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March 2010 March 4th: Yesterday President Obama signed into law, under the Extension to Therapy Act, the extension to the 0% change in the fee schedule and the extension of the exception process till March 31st. CMS lifted it its hold on payment of March claims. The exception process is now in place until the end of the month and made retroactive to January 1st. Claims can now be submitted with the KX modifier and the 2009 guidelines are in place. March 3rd: Late last night Congress passed the Jobs Bill which contained a 30 day extension to the hold on implementing the 21% reduction in the Fee Schedule as well as a Therapy Caps. What does that mean? Well, for now, therapists will still be paid at the 2009 levels for the CPT codes under Part B. However, as for the Caps, all it means is that we are still under the caps but there is a hold on their implementation and the exception process is in place and retroactive to January 1st. This stop gap effort will expire on March 31st. In the meantime, therapists are in limbo. It is widely anticipated that eventually there will be, at a minimum, a 1 year extension of the exception process that will be made retrospective to January 1st. So stay tuned and contact your Representatives and Senators in order to emphasize just what this is doing to the Rehab profession. The freeze in the decrease in payment keeps the physicians happy for another month, however, without the exception process, lots of beneficiaries are going to have problems getting appropriate care. Although the outpatient hospital setting is not under the caps, they would certainly have extreme difficulty in handling the patients who could be without care. March 1st: Well we were in a hurry and wait mode last week waiting for Congress to do something about the therapy caps and the reduction in the fee schedule. Unfortunately, politics got in the way and nothing was done. However, CMS believes that it will be addressed soon and issued instructions to it claims contractors to hold all claims beginning with March 1st for 10 business days. So they obviously expect some action within the next two weeks. We'll post whatever happens on the website so stay tuned. RAC info: As of this time, the RACs are still focusing on DRGs and physician's services. CERT info: The CERT contractor issued its National Error Rate Report for November 2009. The error rate had increased from 3.6$ in May 2008 to over 7% in November. The reason for this is the more stringent processes that had been introduced by CMS which they had not been following. The number of denials increased predominantly for DMEs and physician charges, guess why? Illegible signatures. This is becoming a huge issue for physicians, and therapists are also not excluded for that one. We have addressed these issues in our latest Newsletter. Follow this link to access our latest edition. Latest Medicare News and Rules For Therapists Newsletter
February 2010 February 10th: The APTA announced yesterday the Senate released a draft version of the "Jobs Bill" and included in are provisions addressing the caps and the conversion factor. The proposal is to extend the exception process for one more year and make it retroactive to January 1st. They also propose keeping the 2009 conversion factor in place until September 30th. There were hopes that this would get passed this week but because of the "climate change" going on in Washington, all votes have been postponed for this week. Next week will see no action as it is a "work week at home" due to the Presidents Day Holiday. Sounds like a good time to get hold of your representatives and relate your concerns. We still are waiting on Congress to see if we are going to have the exception process extended or not! There have been moves on the Hill with Senator Baucus indicating that he is drafting a bill to address the caps and the exception process along with other items that expired January 1st. In the meantime, CMS has stated that providers could hold up billing until this problem has been resolved. Well! that works as long as the exception process is allowed, otherwise both patients and providers may be in trouble. January 2010 Happy New Year to Everyone. Well, what a start to the New Year and what a difference a day makes! It appears that the huge changes in Health Care may be delayed somewhat. However, as we stand, things are not looking good for rehab services. The cap is back in place and the new amount is $1860 per cap, the exception has expired and we are still scheduled for the 21% decrease in reimbursement as of March 1st. We can look at that with perverse "British Humour" and say, well, at least the patient is going to get "More Bang for their Cap Buck". No doubt sanity will prevail and we will get both of those big problems resolved. CMS held their SNF open door on Thursday the 21st and announced that everything is on schedule for the MDS 3.0 and RUG IV implementation on October 1st. They have published more of the RAI Manual on their website and the final sections should be there by the end of the month. December 2009 December 25th: First of all a Merry Christmas and a Happy New Year to you all. These last two months have been extremely busy for us at Encompass and so apologies for the delayed updates. We will list newest news first which is that the Senate has passed a bill authorizing a 60 day extension of the present fee for service payment for the CPT codes. This prevents the 21% decrease in reimbursement scheduled for January 1st 2010. Unfortunately, the Senate did not address the CAPs and so, as of January 1st, therapy services will be subject to the Medicare CAP limit of $1860 with no exception process in place. The patient may still receive services in the Hospital Outpatient setting which is not subject to the CAPs. The RACS are now up and operational. All 4 have been performing the "black and white" issues related to billing audits, however, Connolly Consulting Associates, LLC have already started Inpatient Hospital DRGs relating to "Incorrect Coding". Here they will determine if the DRG billed is supported by the documentation. This review will not include review for Medical Necessity. The process of Complex Medical Review will not be initiated with the RACs until this coming year. So what is a Complex Medical Review compared to the Medical Reviews we are used to undergoing! The complex review consists of software that collects and analyses data from various sources to present the entire picture of a beneficiary's claim history regardless of where the claim was processed. The primary source of this data will be the CMS National Claims History. This process of complex medical review will also to carried out by the new ZPICs (Zone Program Integrity Contractors). This type of review will allow the contractors to be both proactive as well as reactive in detecting both abusive and fraudulent practices by both global provider types and specific providers. CMS has announced 3 of the 7 ZPIC contract awards. The ZPICs are replacing the original Program Safeguard Contractors that were established at the beginning of 2000. As a result of the adoption of the MAC strategy, CMS is reassigning the ZPIC jurisdictions so that workloads align with the new MACs. The intent of these realignments is to have one ZPIC responsible for the detection and deterrence of fraud, waste, and abuse across all claim types. CMS anticipates that the ability of a ZPIC to analyze data across all claims types will vastly improve identification of potential fraud. The format of the review process CMS has now posted the RAI Manual on its website. The first educational program was presented live on December 17th and is available through their website as a video recording for the healthcare providers. This presentation discussed the changes to the MDS 3.0 as well as a small amount on the RUG VI payment system. Train the trainers will start some time in March or April and then those trained will then be responsible for getting the training out within their State. The speaker also announced that the long awaited SNF-ABN should be published on the ABN website sometime in January.
November November 1st: CMS had a rush to get the MDS 3.0 posted by the end of October, but they did make it. We didn't get the RAI Manual, however, that's going to be delayed till the end of the month. No real dramatic changes but we have a vision of how the new RUG IV will be calculated. Indicated in the new Section O: Special Treatments and Procedures, O0400: Therapies, each discipline has it own individual subsection, A - Speech Pathology, B - Occupational Therapy and C - Physical Therapy. In each subsection it is required to identify 1. the total number of minutes that this service was administered individually to the resident, 2. the total number of minutes this service was administered concurrently with one other resident and 3. the total number of minutes it was administered as part of a group of residents. Also required is the number of days, the date that the most recent therapy started since the last assessment and the date the most recent therapy ended (dashes if ongoing). We have not been given any breakdown of how minutes will be totaled but based on the terminology in the Final Rule we may make the presumption that no more than 50% of the total RUG minutes can come from concurrent therapy, just like only 25% can come from group comprising of no more than 4 participants. This is going to make an interesting calculation for the therapists! CMS also unveiled its proposed assessment tools for an alternate payment to the fee schedule. As mandated by Congress, CMS must come up with an alternative method to pay for therapy outpatient services. CMS is requesting feedback from the therapy community as to how these tools could work. Deadline for feedback is December 8th. The information was published in the Federal Register on October 9th, the following is directly from the FR: "4. Type of Information Collection Request: New collection; Title of Information Collection: Data Collection For Developing Outpatient Therapy Payment Alternatives (DOTPA) ; Use: In Section 545 of the Benefits Improvement and Protection Act (BIPA) of 2000, the Congress required the Secretary of the Department of Health and Human Services to report on the development of standardized assessment instruments for outpatient therapy. Currently, CMS does not collect these data. The purposes of this project are to identify, collect, and analyze therapy-related information tied to beneficiary need and the effectiveness of outpatient therapy services that is currently unavailable to CMS. The ultimate goal is to develop payment method alternatives to the current financial cap on Medicare outpatient therapy services. Form Number: CMS–10298 (OMB#: 0938–New); Frequency: Reporting—Yearly; Affected Public: Business or other for-profit and not-for-profit institutions; Number of Respondents: 190; Total Annual Responses: 38,632; Total Annual Hours: 13,658. (For policy questions regarding this collection contact David Bott at 410–786–0249. For all other issues call 410–786–1326.)" The contract for the development of these tool was given to Research Triangle International in N Carolina. The company has published the proposed versions of the assessment and is seeking feedback. There are two types of settings, the institutional setting and the community based setting. These forms can be accessed directly through the RTI website at: http://optherapy.rti.org/AssessmentTool/tabid/67/Default.aspx Resembling the MDS and OASIS, the forms are supposed to take about 15 to 30 minutes to complete and will, based on other information that CMS has published in other Final Rules, produce a payment code based on conditions and other complexities. CMS announced several years ago that it had established 21 groupings that required approximately the same time and resources. Not so good news in relation to the Part B reimbursement rates for 2010 as an amendment before Congress to prevent the scheduled 21% decrease did not gain sufficient support and so that is where we seem to be going for next year. The final rule is scheduled to be published in the Federal Register towards the end of the month. One can get access to the word version but it takes a little reading being some 1669 pages long.
October October 25th: During the CMS SNF open door audio-conference, the question of what happens to the SNF stay if the RAC or other program safeguard contractor determines that the hospital stay was not medically necessary at the level provided, thus not meeting the 3 day technical requirement for SNF Part A coverage. The speaker referred to the IOM Coverage Manual Pub.100-02, Chapter 8, section 20.1 that contains the guidelines for the 3 day prior hospitalization. "When the facts that come to the intermediary attention during the course of its normal claims review process indicate that the hospitalization may not have been medically necessary, it will fully develop the case, checking with the attending physician and the hospital, as appropriate. The intermediary will rule the stay unnecessary only when hospitalization for 3 days represents a substantial departure from normal medical practice." It appeared that the general feeling from the presenters was that the SNF would not be penalized providing that the admission to the SNF follows normal hospitalization practices. CMS also indicated that they were still on schedule to have the MDS 3.0 and the RAI Manual posted on their web site before the end of the month. October 5th: CMS has updated the CORF manual and has now standardized the certification interval with other Part B requirements at 90 days. The regulations still require that the physician approve the plan of treatment before treatment begins. The OIG published its work plan for the new fiscal year and is setting its sight on the accuracy of the billing in SNFs and HHAs. It will determine if the claims billed are supported by the medical record. In 2006, a similar review reported an error of 22 percent of claims being billed at a higher RUG than supported in SNF. Also under the eye of the OIG will be PTs in Independent Practice. The OIG noted that previous investigations had revealed poor documentation to support medical necessity and reasonableness of services. They will focus on Independent Practitioners who have high utilization rate for outpatient physical therapy services and determine if Medicare was billed appropriately based on CMS and LCD guidelines. CMS has not yet published the final version of the MDS 3.0 or the RAI Manual, both promised by October 1st. We've got used to that by now. The APTA obtained a little headway with their goal of direct access through Medicare with an amendment being included in one of the bills in front of Congress allowing the Secretary of Health and Human Service to have a demonstration of the feasibility of direct access in rural areas where there is a lack of physician coverage. At least it's a foot in the door. September September will be remembered for little Hurricane activity and the HealthCare Tea Parties. Not a great deal of importance occurred. Several of the MACs published the reminder of the definition of a signature is, in order to satisfy Medical Review criteria. According to the Program Integrity Manual which identified the guidelines for the reviewers to follow, a signature is a legible identifier and can be handwritten or electronic, it cannot be a stamped signature. As a signature is a unique identifier of the person we are recommending that, unless you have the electronic signature capabilities you print your Full Legal Name as on your license followed by your professional title and license number followed by your actual signature. This should clearly indicate to the reviewer that the service was performed by a qualified professional entitled to bill the Medicare program. THE dreaded RAC contractors hurriedly published their set of "issues" on their websites. They are initiating what is termed black and white issues which are performed through an edit system and do not require the submission of the medical records. The only thing that appears to effect rehab is the issue related to hospital outpatient and their billing of more than 1 unit for speech language and speech swallowing treatments. As we are aware all the Speech codes are non-time sensitive units and can only be billed as 1 unit regardless of the time that is spent. August August 3rd: What happened to July? You may well ask, it's the same question I have been asking myself. The major event occurred on July 31st when CMS published its Final Rule for 2010 for both SNF and IRF. So technically we are not that late. As far as therapy is concerned, in the IRF FR, there are few direct patient care changes. The rule addresses mostly coverage changes which will impact the Medical Review process after January 1st 2010. The main changes are in the pre-admission screening required for admit and the patient care conferences being required weekly rather than biweekly. The rule comments on the use of group therapy and will follow up with recommendations for number of patients in a group treatment. As far as the SNF FR, the changes identified in the interim rule for services provided Oct 1st 2010 with the implementation of the MDS 3.0 have been adapted from the interim rule suggestions. The focus of "getting paid for what you do" has been furthered with changes to the proposed rule concerning the creation of the RUG level for the 5 day MDS if there have not been enough therapy provided to generate a RUG level (replacing the section T prediction) or the short stay patient; how the start of care OMRA can be appropriately utilized both during an observation period as well as outside of one. As expected, the focus on the appropriate use of concurrent therapy is addressed in some depth along with the use of aides and possible future documentation guidelines. Swing-bed units are also addressed with changes occurring in 2010 with the implementation of the MDS 3.0 An interesting point we noticed between the two FRs was the number of comments received by CMS in reference to the proposed changes to both regulations. CMS received 687 responses to the IRF proposed rules and a whopping 112 concerning the SNF changes. Are we missing something here? How many IRFs are there compared with SNFs? Less than 2000 compared with over 15,000. We will highlight some of the major proposed changes and, when the final rule is published will have both it and the sections applicable to therapy available through our links. Concurrent Therapy: Concurrent therapy, starting October 1st 2010 will consist on a maximum of 2 patients at a time. Treating more than that - Medicare's Part B definition of "supervised therapy - will be non admissible in the MDS 3.0 to create a RUG IV payment level. Bonefide group therapy will still be allowed with the ability to add upto 25% of the total minutes in the observation period, same as now. The therapist will be required to identify in the medical record:
The rule reinforces that concurrent therapy can be a viable adjunct to individual services but should not replace it. The rule also identifies that, under the current system, patient have been placed in higher RUG levels through use of concurrent therapy during an observation period, and that, in some instances, that has not been the appropriate level for the patient's needs. It continues with the statement "We regard it as likely that providers will ask therapists to modify their treatment plans to make sure that patients qualify for the higher therapy groups. However, this type of behavioral adjustment, even if it increases labor cost, may not be reflective of actual patient need." Throughout the document, CMS reinforces that treating patient concurrently does not increase the cost of the therapist's time, as seeing 2 patients for 1 hour still only costs 1 hour of salary while generating 2 sources of payment. As RUG reimbursement levels are based on a case mix which takes into consideration resource utilization and cost, CMS identifies "When a therapist treats two patients concurrently for an hour, it does not cost the SNF twice the amount (or 2 hours of the therapist’s salary) to provide those services. The therapist would appropriately receive one hour’s salary for the hour of therapy provided, regardless of whether the therapist treated one patient individually or two patients concurrently for that hour. Therefore, Medicare should pay for the one hour of the therapist’s time." CMS also identifies that there are also multiple issues affecting the delivery of therapy including the patient's right of self determination (preference to be treated individually or to be treated with others concurrently) and whether this preference is met, (Possible State Survey issue here?); Infection control procedures and facility layout (logistical feasibility of treating multiple patients and maintaining proper and adequate supervision). Also in this response section, it is identified that CMS will be monitoring the use of group therapy time, analyzing it and "address as needed in the future". Documentation: The rule briefly touches on documentation requirements, "Under Medicare Part B therapy services, CMS has issued documentation requirements. When these requirements were developed, CMS worked closely with the Medicare contractors, professional therapy associations, and multiple components within CMS. We intend to address therapy documentation issues for SNF PPS in a similar fashion to determine the most appropriate documentation requirements." [How long have we been saying standardize documentation for Parts A and B?] Use of Aides: CMS reiterates that the role of the therapy aide is to "provide support services to the therapist." the response continues " ...... we intend to monitor the use of therapy aides, and if necessary, propose changes to MDS reporting requirements in the future." An example of how CMS looks at response from providers and others is the change that CMS has made in reference to the short stay patient or the patient that does not RUG into a therapy reimbursement level during the 5 day assessment. In the proposed rule, the ability to predict a patient into RUG level through section T was eliminated and replaced with a simplistic formula based on days treated and minutes provided that would only generate the Medium and Low categories. What has been proposed is based on the same allocation but has been expanded to include all RUG levels, not just low and medium. Therefore in the new proposal, the following " ......if the average daily therapy minutes provided are between 15-29 minutes, the record will be assigned to the Rehabilitation Low category (RLx). ...... the assignment for other rehabilitation categories will be based on the average daily minutes of therapy provided, as follows: • Average daily therapy minutes are between 30-64 minutes, a Rehabilitation Medium category (RMx) • Average daily therapy minutes are between 65-99 minutes, a Rehabilitation High category (RHx) • Average daily therapy minutes are between 100-143 minutes, a Rehabilitation Very High category (RVx) • Average daily therapy minutes are 144 or greater, a Rehabilitation Ultra High category (RUx)" This should alleviate the possibility of treating the patient before they have stabilized in order to obtain a high reimbursement level. The addition of the start of care OMRA along with examples of how it may be utilized was also expanded, so that, by choosing the appropriate ARD from the ones already allowed, the facility can utilize this assessment to replace another mandated PPS MDS. The example given is of a patient started on day 9, the ARD can be day 11 through day 14 for the 14 day assessment, therefore by choosing one of those days (along with any grace days) would produce a payment for day 9 through day 14 under the OMRA and then continue through day 30 due to it replacing the required 14 day MDS. In the rule, SWING-BED units were also addressed. Starting October 1st 2010, Swing-beds will be using a modified version of the MDS 3.0, similar to the MPAF for SNF, but with fewer items to capture appropriate payments rate. Again, CMS identifies that it will continue to monitor quality of care through this assessment.
June June 28th: CMS unveiled the roll out of the RAC program. The initial phase appears focused on Hospital DRGs, Coding errors and DME. The major thrust will come next year as the RACs obtain permission of the Medical Necessity Reviews from CMS. For the pdf identifying the roll out, follow the following link RAC Review Strategy To identify if you are in a yellow, green or blue state follow this link RAC expansion schedule REMEMBER! The RAC is just the same as any other Medical Review, the only difference is in how they are paid. Because of this payment system they are aggressive and are going to target the providers where they can get the maximum repayment, and, unlike the demonstration, if the denial is overturned at ANY level, they must give back the CMS payment. What can you do to be prepared, well, get yourself a compliance program and start internal auditing systems. How can you do that, well, funny you should ask, we happen to have some of those tools available with others under development. Bookmark our website to keep informed. June 1st: CMS held a SNF open door forum on May 28th, but did not anything significant to what we are aware of in the Interim Final Rule. IF you haven't read any of the rule yet, you can excess important therapy information through the SNF section at the following link. Interim Rule Highlights May May 8th: CMS has published a new draft version of the MDS 3.0. In it, they have reverted back to the 2 levels of grading ADL performance as in the present MDS 2.0. They also emphasized that this version was still a draft and therefore not to start any training with it. The final version will be published this coming October. May 1st: CMS issues the Interim Final Rules for For SNF. CMS has no new surprises for fiscal year 2010 (beginning this Oct 1st) but has outlines its new RUG IV guidelines to be implemented on October 1st, 2010 along with the new MDS 3.0. The proposed rule addresses the use of concurrent therapy and is proposing to have separation of individual one-on-one therapy, concurrent therapy and group therapy recorded in the clinical record and may make only a percentage of concurrent therapy account towards the RUG level. (That should certainly help the perplexed therapist who are under high productivity levels and required concurrent levels!) CMS is also proposing to eliminate the ability to predict a patient into a RUG categories and use days of treatment provided for short stay residents to predict the patient into Rehab Low or Medium. (Amazingly, analysis shows that predicted levels were not always met!) Another use for the OMRA is proposed that would be used to obtain a Rehab RUG level when therapy starts treatment in between MDSs that will make a new RUG level chargeable as of the date of the commencement of therapy. (Hopefully this will prevent the provision of therapy BEFORE the patient is really ready for services.) Also proposed is that the OMRA which is completed after the patient has been discharged from therapy and STILL requires skilled nursing services shall have an ARD between day 1 and day 3 after the patient has been discharged from therapy and the new clinical RUG will go into effect the day after therapy D/C. (This will definitely stop the "extra days of nursing observing for changes " BUT discharging the patient before day 8 after therapy has terminated.) The ability for the SNF to utilize hospital provided treatment will also be abolished. In order to get into the rehab plus extensive categories, the patient will have to receive those services during the facility stay. (This should please the therapy companies who provide actual therapy minutes to meet the rehab high categories only to find that the facility is billing the medium level due to its higher reimbursement!) The major effect of this new rule as far as facilities go is that the overall amount of monies available has been reduced from last year in order to get it back into a budget neutral level. As soon as the Final Rule is published in the Federal Register we will have the link available for you to read.
April April 29th: CMS issues the Interim Final Rule for Inpatient Rehab Facilities. The important changes for Rehab in IRFs are the change for the interdisciplinary care planning meeting changing from every two weeks to weekly and the consideration of no longer allowing group therapy. It also places more responsibility on the Physician in terms of pre and post admission assessments. April 15th: Other than being Tax Day today, things have been very quiet so far this month. We still have bills before Congress concerning the therapy caps, but no movement so far. CMS will be presenting its SNF open door forum tomorrow so we will see what that brings. March Updates March 20th: Trailblazer just announced the results of a Widespread Probe Audit of SNF Part A billing of the upper RUG codes and the result was that, of the 100 claims reviewed, 34% were either partially or totally denied. The overall error rate for this probe was 13.5%.
The problem areas identified were:
Utilization of higher levels
of intensity of rehabilitation than were medically
necessary.
Patients reached their functional
potential without being turned over to restorative care in a
reasonable time frame.
Therapies were continued past the
restoration of the patient’s prior level of functioning.
Therapies were provided to
individuals who were not reasonably capable of participation or
of making/sustaining gains.
Reasons
for denial were:
1. Documentation did not support the
need for continued care in an SNF:
Patients had reached their
potential and were medically stable.
Documentation did not indicate
participation of medically stable patients in ordered therapies.
No gains were accomplished due to
declining physical health issues.
2. Utilization of higher RUG
codes than medically necessary:
Documentation did not
support the intense levels of skilled therapy.
Speech-language pathology
was ordered for cognitive deficits when documentation
indicated there were no deficits.
Patients were not capable
of participating in high levels of intense therapy.
3. Documentation received was
incomplete:
Minimum Data Set (MDS)
was not in the National Repository.
Medical records did not
contain one or a combination of the following documents:
Physician orders for
SNF services.
Certification/recertification for SNF services. March 10th: During the SNF Open Door Forum on March 5th, CMS announced that it was postponing the introduction of the MDS 3.0 for one year to enable a smooth transition. We knew that CMS was running behind their original schedule at the beginning of the year, and, when the final MDS was not published by its deadline of March 1st, we felt that the short time frame to introduce the Manual, the Raps and perform all training, not to say the development of the appropriate software was somewhat ambitious. So we can breath a little easier until October 1st, 2010. So what does that mean for rehab? We were anticipating an introduction of a new rug system RUG-IV, with the new MDS, will that happen in October, we don't yet know. The interim final rule which should be published in April/May will help provide an insight of where the SNF PPS system is heading. We are also anticipating that we may have some new guidelines for documentation based on the Part B guidelines. We are strongly recommending that facilities start to move towards the same documentation systems for both A and B. This will make documentation so much easier for staff and get you a head start for when those regulations are finally introduced. March At his time, we have no idea of the changes that might be occurring to the Medicare program as a result of the initiative from the new administration. As information is forthcoming, we will let you know. There has been a protest about the MAC award for Jurisdiction 11 to Palmetto GBA. This is interesting since they are the FI for this area. What this means is that everything is on hold until May 13th when the GAO will disclose its ruling.
February Update February 24th: Palmetto GBA, MAC for J1 has published its draft LCDs for PT, OT and Speech. There is a comment period available in which interested parties can make comments and suggestion. To access these policies use the following links: LCD_PT or LCD_OT or LCD_SLP go to Palmettos website at www.palmettogba.com CMS finally notified its contractors of the 2009 Therapy Caps limit of $1840 per cap. February President Obama issued an executive order to place a moratorium on any new regulations for Medicare as well as reviewing those that have passed in the last six months. What actual effect that will have on Rehab is not sure at this time. CMS has not yet informed its contractors of the increase in the therapy caps for 2009. Although CMS's beneficiaries have already been informed of this increase, this increase might have come under this executive order. How this looks for the plan to rescind the caps leaves us guessing. Medicare Contracting Reform: On the 6th of this month, CMS announced the satisfaction of the contest of RAC awards and therefore have lifted the moratorium on the RACS. The resolution has resulted in the original awards being maintained, but the two companies that challenged the awards obtained positions as subcontractors to the main RACs. PRG-Schultz, Inc. will work with: Region A: Diversified Collection Services, Inc (DCS) Region B: CGI Technologies and Solutions, Inc. (CGI) Region D: HealthDataInsights, Inc. (HDI) Viant Payment Systems, Inc. will work with: Region C: Connolly Consulting Associates, Inc. Each subcontractor has negotiated different responsibilities in each region, including some claim review. CMS is also in the process of changing the Program Safeguard Contractors (PSC) to Zone Program Integrity Contractors (ZPIC). What the difference in their role will be, we are not sure as yet. Just be aware - BIG BROTHER will be watching. The latest figure for the $$ amount recouped by the demonstration RACs has inched up to almost 1 billion. These programs have been extremely successful in identifying "errors" in billing and recouping Medicare Trust Fund dollars. Clarifying Confusion over Certification, Re-certification and POT review in ORFs and CORFs With the implementation of the 90 day certification interval, there has been confusion between the regulations for "Conditions of Participation. Several of the MACS have been addressing the regulations for ORF (Rehab Agencies) and CORFs. As part of their Medicare certification and survey process, the CORF must have the physician review the plan of treatment and re-certify need at 60 days, not the 90 allowed under the Part B regulations. Under the regulations for ORF, "the plan of care and results of treatment be reviewed by the physician OR by the individual who established the plan at least as often as the patient's condition requires, and the indicated action taken, which for Medicare patients being treated in rehabilitation agencies must be at least every 30 days." Therefore, documentation that the therapist has reviewed the plan and has made appropriate changes, according to patient response and the current plan is appropriate should meet this requirement (progress reports!) and certification of the plan will still proceed under the max 90 days guidelines for physician review and recert. And how will Medicare know? You tell them right there on your bill. Did you know that? On the UB-04, occurrence codes 29, 17 and 30 identify when the associated plan (PT, OT or Speech) was last reviewed, and for CORF, occurrence code 28 identifies the same thing. So, if for CORF, the date exceeds 60 days from the initial treatment date, that's your red flag, for everyone else, including ORF, that period should not exceed 90 days. SNF Info: The MDS 3.0 is still scheduled for implementation on October 1st. Although a little behind and the timeframes for roll out and education have been removed from the CMS website, the speakers at the SNF open door forum indicated that the RAPS and instruction manual are in process. Nothing said yet about RUG-IV. I guess we will have to wait till April/May.
January Update A bill has been introduced in both the House of Representatives and the Senate calling for the elimination of the therapy cap according to a press release from the APTA. The legislation, known as the Medicare Access to Rehabilitation Services Act, was presented by Senators John Ensign, Blanche Lincoln, Susan Collins, and Ben Cardin, and Representatives Xavier Becerra, Mike Ross, and Roy Blunt. As you are aware, the caps can only be repealed by another Act of Congress. The present moratorium is set to run out on December 31st this year. CMS has an alternative payment system in demonstration presently, but this will not be ready for implementation for al least another 3 to 4 years, which would mean another round of congressional acts to maintain any extension of the moratorium and the exception process. CMS is mandated by congress itself to come up with a permanent alternative to the caps. The therapy caps have been controversial since their implementation in 1997 and many argue that they limit access to necessary treatment for seniors.
January 2009 Finally CMS has announced their final selections for the remaining A/B Macs. Interestingly enough there is only one NEW name added to this group. Noridian Administrative Services, LLC (NAS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 6 comprised of Illinois, Minnesota and Wisconsin. NAS is headquartered in Fargo, N.D. They also handle Jurisdiction 3, comprising of Arizona, Montana, North Dakota, South Dakota, Utah, and Wyoming National Government Services (NGS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 8 comprised of Indiana and Michigan. NGS is headquartered in Indianapolis, IN. NGS is also the MAC for Jurisdiction 13, consisting of Connecticut and New York. Cahaba Government Benefit Administrators, LLC (Cahaba GBA) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 10 comprised of Alabama, Georgia and Tennessee. Cahaba GBS is headquartered in Birmingham, AL. Palmetto Government Benefits Administrators, LLC (Palmetto GBA) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 11 comprised of North Carolina, South Carolina, Virginia and West Virginia. Palmetto GBA has its operational headquarters in Columbia, S.C., with some operations performed in Columbus, OH. Palmetto also has Jurisdiction 1 which consists of American Samoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands. Highmark Medicare Services (HMS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 15 comprised of Kentucky and Ohio. HMS is headquartered in Camp Hill, PA. HMS also was awarded Jurisdiction 12, Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania With the finalization of the MAC awards, we will be dealing with a total of 10 MACS servicing the 15 jurisdictions. This should make life a little easier as now, we will only have 10 sets of LCDs to contend with. On December 29th, 2008 CMS announced that it was going to strengthen its efforts to fight Medicare Waste, Fraud, and Abuse from DME suppliers and Home Health Agencies. As a result of the permanently based fraud units in South Florida and South California, more than 1100 DME suppliers have had their privileges revoked and Home Health Agencies in the Miami- Dade area are under harsh scrutiny. In 2007, CMS estimates that more than 1 billion dollars was paid in error for fraudulent claims.
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