM 5 for documentation and choosing the available option; however, when converted to ICD 10 for billing and payment, the person does not meet the criteria for Schizophrenia NOS – therefore, CMS is denying payment. And if you think you are out of the woods in the substance abuse arena, think again; those problems are forthcoming.

RCPA is pleased to offer this webinar: DSM 5/ICD 10 Troubles: Understanding and Rectifying Revenue Problems, by Lisette Wright of Behavioral Health Solutions, P.A. Wright is author of the published curriculum ICD-10 and DSM-5: Coding, Documentation and Clinical Diagnostic Criteria Training, and has trained close to 13,000 clinicians across the country. Her soon-to-be-published graduate level test is titled Coding and Documentation Compliance for the ICD and DSM: A Comprehensive Guide for Clinicians, Routledge, late fall 2016.

Wednesday, June 1, 2:00 – 3:30 pm
Member Registration: $25
Non-Member Registration: $40
Register here no later than Monday, May 30, 2016

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The Office of Mental Health and Substance Abuse Services (OMHSAS) has issued a new bulletin: OMHSAS-16-04 Training Requirements for Licensed Behavior Specialists Who Use Behavioral Specialist Consultant-Autism Spectrum Disorder Services to Provide Applied Behavioral Analysis. The new requirements are effective as of Sunday, May 15, 2016. This bulletin applies to organizations, individuals, and entities approved to provide Behavioral Specialist Consultant-Autism Spectrum Disorder (BSC-ASD) services, and who use these services to provide Applied Behavioral Analysis (ABA) in the fee-for-service and HealthChoices behavioral health managed care delivery systems. The purpose of this bulletin is to notify providers of the training requirements for newly licensed behavior specialists who use BSC-ASD services to provide ABA and who meet the training requirements for the behavior specialist license through trainings approved by the Bureau of Autism Services or the Behavior Analyst Certification Board.

OMHSAS will be marking Mental Health Awareness month with a program called PA on the M.O.V.E.,  Friday, May 13, 2016, in Strawberry Square. In addition, the 2016 PA CARES Training Summit – Promoting Wellness in the Reintegration Process: Enhancing the Lives of Service Members, Veterans and their Families will be held on Thursday, May 12 at Fort Indiantown Gap, Annville, PA. There is no charge for this program but registration is required by May 3.

The Pennsylvania Medical Assistance Transportation Program (MATP) wants to hear from you! The upcoming MATP Advisory Meeting will be held on Thursday, April 28, from 12:30 – 1:30 pm at the Commonwealth Tower (Strawberry Square), 303 Walnut Street, 6th Floor, Room 38, Harrisburg, PA 17105 or you can call in at 855-734-4390 with Conference PIN 693412.

The Office of Mental Health and Substance Abuse Services (OMHSAS) issued a new bulletin entitled:  OMHSAS-16-03: Revised Procedure for Waiver of Office of Mental Health and Substance Abuse Services (OMHSAS) Program Regulations and Standards. It is effective immediately and its purpose is to update and clarify the procedure for submitting and processing requests for a waiver of OMHSAS program regulations and standards that are used to license or approve behavioral health providers.