Payment

 2018 Payment updates

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: https://www.cms.gov/Regulations-and-guidance/Guidance/Transmittals/2018Downloads/R2047OTN.pdf

 If you become aware of issues with Medicare Advantage plans in your state, please contact APTA at advocacy@apta.org 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.

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2019Part2.pdf

 

Value Based Care Podcasts and Resources

http://www.apta.org/VBC/

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- https://www.nhapta.org/Contact/

 

 

 

 APTA

NHAPTA Liberty Square Group
4 Liberty Sq, #500
Boston, MA 02109
(857) 702 – 9915
nhapta@libertysquaregroup.com