Medical Rehab

In recent months, Pennsylvania’s Learning Community has focused on challenges to financing and payment for mental health care in the primary care and collaborative care settings. The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) has provided the field with an array of information, presentations, and other resources related to the financing of mental health services in primary care and integrated care settings. Below are some of the resources that CIHS has made available to us here in Pennsylvania.

  • The ability to bill for both behavioral health and primary care services on the same day is an essential part of integrating care. The Center for Medicare and Medicaid Services (CMS) created the Billing Properly for Behavioral Health Services booklet to help providers understand the laws and regulations that govern billing for behavioral health services.
  • The resource also includes a checklist to help evaluate your billing procedures and identify potential errors, as well as a resource guide for your billing staff to review current guidelines, billing and coding, covered services, and compliance information.
  • Learn ways you can enhance and streamline your billing process through Improving Your Third-Party Billing System, a self-paced online course from SAMHSA’s BHbusiness initiative.

CIHS continually updates its website to present the best and newest resources and information relevant to integrated primary and behavioral health care.

From: “HS, Secretary’s Office”
Date: January 5, 2017 at 1:01:56 PM EST
Subject: [DHS-STAKEHOLDERS] DHS Awards Medicaid Agreements

Department of Human Services (DHS) Secretary Ted Dallas announced that DHS has agreed to move forward and negotiate agreements with six managed care organizations (MCOs) to deliver physical health services to Pennsylvanians through HealthChoices, Pennsylvania’s mandatory Medicaid managed care program since 1997.

“These agreements will be the most significant changes to Pennsylvania’s Medicaid program since we moved to managed care two decades ago,” said Dallas. “Over the next three years, MCOs will be investing billions of dollars in innovative approaches that reward high-quality care that improves patient health rather than just providing services for a fee.”

The $12 billion, three-year contracts include a 30 percent target for payments based on value received or outcomes, rather than on the quantity of services provided.

The MCOs were selected based on several criteria, including their current performance, the level of customer service delivered, member satisfaction, and their value-based performance plan. Performance criteria measured, among other things, management of chronic conditions such as high blood pressure, diabetes, and asthma; frequency of prenatal and post-partum care; and access to preventive services.

“The average performance ratings of the selected organizations are consistently higher than the current averages in every region. This transition will result in higher levels of quality care for the 2.2 million Pennsylvanians served by Medicaid,” said Dallas.

To drive Pennsylvania’s Medicaid system towards these better outcomes, the three-year agreements set gradual targets for all MCOs to increase the percentage of value-based or outcome-based provider contracts they have with hospitals, doctors, and other providers to 30 percent of the medical funds they receive from DHS. The result will be that billions in funds that would have otherwise been spent on traditional payment arrangements will instead be invested in outcome or value-based options such as:

  • Accountable care organizations (voluntary networks of hospitals, doctors, and other providers that work together to provide coordinated care to patients);
  • Bundled payments (increases value-based purchasing);
  • Patient-centered medical homes; and
  • Other performance-based payments.

“We’re going to reward folks for providing the right services, not just more services. You get what you pay for so we’re shifting the focus of Pennsylvania’s Medicaid system toward paying providers based on the quality, rather than the quantity of care they give patients,” said Dallas. “In addition, by focusing on improving the health of consumers, we will drive down the cost of care and ultimately save the taxpayer funds we spend on health care in Pennsylvania.”

HealthChoices delivers quality medical care and timely access to all appropriate services to 2.2 million children, individuals with disabilities, pregnant women, and low-income Pennsylvanians.

For more information, visit or

DHS has selected the following MCOs to proceed with negotiations to deliver services in Pennsylvania beginning in June 2017. The agreements are awarded in five geographic regions:

Southeast Region Gateway Health
Health Partners Plans
PA Health and Wellness
UPMC for You
Vista–Keystone First Health Plan
Southwest Region Gateway Health
PA Health and Wellness
UPMC for You
Vista—AmeriHealth Caritas Health Plan
Lehigh/Capital Region Gateway Health
Geisinger Health Plan
Health Partners Plans
PA Health and Wellness
Northeast Region Gateway Health
Geisinger Health Plan
UPMC for You
Northwest Region Gateway Health
UPMC for You
Vista—AmeriHealth Caritas Health Plan


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On December 20, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the release of a final rule that will implement three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement (CJR) model under Section 1115A of the Social Security Act.

The finalization of these new Innovation Center models will continue the shift of Medicare payments from rewarding quantity to rewarding quality by creating incentives for hospitals to deliver better care to patients at a lower cost. The models will reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery.

The announcement finalizes significant new policies that:

  • Improve orthopedic care: One new payment model will support clinicians in providing care to patients who receive surgery after a hip fracture, other than hip replacement. In addition, CMS is finalizing updates to the CJR Model, which began in April 2016.
  • Improve cardiac care: Three new payment models will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery.
  • Provides an accountable care organization (ACO) opportunity for small practices: The new Medicare ACO Track 1+ Model will have more limited downside risk than Tracks 2 or 3 of the Medicare Shared Savings Program in order to encourage more practices, especially small practices, to advance to performance-based risk.

The final rule makes several modest adjustments to the CJR Model that are largely conforming changes for consistency with the other episode payment models. These include refinements for use of the skilled nursing facility waiver, exclusion of beneficiaries participating in selected ACOs, and revising target pricing methodology to include reconciliation and repayment amounts for performance years 3, 4, and 5. CMS is finalizing revisions to the quality adjustment to incorporate improvement as well as absolute performance, and also finalized changes to align CJR with the episode payment models around financial arrangements and beneficiary engagement incentives, compliance enforcement, appeals processes, and beneficiary notifications.

The final rule is scheduled to be published in the Federal Register on January 3, 2017, and is effective on February 18, 2017.

The decision for Pennsylvania to postpone the implementation of Community HealthChoices (CHC) was announced today. This decision was made as a result of the delays associated with the resolution of several bid protests.

Following the announcement of the selection of the managed care organizations (MCOs) that would deliver health care coverage in Community HealthChoices, several protests were filed. As a result, the progress of major components of CHC implementation was delayed, resulting in the Department of Human Services (DHS) feeling uncertain with moving forward with their established start dates. Some of the impacted activities associated with this decision include:

  • Developing an adequate network: DHS has not been able to engage with the selected offerors. The agreement and rate negotiations and finalization typically take six weeks, and the agreements need to be finalized before the MCOs are able to engage in network development activities. The current delays mean the MCOs will not have enough time to meet the network adequacy requirements by July 1, 2017.
  • Completing a readiness review: Readiness review is a requirement for the MCOs before they are certified to be able to go live and provide services. Protests prohibit MCO engagement for readiness review and the window to complete the certification continuously shrinks. New programs require a minimum of six months to complete a readiness review.
  • Communicating: Communication about selected MCOs and their available networks is a critical component to CHC education and outreach. Individuals who will be enrolling in CHC need to have complete information about the MCO provider network in order to be able to make an informed provider choice. That communication will not be able to take place until the agreements are largely finalized and the MCOs are in a position to provide network information.

Important dates to note include:

  • Phase 1 will now begin in January 2018 in the Southwest region of the state.
  • Phase 2 will now begin in July 2018 in the Southeast region of the state.
  • The January 2019 start date for the rest of the state remains unchanged.

Thursday, January 12, 2017 • Harrisburg, Pennsylvania

In the wake of new technology and the Affordable Care Act, there has been a movement to reform the way behavioral health providers deliver and are paid for their services. Specifically, there is a consensus that health reform cannot be achieved without improved quality and simultaneously decreasing cost.

The Alliance for Health Reform hosted a briefing on Monday, December 12 to discuss the social determinants of health. For those who were unable to attend, here is the video and a transcript.

The financing of medical care is typically siloed from investments in housing, nutrition, criminal justice, and other social supports, even though all of these factors affect health outcomes and life expectancy. When allocating public dollars, policymakers need to know what investments can have the greatest impact on the health of individuals. This briefing examined the challenges of aligning or combining funding sources to achieve better health outcomes, how analysts can prove value in such ventures, and the role of health care professionals in caring for patients who have both medical and non-medical needs.

The National Council for Behavioral Health wants to help you prepare for this journey and invites you to join the new Practice Transformation Academy to get there. The National Council’s newest learning community, the Practice Transformation Academy, is a year-long change management program designed for senior leaders charged with overseeing the organizational transitions necessary for success in value-based payment arrangements. Through comprehensive technical assistance, participating organizations will have the opportunity to: design clinical pathways; create robust, data-driven quality improvement practices; and implement sustainable business operations.

Don’t miss the opportunity for peer-to-peer and individualized coaching to develop your organization’s roadmap and accomplish a practice transformation stretch goal unique to your organization. The program begins in March 2017 and runs through March 2018.

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The Centers for Medicare and Medicaid Services (CMS) finalized a new Therapy Information section on the inpatient rehabilitation facility (IRF) patient assessment instrument (PAI) in the fiscal year (FY) 2015 IRF Prospective Payment System (PPS) final rule.

On January 12, 2017, from 1:30 pm to 3:00 pm, CMS will conduct a call focusing on this IRF-PAI therapy information data collection. During this call, CMS will focus on reviewing the types and methods of therapy collected on the IRF-PAI, examples of each type of therapy, and how to accurately code and complete the therapy information section on the IRF-PAI. Prior to the call, participants are encouraged to review the IRF-PAI Training Manual. A question and answer session will follow the presentation.

To participate, registration is required. Registration will close at 12:00 pm on January 12, 2017, or when available space has been filled. The call presentation will be posted at least one day in advance on the MLN National Provider Calls and Events web page.

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On Thursday, December 1, 2016, the Centers for Medicare and Medicaid Services will conduct a call from 1:30 pm to 3:00 pm that will focus on the soon to be released Certification and Survey Provider Enhanced Reports (CASPER) Quality Measure (QM) reports for the inpatient rehabilitation facility (IRF) quality reporting program. Agenda topics include:

  • Quality measures for public reporting in 2016;
  • Reports associated with public reporting;
  • Content of the CASPER QM reports by data source;
  • How to interpret facility and patient level results;
  • Accessing reports in CASPER; and
  • Resources for providers.

To register or for more information, visit MLN Connects Event Registration. Because space may be limited, those interested are encouraged to register early.

Yesterday, a Texas federal judge issued a temporary injunction to the Department of Labor’s (DOL) overtime rule. In granting the preliminary injunction, the federal judge said the DOL’s overtime rule exceeds the authority the agency was granted by Congress.

As you may recall, the DOL’s overtime rule was announced in May, and it has been opposed by many businesses and nonprofits. The rule was to take effect on December 1 of this year. Now with yesterday’s ruling, it is likely that President-elect Trump’s administration, which opposed the rule, will have time to review it and make changes and/or roll back various provisions contained in the current rule.

The DOL could appeal the Tuesday ruling, but with the Obama administration only having approximately two months in office, an appeal is unlikely. With many RCPA members already implementing and announcing changes to comply with the DOL’s overtime rule, it might be difficult for those members to roll back these changes, because it may impact employee morale. As further information is released, RCPA will provide additional guidance to members. Please contact Jack Phillips, RCPA Director of Government Affairs with any questions.