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Legislative, Advocacy and Payment Update – First Quarter 2018 Recap


What You Need to Know…


Submitted by NHAPTA President Mark Mailloux and Advocacy Team




Federal Legislative Update 


On February 9, 2018 the looming threat of a hard cap on physical therapy services under Medicare Part B was eliminated. Congress enacted a permanent solution to the problematic hard cap on outpatient physical therapy services under Medicare Part B, ending a 20-year cycle of patient uncertainty and wasteful short-term fixes.  APTA has worked tirelessly towards this effort.


However, it’s not all good news. Congress chose to offset the cost of the permanent fix (estimated at $6.47 billion) with a last-minute addition of a payment differential for services provided by physical therapist assistants (PTAs) and certified occupational therapy assistants (COTAs) compared with payment for the same services provided by physical therapists (PTs) and occupational therapists (OTs), respectively. The payment differential, which was strongly opposed by APTA and other stakeholders, states that PTAs and OTAs will be paid at 85% of the Medicare physician fee schedule beginning in 2022.  While this is somewhat comparable to the payment differential between physician assistants and physicians, it was not part of the 2017 bipartisan agreement legislators had reached in 2017 and was not part of the discussions or negotiations on Capitol Hill prior to February 8, 2018.


“Stopping the hard cap is a victory for our patients, and for our dedicated advocates,” said APTA President Sharon L. Dunn, PT, PhD, board-certified orthopaedic clinical specialist. “For 2 decades we have held back the hard cap through repeated short-term fixes—17 in total—that were achieved each time only through significant lobbying efforts by APTA and other members of the Therapy Cap Coalition. In that time, the hard cap was a genuine and persistent threat to our most vulnerable patients, a threat we saw realized earlier this year when Congress failed to extend the therapy cap exceptions process. Today that threat has been eliminated.”


Dunn said the January 1, 2022, implementation date for the opposed PTA payment cut provides time to explore solutions with the Centers for Medicare and Medicaid Services (CMS) as it develops proposed rules.


“APTA will leverage its congressional champions, the APTA Public Policy and Advocacy Committee, and the PTA Caucus on strategies to address the CMS activities,” Dunn said. “Our collective efforts will drive the association’s work to ensure that guidance to implement the new policy is favorable to PTAs and the profession, while ensuring access is not limited for those in need of our services.”


Here are the highlights of provisions included in this new policy:


  • Claims that go above $2,010 (adjusted annually) still will require the use of the KX modifier for attestation that services are medically necessary.
  • The threshold for targeted medical review will be lowered from the current $3,700 to $3,000 through 2027; however, CMS will not receive any increased funding to pursue expanded medical review, and the overall number of targeted medical reviews is not expected to increase.
  • Claims that go above $3,000 will not automatically be subject to targeted medical review. Instead, only a percentage of providers who meet certain criteria will be targeted, such as those who have had a high claims denial percentage or have aberrant billing patterns compared with their peers.
  • For home health, the deal includes positives related to rural add-ons, a market basket update increase of 1.5% in 2020, and use of home health medical records for determining eligibility. However, it also requires a switch from a 60-day to a 30-day episode in 2020 and eliminates the use of therapy thresholds in case-mix adjustment factors.


Read more here:


Want more quick tips about this new legislation? Read here:




State Legislative Update 


NHAPTA is always following bills in the NH legislature that may affect our profession.  Here is a sampling of what we are currently following: 


HB 1353: Establishing a Commission to Study Equal Access and Opportunity for Students with Disabilities to Participate in Athletics. (Referred for Study: may come back next session)


              This bill establishes a commission to study equal access and opportunity for students with disabilities to participate in athletics. 


HB 1471: Relative to Telemedicine and Establishing A Committee to Study Health Care Reimbursement For Telemedicine and Telehealth.  (Currently moving through Senate with Ought to Pass recommendation) 


HB 1784: Relative to Cost Comparison for Certain Health Procedures. (Referred for Study)


This bill establishes procedures for cost comparison for certain health care procedures. Under this bill, insurance carriers shall establish an incentive program for its enrollees who undergo comparison shopping for such procedures. The bill grants rulemaking authority to the insurance commissioner for the purposes of the bill. 


SB 352: Relative to Examinations of Injured Employees Under Workers’ Compensation Law. (Referred for Study)


This bill allows an injured employee covered under workers' compensation who is dissatisfied with a determination by the employer or the employer's insurance carrier to obtain an independent examination. Current law limits this option to injured employees covered by a managed care organization. 


SB 334: Relative to Temporary Licenses for Occupations and Professions for Persons from Other States. (Through Senate, working through House)


              This bill allows persons licensed for certain allied health professions in Connecticut, Massachusetts, Maine, New York, or Vermont to be granted a temporary license to practice in this state while applying for regular licensure. 


SB 473: Relative to Employment Contract Restrictions Upon Health Care Providers. (Passed House, working through Senate)


This bill prohibits contract provisions of health care professionals that limit the ability of such professional to practice their profession in any geographic area after leaving a partnership, employment, or professional relationship. 


In total we are actively following about 20+ bills that are working their way through the current legislative session.  For more information on these bills and others go to: 


Advocacy Update


APTA FaceBook Event - Beyond Opioids: Transforming Pain Management to Improve Health


APTA presented a great hour long program with the panelists representing the voice of patients, the CDC, American Academy of Pain Medicine, physical therapists and employer representatives.  Don’t have an hour…. Check out the 4 minute recap and see how we can make a difference


APTA Action App 


The APTA Action app is a powerful grassroots tool for physical therapists, physical therapist assistants, students, and patients on the go. 


Available for free download in the Apple and Google Play app stores “APTA Action App”, the app includes an action center, Congressional directory, talking points, and more, including the opportunity to donate to PT-PAC. It has a section specifically dedicated to follow State Advocacy issues that potentially impact NH therapists and provides the opportunity to reach out to members of the NH state legislature and U.S. congress. 


Payment Update 


CMS has issued guidance to the Medicare Administrative Contractors on the reprocessing of therapy claims with the KX modifier (among others). The MACs are instructed to: 


  • Automatically reprocess therapy claims with the KX modifier which were denied prior to implementation of the Bipartisan Budget Act of 2018.
  • Automatically reprocess therapy claims with the KX modifier which were denied due to an error in a Technical Direction Letter attachment dated February 12, 2018.
  • Also - Contractors will reprocess 2018 therapy claims which cannot be automatically reprocessed “only if brought to your attention.” (Hence, providers should keep track of those therapy claims with the KX modifier which should have been reprocessed but are not).


Contractors also are instructed to reprocess Medicare Physician Fee Schedule claims impacted by the work Geographic Practice Cost Index Floor fee increase, install the revised home health Pricer which reflects the extension of the 3% home health rural add-on, and more. 


In terms of timing of the reprocessing of claims, the transmittal states “Contractors shall begin reprocessing affected claims as soon as possible. Contractors shall ensure all reprocessing actions have been initiated within 6 months of the issuance date of this Change Request for therapy and Medicare Physician Fee Schedule adjustments.


A provider education article related to this instruction will be available soon. 


To view the transmittal: 


If you become aware of issues with Medicare Advantage plans in your state, please contact APTA at so we can advise on next steps.    


Transparency & Timeliness with Prior Authorization Processes


CMS is aware of stakeholder concerns about the burdens imposed by coverage restrictions such as prior authorizations (PA) in the Part C program. MAOs (Medicare Advantage Organizations) receive a capitated payment from CMS and are accountable for furnishing all medically necessary Part A and B services through a network of contracted providers. They are permitted to manage the delivery of benefits within their provider networks using utilization management tools such as prior authorization (PA). CMS would like to remind MAOs that they should be transparent and provide adequate notice of any coverage restrictions, such as PA requirements, to providers and enrollees.


Plans should specify the existence of any coverage restrictions, including what information is needed when submitting a PA request, in the plan’s Evidence of Coverage (EOC), their contracts with providers and additional provider communications/materials (e.g., provider manuals). Where an enrollee or provider is attempting to satisfy a PA requirement and the plan requires or has a PA request form, the plan should make PA request forms available and easily accessible. MAOs should ensure they are delivering timely decisions on PA requests.


CMS reminds MAOs that requests for PA for a service (whether by an enrollee directly or by a provider on behalf of an enrollee) are requests for a pre-service organization determination. Therefore, these requests are subject to applicable pre-service organization determination adjudication timeframes and notice requirements under the MA regulations. See 42 CFR §§422.568 and 422.572. 


Value Based Care Podcasts and Resources


APTA has recently made available a new 21-part podcast series on value-based care. The free series, delivered in easily digestible 5- to 7-minute presentations, moves from big-picture questions such as "What is value?" and "Why do we need quality measures?" to the nitty-gritty of the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs). The series is part of APTA's efforts to educate physical therapists and physical therapist assistants on changes that currently are voluntary, but could be mandatory as early as 2019 and merit attention now. A link to the podcasts, as well as a wide range of other resources on value-based care, can be found on the association's Value-Based Care webpage.


Getting Started


Value-Based Care Podcast Series


APTA's comprehensive podcast series explains the move toward value-based care and how physical therapists can participate in the Quality Payment Program (QPP). Includes information on MIPS and APMs.


Value-Based Care: Self-Assessment Quiz


Take a quick 3-question quiz to identify where you are in the continuum of health care payment reform.


Evolving Payment System (.pdf)


View and download APTA's infographic outlining how payment for health care is evolving


Value-Based Care: Where Alternative Payment Systems, Clinical Practice Guidelines, and the Physical Therapy Outcomes Registry Come Together


E-Learning Course | 0.2 CEUs


Productivity or Value: What is the Difference and How Should PTs be judged on Performance?


E-Learning Course | FREE to APTA Members 


APTA relies on members to help monitor payment changes.  Please let us know if you/your facility notes something of concern by using-









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