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  • Ready for the Post-SGR World? APTA Offers Highlights of New Medicare Law

    If you think the new Medicare legislation is only about ending the sustainable growth rate (SGR) and extending therapy cap exceptions for 2 years, think again: the new authorization act also contains some substantial changes around manual medical review, quality reporting, and incentives for participation in alternative payment models, to name a few.

    Highlights of the changes (.pdf) taking place through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are now available on the APTA website. Some of the changes were imposed immediately; others will be implemented over time. The bottom line: MACRA is laying the groundwork for a significant transformation in how physical therapists (PTs) and other health professionals are paid.

    Among the changes:

    Manual medical reviews of therapy cap exceptions won't be based solely on dollar amounts.
    Sometime around mid-July, the $3,700 trigger for manual medical review (MMR) will be replaced with a system that links MMR to provider behavior and other factors. CMS will look at whether a provider has a pattern of "aberrant" billing practices, the provider's claims denial percentage, whether the provider is newly enrolled, what types of medical conditions are being treated, and whether the provider is part of a group that includes another provider who has been identified in terms of the those factors. The new process will apply to exception reviews that have not been conducted by the anticipated July startup date. APTA will meet with CMS to discuss implementation, and will share details with members over the coming months.

    PQRS, value-based modifiers, and electronic health records meaningful use may be consolidated into a single new quality program.
    These quality programs stay in place for now, but prepare for MIPS—the Merit-Based Incentive Payment System—set to be launched in the future. MIPS will evaluate performance according to quality, resource use, meaningful use, and clinical practice improvement. There are still many details that need to be worked out in terms of the reach of these programs in the future.

    Participation in alternative payment models (APMs) could be a rewarding experience.
    CMS will offer 5% bonuses to PTs and other health care professionals involved in APMs such as accountable care organizations, medical homes, and bundled care systems. Beginning in 2026, CMS will stratify annual updates, providing a .75% annual update to health care professionals engaged in APMs, and .25% for those who aren't.

    Other changes in the new law include a new 1% payment update factor for postacute care providers; the inclusion of physician assistants, nurse practitioners, and nurse clinical specialists as professionals qualified to provide documentation for certain types of durable medical equipment; and requirements that Medicare administrative contractors (MACs) provide ongoing outreach, education, training, and technical assistance to providers.

    Want more information on how the therapy cap exceptions process will work under MACRA? Check out the newly revised therapy cap FAQs.


    • So we aren't even qualified enough to order DME? But others were given that ability who likely know less about DME use and might not even know the ICF model exists?? How sad for us.

      Posted by John on 5/6/2015 7:23 PM

    • Goverment regs are out of hand. CMS does not care about people, they only want to limit care. MACS run CMS because they are insurance companies. Please put my membership dollars to good use instead of "caving" . (dues paid for 32 years, all personal dollars)

      Posted by Vince Smith on 5/7/2015 1:15 PM

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