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Medical Rehab

On December 11, 2017, the Centers for Medicare and Medicaid Services (CMS) issued Medicare Learning Network (MLN) Matters Article, SE17036, which provides information about new instructions recently issued to Medicare medical review contractors. The guidance also provides the standards to use when reviewing claims for compliance with the intensity of therapy requirements for inpatient rehabilitation facility (IRF) claims.

If you have any questions, please contact your MAC at their toll-free number, available online.

The Department of Human Services has been working in collaboration with Managed Care Organizations (MCOs), county oversight organizations, and RCPA regarding the concerns and challenges with implementing federal Ordering, Referring and Prescribing (ORP) requirements by the January 1, 2018 deadline. The Department of Human Services has informed RCPA of the following:

  • The ORP requirements for Fee-for-Service continue to apply; i.e., allORP practitioners must be enrolled in the Pennsylvania Medical Assistance (MA) Program or the rendering provider will not be paid.
  • In the HealthChoices managed care delivery system, if a rendering network provider submits a claim to an MCO with the National Provider Identifier (NPI) information that results in edits identifying that the non-networkORP is not enrolled in MA, the claim can be paid. However, if the non-MA enrolled ORP has a high volume of claims, the MCO will work with the network provider and non-MA enrolled ORP to have them enroll in MA or work to transition the member to an enrolled MA provider.

Contact your contracting BH-MCO for additional information.

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The Centers for Medicare and Medicaid Services (CMS) published a final rule and interim final rule with comment period that cancels the Episode Payment Models (EPM) and Cardiac Rehabilitation (CR) Incentive Payment Model and rescinds the regulations governing these models in the December 1, 2017 Federal Register. It also implements certain revisions to the Comprehensive Care for Joint Replacement (CJR) model. Some of these revisions include:

  • Allowing certain hospitals selected for participation in the CJR model a one-time option to choose whether to continue their participation in the model;
  • Technical refinements and clarifications for certain payment, reconciliation, and quality provisions; and
  • Change to increase the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track.

An interim final rule with comment period is also being issued in conjunction with the final rule in order to address the need for a policy to provide some flexibility in the determination of episode costs for providers located in areas impacted by extreme and uncontrollable circumstances.

Comments will be accepted on the interim final rule with comment period until January 30, 2018. The final and interim final regulations become effective on January 1, 2018.

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On November 13, 2017, the Centers for Medicare and Medicaid Services (CMS) began to post a list of potential audits for Recovery Audit Contractors (RACs) to review. The topics will be listed, on a monthly basis, on the Provider Resources page of the CMS website. The topics currently proposed include: review of pre-admission screening, post-admission examination, and other requirements for inpatient rehabilitation facility (IRF) stays. The review type is identified as a “complex review.” Comments or questions should be submitted via email.

Executive Order to Review State Licensure Board Requirements & Processes

In the November 11, 2017 Pennsylvania Bulletin, Governor Wolf issued an Executive Order (No. 2017-03) that directs the Commissioner of Professional and Occupational Affairs within the Department of State to conduct a review of the State Professional and Occupational Licensure board requirements and processes. This includes a comprehensive review of the processes, fees, training, and continuing education requirements and prepared report for each type of professional and occupational license. The report is to include: training requirements; licensing, registration, and renewal fees; continuing education requirements; and any other requirements described within the executive order. The report is to also include information regarding the number of other states which require a license for each professional or occupational license, the national and regional averages for training requirements, fees, and continuing education requirements.

The Commissioner has been given the authority to establish an advisory group to assist with the research, data collection, and formatting of the reports, and any other function the Commissioner deems necessary. The advisory group shall be composed of members chosen by the Commissioner from the professional Boards and Commissions, Bureau of Professional and Occupational Affairs (BPOA) staff, and any other persons the Commissioner deems necessary. The advisory group must be established within 30 days from the effective date of this executive order. Additional details regarding the report are provided in the bulletin.

The report is due to the Governor, the Secretary of Policy and Planning, and the Secretary of the Commonwealth no later than 180 days from the establishment of the advisory group or 210 days from the effective date of this executive order, whichever is sooner.

Some of the boards impacted by this executive order include: State Board of Physical Therapy, State Board of Speech–Language Pathology and Audiology, the State Board of Medicine, the State Board of Nursing, the State Board of Occupational Therapy, etc.

The executive order is effective immediately.

On November 3, 2017, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2018 Medicare Physician Fee Schedule final rule. The proposed rule updates payment policies, payment rates, and quality provisions for services with an overall payment update of .41 percent.

Some of the key provisions finalized in the rule include:

  • Addition of several codes to the list of telehealth services, eliminating the required reporting of the telehealth modifier GT for professional claims in an effort to reduce administrative burden for practitioners, and separating payment for CPT code 99091, which describes certain remote patient monitoring, for 2018;
  • Adoption of CPT codes for CY 2018 for reporting several care management services currently reported using Medicare G-codes and clarifying a few policies regarding chronic care management;
  • Increase in payment rates for office-based behavioral health services that better recognizes overhead expenses for office-based face-to-face services with a patient;
  • Revision of Part B drug payments for infusion drugs furnished through an item of durable medical equipment (DME) to conform with requirements of the 21st Century Cures Act;
  • Revision of payment for chronic care management in Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs), and establishing requirements and payment for RHCs and FQHCs furnishing general behavioral health integration (BHI) services and psychiatric collaborative care model (CoCM) services;
  • Implementation of the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018;
  • Change to the current Physician Quality Reporting System (PQRS) program policy that requires reporting of 9 measures across 3 National Quality Strategy domains to only require reporting of 6 measures for the PQRS with no domain requirement; and
  • Revision to the rules for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program to reduce burden and streamline program operations.

In addition, CMS indicated they will continue to consider the following based on comments from stakeholders:

  • Stakeholder input in response to the proposed rule’s comment solicitation on how CMS could expand access to telehealth services, within the current statutory authority;
  • Reviewing and updating “outdated” Evaluation and Management (E/M) visit codes; and
  • Reviewing stakeholders’ comments for potential future rulemaking or publication of sub-regulatory guidance pertaining to the Clinical Laboratory Fee Schedule (CLFS) data collection and reporting periods.

The final rule will be published in the November 15, 2017 Federal Register.

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The inpatient rehabilitation facility (IRF) quality reporting program (QRP) submission deadline is coming up on Wednesday, November 15, 2017. The submission deadline includes both the IRF patient assessment instrument (PAI) assessment data and the IRF data that is submitted to the Centers for Medicare and Medicaid Services (CMS) via the Center for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) for discharges. Providers are encouraged to run validation/output reports prior to each quarterly reporting deadline to ensure all required data is submitted. The list of required measures are posted on the IRF Quality Reporting Data Submission Deadlines web page.

The Energy & Commerce House Health Subcommittee scheduled a hearing for Wednesday, November 8, 2017, at 10:00 am in room 2123 of the Rayburn House Office Building. The hearing will focus on the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 and Alternative Payment Models: Developing Options for Value-based Care.

Members of the subcommittee will discuss alternative payment models (APMs) and hear from those that are already engaged in the transition to value-based care, as well as those developing new models and stakeholders who are already delivering improved outcomes and savings for Medicare beneficiaries and taxpayers.

The Majority Memorandum, witness list, and witness testimony for the hearing will be available here as they are posted.