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  • Proposed Outpatient Payment Rule From CMS Continues Previous Trends

    The US Centers for Medicare and Medicaid Services (CMS) is pushing for an outpatient environment in which payments vary less according to who owns a facility, hospitals get a supervision break, and patients have access to clear information on how much they're being charged for items and services. All 3 concepts figure heavily into the proposed 2020 outpatient payment system (OPPS) rule.

    The proposed rule, released July 29, would complete a 2-year CMS effort to move toward a "site neutral" payment model in its reimbursements for physician services, doing away with a system that pays so-called "off campus" hospital-owned facilities more than it does their independent equivalents. Payment for physical therapy services in outpatient settings are paid under the CMS physician fee schedule and so are not impacted by the OPPS site-neutral policies.

    Other trends continue as well, including an APTA-supported move toward easing supervision burdens placed on hospitals. The proposed rule would change supervision requirements for outpatient therapeutic services in all hospitals from "direct" to "general," meaning that while a given procedure would be furnished under a physician's overall direction and control, the physician's physical presence no longer will be required during the performance of the procedure. The change is viewed as a particularly positive one for critical-access hospitals and other facilities in underserved areas.

    A shift toward greater transparency also is reflected in the proposed rule, with CMS aiming to require hospitals to make their standard charges public for all items and services. These standard charge lists—a facility's gross and payer-negotiated charges for supplies, procedures, beds and food, practitioner services, and a host of other items—would also be required for a limited set of so-called "shoppable services" that can be scheduled by a consumer in advance. CMS puts teeth into the requirement through monetary penalties and publication of violations for facilities that don't comply.

    Another trend APTA is watching: prior authorization, which in the proposed rule would be required for several cosmetic procedures including rhinoplasty. While this doesn't directly affect services associated with physical therapy, APTA advocates in general against prior authorization requirements that slow the delivery of care and limit patient access to appropriate interventions.

    Also included in the proposed OPPS:

    • Payment rates for outpatient hospitals and ambulatory surgical centers (ASCs) would increase by 2.7%.
    • CMS is soliciting comments on adding 4 safety measures to the Outpatient Quality Reporting Program that have already been required of ASCs: patient falls, patient burns, wrong site/side/procedure/implant, and all-cause hospital transfers/admissions.

    A CMS fact sheet on the proposed rule is available online. APTA is analyzing the proposed rule and will provide comments to CMS by the September 27 deadline.


    • I do not see this as any help to the Private Practice PTs. How about making PTA supervision requirements equal to all other setting. It makes no sense for example that a patient following a TKA can be seen by a PTA in the hospital without the PT being on campus. Then move to a SNF, where the PTA can treat again without the PT being on campus. Then they progress and go to home health and yet again can been seen by a PTA without the PT being in the house. Then lastly the pt makes it to the Private Practice and NOW the PT has to be in the building for the PTA to be able to treat. On top of that CMS now wants to pay less if the PTA treats even though the PT is required to be in the building!!!! The Private practice makes less money than all of the mentioned settings and now THEY want to take even more money away??? APTA and PPS where are you - this must stop - those in Private practice should not be penalized for going on their own and if PTs are not going to be allowed to make a decent living then we should have never moved to the DPT and higher costs of education!!

      Posted by Jerry Yarborough on 7/31/2019 10:34 PM

    • I agree with Jerry. Very little of this seems to be directly related with helping my private practice and this lack of supervisory changes seem punitive especially in light of proposed declining reimbursement for PTA's by CMS. I would like the APTA to reign in its focus to issues directly related to our profession, in particular private practice. I understand the notion that outpatient services are viewed by CMS as being similar whether outpatient PT or ambulatory surgery but I would like to hear that APTA is having direct conversations about increasing reimbursement for PT, not decreasing it. Less regulatory controls which limit our ability to actually provide direct access for CMS which really is non-existent for Medicare. I routinely have to wait to see Medicare patient's after IE until the MD gets back in the office from vacations or generally being unavailable to sign my POC's. The FPTA in Florida got us 10 more days to treat for direct access but this still limits our ability to treat more complex patients. Lets talk about matching the actual value of our services with better reimbursement and less regulation so we can really move to the forefront as a first choice provider for the sprain/strain, back pain, sports injuries, etc, instead of where we still seem to be, undervalued and underutilized.

      Posted by Joe on 8/1/2019 9:42 AM

    • To add to Jerry's comment; I'm very disappointed in the APTA for not advocating for the therapists in private practice. Our overall fee schedule over the last many years has decreased while our expenses have gone through the roof. Now in NY where minimum wage is has increased to $15, UHC Communtiy plan is requiring rior auth in a way that is very difficult to obtain and will increase the both the administrative and clinical burden while paying us a measly $40/avg visit & GHI is still paying $27/visit! Apta, its time to wake up!!!

      Posted by Mordechai M Shedrowitzky on 8/1/2019 11:52 AM

    • Right on Jerry! Follow the dollar! Hospital power continues to drive up cost.

      Posted by Dan Fleury on 8/1/2019 12:40 PM

    • All of the above comments ring true! I have worked in all different venues for more than a quarter century in total but struggle the most now that I ventured out and own my own practice! I belong to the private practice section but I have not seen any headway into trying to equal the obvious disparity shown with providing the same care in a different venue.

      Posted by Ivan John Orta on 8/7/2019 5:32 PM

    • General supervision for PTA's in all settings especially with the proposed reimbursement rate for PTA furnishing services! These arbitrary rules/policies make no sense...time to go! Also, need to get rid of the referral requirement/PCP signing POC for physical therapists who all for the most part DPT's!

      Posted by Casey Cortney on 8/7/2019 6:47 PM

    • I am with you Jerry! I think the APTA like most other "organizations" are influenced by large money donors and makers (Hospitals, Chain practices, etc...). I have been a PT for 20 years and a private practice owner for 12 years. I have invested in my education from MPT to DPT, added a COMT, CLT. I have trained and provided jobs to PTs, PTAs, and support staff in my private practice over those 12 years. The endless burden on a private practice owner to carry ALL the responsibility regarding the care of patients, documentation, and billing has become exceedingly stressful (to me not worth it). I currently have a private practice with 5 private treatment rooms all with desk and high low tables and of course a gym. Currently, I am the only provider in my clinic (occupying one room while the other 4 sit idle) and I could not be happier. My pay check is lousy and it does not look like it will to get any better in the near future. However, I can sleep at night knowing that I provide high quality care to my patients and don't have to worry about other therapists skimping on their patients in my practice that always became my head and heart ache. With that said, I am perpetually frustrated when patients show up on my doorstep after being mistreated by other clinics and knowing that clinic gets paid the same rate that i do. I am perpetually frustrated with the APTA as they send new headlines that they are fighting for us,but I think the APTA has forgotten us; here is my case. APTA remember back in 1997 when the $1500.00 rehabilitation cap was put in place on outpatient (Not Hospital outpatient) clinics and in the law speech therapy and physical therapy were combined cap?....you never got it changed! APTA remember when the cap was lifted for a couple years then reinstated in 2007 back on outpatient clinics....we are still under a cap and speech and physical therapy combined....never changed! APTA remember the boloney multiple payment procedure reduction that screws us every patient every visit....it has never been changed! Every year private practice owners have to worry what new regulations, what new cuts, what new expenses are going to take us out. Furthermore, we can't pass the charges onto patients because we are locked in stupid contracts and regulations forbidding us that option...we have to sigh and take the hit. I could continue to rant, but I will stop. I have no ill feelings toward the APTA, they do try, but we have to remember they are utterly useless in a political system that makes laws on whom gives congress the most money. I think as private practice providers, we cannot rely on the APTA to demonstrate, validate, and/or represent our "value." I think as private practice providers, we need to wake up every morning and go to bed every night and honestly evaluate our own worth to the communities we serve and help. We have to accept the fact that we continue to be demonized and disrespected by insurance companies that we are inherently useless and wasteful. We have to continue to plead our patient's case to insurance representatives that are complete idiots and are so uninformed that they have scripted lines to tell us. For example, insurance rep says "we will approve 2 more visits (though I ask for 6) and they need to be discharged on a HEP"....I tell them bluntly, they have been on an HEP since the first visit and it gets updated every visit....sigh! In closing, carry on APTA and good luck to you! I wish you well and by the way, you have forgotten us private practice owners.

      Posted by James Trout on 8/7/2019 8:15 PM

    • I agree with all of the above. Statistically there are better outcomes in a private practice setting as most therapists in these settings are driving to education and are more evidence based in treatment plans. Over the past 30 years I have lost all faith in our organization. The future of PT will be a doctorate level degree that makes $20 per hour. Exactly the reason for shortages in physicians and we are now stuck with less educated PA/NPA’s.

      Posted by Lee on 8/7/2019 9:20 PM

    • I 100% agree the sentiments of the other posts regarding supervision. It appears that once again the big revenue hospital (even rural hospitals have much greater revenue than the average private practice outpatient PT clinic) is being provided with advantage over private practice clinics. To add insult to injury, the APTA is presenting this as a victory? How is this even possible?

      Posted by Bill on 8/8/2019 7:16 AM

    • Thank you for all the comments. So sad what continues to affect our profession...I have nothing to add, I think you've said it all.

      Posted by Heidi Aga on 8/8/2019 11:33 AM

    • I agree with all of the above, as a private practice owner, I haven't seen anything coming out to help us in this setting.

      Posted by Chris on 8/8/2019 2:21 PM

    • I’ve been watching this nonsense for 39+ years now. The American physical therapy Association is nothing more than a bloated bureaucracy that seeks first to preserve itself. I have an idea, for every time we have new requirements and new regulations put on us and every time we have a cut in reimbursement we see APTA cut staff by 20%. Take the money that is saved and give it to the lobbyists who can then implement a solid plan of attack. The APTA is nothing more than a paper tiger that placates its members with false progress.

      Posted by Brian on 8/8/2019 5:03 PM

    • I agree with previous comments and I would like to add some additional ideas. After 40+ years of experience as a PT, I would estimate that only 1 out of 100 PT's own their own PT outpatient practice. The APTA needs to also address the interests of the other 99%. Why are there so few PT's who own their own practice? The private practice section of the APTA found the primary reason was lack of capital and the primary reason a new practice fails is lack of sufficient capital. Their suggestion for the best way to obtain the needed capital was to find an angel (spouse?, parent?). I think a better idea would be to increase re-imbursement for all PT's so we can pay our varying expenses for student debt, mortgage/rent, retirement savings, child rearing, etc. with enough left over to begin to accumulate capital to open our own practices. If we can have more PT's owning their own practices, the APTA would be more sensitive to the interests of the private practice owners. First, we need a strategy to raise salaries across the board. Low salaries are one of the reasons we have low insurance re-imbursement rates. In other fields, unionized workers earn 27% higher salaries on average than their non-unionized colleagues and have better benefits. I don't know why PT's have left this arrow in their quivers. I'm sure there are other strategies and I would like to hear other ideas that have not already been tried without success. Another idea would be a higher re-imbursement rate when the therapy is provided by a PT with advanced certification such as board certified specialist, certification in manual therapy, certification in dry needling, certification in mechanical diagnosis and therapy, or certification in other areas. When I broke my wrist, I could not find a single PT in my area who was certified in manual therapy and had to settle for a local PT owned practice where manual therapy treatments for me were rare and when present crude and not very effective. When my girl friend was having LBP that was resistant to conservative treatment I offered to find her someone who was Cert. MDT. The closest one was in the next state and did not accept her insurance. She travelled and paid out of her limited resources for a treatment that was finally effective. I think, as a profession, we have a responsibility to make these advanced skills available to all our patients. Here's my idea. All insurance would pay an extra $10 for a treatment personally provided by a PT with advanced certification. APTA should start advocating for this change. If treating 2 patients/hour (although almost all practices in my area have productivity goals of 3 patients/hour and sometimes as much as 5 patients/hour). $10 dollars/hour is $40,000 per year, half going to the PT and half going to the practice owner unless the practice owner is the one with advanced certification who would keep the entire $40,000 for herself. I think an extra $20,000 to $40,000 per year would incentivize many PT's to pursue advanced certifications so we could begin to provide these essential services to our patients while accumulating the capital needed to open or keep open our practices. I would love to hear some feedback from others on these ideas.

      Posted by John Skelly, PT, DPT, OCS, MTC, Cert. MDT on 8/8/2019 5:15 PM

    • Absolutely! If APTA isn't going to defend our reimbursements and work toward lowering the admin burden associated with CMS regulations, I'm going to have to keep my dues money. Wake up APTA!

      Posted by Shirley Reed on 8/9/2019 7:49 AM

    • The reason that hospitals and other institutional settings have been afforded a level of general supervision for PTAs is because these health care facilities must meet Conditions of Participation in order to begin and continue participating in the Medicare and Medicaid Programs. According to CMS, these health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. These facilities also must be surveyed by the state to make sure they are meeting these safety and quality standards. Private practitioners do not have to meet Conditions of Participation and are not surveyed by the state. APTA has communicated with CMS in the past regarding changing the supervision level of PTAs from direct supervision to general in the private practice setting, but the trade-off would be requiring private practitioners to meet Conditions of Participation.

      Posted by APTA Staff on 8/9/2019 8:48 AM

    • Thank you for the clarification above, however it is obvious from all the comments we as private practice owners are drowning in restrictive policies and overhead and want to see some real work by our organization to lighten our load and help us be reimbursed appropriately. We work hard and our reputation & success depends on us getting good outcomes, yet we continue to see declines in reimbursement and additional programs that require us to pay more overhead. It is ridiculous. I love my work, but I am tired of fighting an uphill battle against POPS, Hospitals & insurance companies that want to pay us pennies.

      Posted by Kristi Olivotti on 8/24/2019 9:14 AM

    • Hear! Hear! Ditto all comments. Reimbursement hassles make me think seriously about retiring but I love me work...

      Posted by J Mast on 8/28/2019 11:58 AM

    • Very disappointing that the APTA continues to cater to the hospital systems rather than helping our private practices! I guess money talks as always.

      Posted by Chris on 8/30/2019 7:07 PM

    • I agree with all comments mentioned above. I myself is in private practice and have been an APTA member since 1992. I completely feel same sentiment with other private practice. Our practice expense keep rising and our reimbursement keep decreasing. There will be a point where all PP can no longer afford to keep the door open. Let’s say all of us PP APTA members boycott our membership dues since these hypocrites organization is working against us anyway. Let’s see how many will join me. I have dealt with them and at one point been on a PT PAC $$$$. I said that is enough.

      Posted by Alex on 8/31/2019 2:47 PM

    • I think all of the comments above are interesting and are founded. However, just for clarification, what does "site neutral" mean? Does that mean that hospital based off-site outpatient facilities will no longer receive the facility fee? I know this is obviously speaking about Medicare, but when patients come in and report that they paid $75 for a visit and $75 for a facility fee (for Anthem), this is a problem. Especially, when physicians are obliged to refer to the hospital based services. I'm just curious. Thanks.

      Posted by Leigh Langerwerf on 9/5/2019 2:53 PM

    • @Leigh (get ready for a long one!) In the context of Medicare – Congress and CMS have been concerned about Medicare programs (Outpatient Prospective Payment System) paying more for the same services provided at hospital outpatient departments than in other settings, such as an ambulatory surgery center, physician office, or community outpatient facility. GAO conducted a report several years ago and concluded that paying substantially more for the same service when performed in an HOPD rather than a physician office provides an incentive to shift services that were once performed in physician offices to HOPDs after consolidations have occurred. Accordingly, Congress and CMS have undertaken efforts to make payments to off-campus hospital departments “site neutral," meaning the hospital’s services are not reimbursed under the Medicare Outpatient Prospective Payment System, but instead are paid a Medicare Physician Fee Schedule equivalent rate, which is the same rate Medicare would pay to a physician practice for the same service. In the context of the CY 2020 OPPS proposed rule, CMS states it is continuing its policy to use the Medicare Physician Fee Schedule (PFS)- equivalent payment rate for the hospital outpatient clinic visit (HCPCS code G0463 [conducted by a physician]) when it is furnished by certain off-campus provider-based departments. **Note: Outpatient physical therapy services furnished under a plan of care are already paid under the Medicare Physician Fee Schedule in the hospital. Also, under Medicare, outpatient rehabilitative therapy procedures, including those relating to PT, OT, and SLP, regardless of whether they are furnished in facility or nonfacility settings, are paid the nonfacility rate. Please also note that the Medicare nonfacility rate is higher than the facility rate. References: Chapters 5 and Chapter 12 of the Medicare Claims Processing Manual.

      Posted by APTA Staff on 9/6/2019 8:03 AM

    • Hello everyone, I am a PTA and have been researching the PDPM/PDGM changes at length in order to make the best decision as to which setting will provide the most stability. I was in Skilled Nursing PRN; although I am technically still employed there, I haven't been offered any hours because I would not accept the 10/hour pay cut that "everyone else" accepted. I am currently working in HH, but I know the changes are hitting in January, so I figure it will be another repeat of the same thing. I have been offered a job in OP, but I will have to make a substantial move for it. With what I am reading, it sounds like it's a high possibility I will have the same thing repeat, yet again. I have asked management if that is the case and was told that wouldn't happen; but as we all know you have to be careful about trusting your resources. I have a BA in Exercise Science as well, and am seriously considering getting re-certified as an Exercise Physiologist and getting my own thing going, because trusting someone to provide a stable job in this setting with these change honestly seems kind of ignorant at this point. Any thoughts or suggestions as to what you would do in my situation are appreciated. I know nothing is guaranteed, but it never hurts to get the most information possible before making large decisions.

      Posted by Kylie on 11/27/2019 10:17 AM

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