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Medical Rehab

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On July 19, 2016, the Office of Inspector General (OIG) for the US Department of Health and Human Services (HHS) issued a report, Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries, part of a series on adverse events in health care settings or harm resulting from medical care. This report cites that incidence of these events in rehabilitation hospitals is similar to that of acute care hospitals and skilled nursing facilities that has been reported in previous OIG findings. The findings from this report resulted from the review of a national sample of medical records from 417 Medicare beneficiaries discharged from rehab hospitals in March 2012.

The OIG recommended that the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) raise awareness of patient safety issues in rehabilitation hospitals and other health care settings. CMS and AHRQ concurred with the OIG recommendations.

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.

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The Centers for Medicare and Medicaid Services (CMS) issued the calendar year (CY) 2017 Medicare Physician Fee Schedule Proposed Rule, which was published in the July 15, 2016 Federal Register. Some of the key provisions proposed include:

New Physical Therapy and Occupational Therapy Codes

CMS is proposing new CPT codes for physical therapy and occupational therapy evaluative procedures. The new codes are listed on Page 350 of the proposed rule in table 19 and include: 97X61, 97X62, 97X63, 97X64, 97X65, 97X66, 97X67, and 97X68. These codes are deemed “always therapy” regardless of the type of provider who bills for the service, and thus are subject to the statutory therapy caps.

Misvalued Therapy Codes

As part of the continued misvalued code initiative, CMS identifies ten potential therapy codes that fall under the “codes that account for the majority of spending under the physician fee schedule” statutory category. The ten codes that CMS requests comment on include the following: 97032 electrical stimulation; 97035 ultrasound therapy; 97110 therapeutic exercises; 97112 neuromuscular reeducation; 97113 aquatic therapy/exercises; 97116 gait training therapy; 97140 manual therapy 1/regions; 97530 therapeutic activities; 97535 self-care management training; and G0283 electrical stimulation other than wound.

Physician Value-based Modifier

The Value-based Payment Modifier (VM) provides for differential payments under the PFS to self-employed physicians, groups of physicians, and other eligible professionals (EPs) based on the quality and cost of care they furnish to beneficiaries enrolled in the traditional Medicare Fee-for-Service (FFS) program. Under the VM Program, performance on quality and cost measures can translate into payment incentives for EPs who provide high quality, efficient care, while EPs who underperform may be subject to a downward adjustment. This program is set to expire on January 1, 2019, as a new comprehensive program required by the Medicare Access and CHIP Reauthorization Act, called the Merit-based Incentive Program, begins in CY 2019. For CY 2017, CMS requests feedback on four scenarios that aim to help physician groups and solo practitioners better predict the outcome of their final VM adjustment and to minimize claims reprocessing.

Medicare Shared Savings Program

Within the Medicare Shared Savings Program, CMS proposes to introduce beneficiary protections related to the use of the skilled nursing facility (SNF) 3-Day Waiver, currently limited to beneficiaries in a Track 3 Accountable Care Organization (ACO). CMS estimates the first SNF 3-day rule waiver applications from Track 3 ACOs to be accepted later this summer. The following additional beneficiary protections are proposed in order to ensure proper use of the SNF 3-day rule waiver:

  • Establishment of a 90-day grace period that would permit payment for SNF services provided to beneficiaries who were initially on an ACO’s prospective assignment list for a performance year, but subsequently excluded during the performance year;
  • Requirement that a beneficiary who was never prospectively assigned to a waiver-approved ACO is not subject to non-covered SNF services; and
  • Misuse of a waiver may result in CMS taking remedial action against an ACO. CMS has indicated they will develop a process for ACOs to confirm that they have met all the SNF 3-day rule waiver requirements and requests comments on the proposed beneficiary protection policies.

Medicare Advantage Provider Enrollment

CMS proposes to require Medicare Advantage (MA) organization providers and suppliers to also be enrolled in Medicare in an approved status. The statutory definition of a “provider of services” includes a hospital, critical access hospital, SNF, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice. According to CMS, this requirement is needed to ensure that MA enrollees receive appropriate or medically necessary items or services from health care providers and suppliers that fully comply with Medicare enrollment requirements and have not had their privileges revoked. The Medicare enrollment requirement would be part of CMS contracts with MA plans, and those failing to meet this requirement could be subject to contract actions ranging from sanctions to termination. This proposal would create consistency with the provider and supplier enrollment requirements for all other Parts of Medicare (i.e., Medicare Part A, Part B, and Part D), and would also parallel requirements for providers participating in Medicaid managed care organizations.

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The Centers for Medicare and Medicaid Services (CMS) will be hosting a two-day, in-person training event on Tuesday, August 9 and Wednesday, August 10, 2016 on the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) in Chicago, IL. This event will also be accessible via streaming media (registration is not required to participate via webcast). The event is scheduled to begin at 9:00 am EDT both days. This training is for IRF providers, associations, and organizations. The objective is to provide IRFs with assessment-based data collection instructions and updates associated with the changes in the October 1, 2016, release of the IRF-Patient Assessment Instrument V 1.4 and other reporting requirements of the IRF QRP. IRF preview reports and IRF Compare will also be discussed.

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The Centers for Medicare and Medicaid Services (CMS) published the proposed hospital outpatient prospective payment system (OPPS) payment rule for calendar year (CY) 2017 in the July 14, 2016 Federal Register. A key proposal in the rule is to implement Section 603 of the Bipartisan Budget Act of 2015 (also known as the Site Neutral Payments Provision), which provides that certain hospital off-campus outpatient departments would no longer be paid under OPPS. Currently, Medicare pays for the same services at a higher rate if those services are provided in a hospital outpatient department, rather than a physician’s office. This payment differential has encouraged hospitals to acquire physician offices in order to receive the higher rates. This acquisition trend and difference in payment has been highlighted as a long-standing issue of concern by congress, the Medicare Payment Advisory Commission, and the Department of Health and Human Services Office of Inspector General.

In addition, based on concerns raised by health care providers on the patient experience survey questions about pain management, CMS is proposing to remove the pain management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems survey, for purposes of the Hospital Value Based Purchasing Program. The goal is to eliminate any potential financial pressure clinicians may feel to overprescribe pain medications.

CMS has also included a provision to increase flexibility for hospitals that participate in the Medicare electronic health records (EHR) incentive program. Earlier this year, CMS conducted a review of the Medicare EHR Incentive Program for clinicians as part of the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), with the aim of reconsidering the program so we move closer to achieving the full potential that health information technology offers. Based on that review, CMS streamlined EHR reporting requirements under the proposed rule to implement certain provisions of MACRA, to increase flexibility and support improved patient outcomes. CMS is proposing to take a similar step for hospitals participating in the Medicare EHR Incentive Program. These changes include a proposal for clinicians, hospitals, and critical access hospitals to use a 90-day EHR reporting period in 2016 (down from a full calendar year for returning participants). This increases flexibility and lowers the reporting burden for hospital providers.

Finally, CMS proposes to add new quality measures to the Hospital Outpatient Quality Reporting Program that are focused on improving patient outcomes and experience of care. Other changes in the proposed rule would enhance the outcome requirements for organ transplant programs, so that the programs may help more beneficiaries accept more grafts, while maintaining compliance with Medicare standards for patient and graft survival.

CMS estimates that the updates in the proposed rule would increase OPPS payments by 1.6 percent. Comments on the proposed rule will be accepted through Tuesday, September 6, 2016.

RCPA recently sent a letter to the Senate Banking and Insurance Committee supporting SB 1305. Sponsored by Senator Yaw, the bill would require insurance coverage for abuse deterrent opioids that is equal to coverage of other opioids, while prohibiting higher copays for pills that cannot be crushed or diluted.

Gov. Tom Wolf also supports similar requirements contained in SB 1305. The governor has called for a requirement that all of the state’s physicians check patients’ drug histories in a new database every time they prescribe controlled substances, including opioids. Several important pieces of legislation have passed the Senate, and await action in the House. Currently, there are a number of bills in both the House and Senate dealing with the opioid crisis.

RCPA has been working with various groups and supports SB 1305, because it reflects the collective expertise and resultant recommendations of the Joint State Government Commission Task Force and Advisory Committee on Opioid Prescription Drug Proliferation. RCPA encourages its members to contact your state senator and ask for their support of SB 1305.

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.

The Office of Vocational Rehabilitation (OVR) is conducting a comprehensive statewide needs assessment designed to meet and satisfy the state plan requirements in the Rehabilitation Act of 1973, as amended, and the Workforce Innovation and Opportunity Act. As part of this assessment, the Institute on Disabilities at Temple University is asking Pennsylvania employers and workforce professionals to complete a brief survey to identify how OVR can better support employers and employees across Pennsylvania.

This project is being conducted in cooperation with the Pennsylvania Rehabilitation Council and with the assistance of the Institute on Disabilities. If you are an employer or a workforce professional you are encouraged to complete this brief survey by Monday, August 1. Once you’ve completed the survey, you can enter in a drawing to win a $20 Target gift card.

The Institute on Disabilities is also seeking employer stakeholders to participate in brief phone interviews and share their expertise with the Institute. Interested employers can email or call 215-204-9544.

The Department of Human Services (DHS) is now implementing a new simplified process called the Elderly/Disabled Simplified Application Process (ESAP) for the Supplemental Nutrition Assistance Program (SNAP), commonly referred to as the food stamp program. The federally approved process simplifies the SNAP application and recertification process for older Pennsylvanians and individuals with a disability who have no earned income.

“The new simplified process will help ensure that some of the most vulnerable Pennsylvanians have easier access to the SNAP benefits that are critical to their health and well-being,” said DHS Secretary Ted Dallas. “Through enhanced data matches and other steps, the ESAP process helps these Pennsylvanians overcome barriers such as limited mobility and lack of access to the internet and helps realize the governor’s vision of a government that works.”

ESAP is available to households that meet all of the following criteria:

  • Every member in the household is at least 60 years old, has a disability, or both;
  • No member of the household has earned income; and
  • For SNAP eligibility, a household includes only individuals who live under one roof and who purchase and prepare meals together.

Through the use of data verification, DHS will be able to reduce the current application from 24 pages to a simplified two-page application. In addition to the simplified application process, ESAP households will now have a 36-month certification period, as opposed to the current 12-month recertification period.

“This initiative, part of Governor Wolf’s larger forthcoming statewide hunger plan, will increase SNAP participation by reducing barriers to participation and providing people with easier access to nutrition,” said Dallas.

“Hunger among seniors is a growing concern, and SNAP is a critical piece of the social safety net enabling older Pennsylvanians to access healthy and nutritious foods,” said Department of Aging Secretary Teresa Osborne. “DHS’ successful pursuit of a streamlined and simplified SNAP eligibility process will benefit seniors throughout the commonwealth, and highlights the positive results that occur when agencies work together to provide people with easier access to services and programs that have the capacity to improve their quality of life.”

On September 29, 2015, Governor Wolf brought together leaders from nonprofit anti-hunger organizations, the food industry, and government to discuss food security in Pennsylvania and signed Executive Order 2015-12, which created the Governor’s Food Security Partnership. To apply for SNAP using the ESAP form, visit the COMPASS web page. For more information on SNAP benefits visit the DHS website.