Yesterday, the Centers for Medicare and Medicaid Services (CMS) issued interim guidance on how the manual medical review process will be implemented in 2013 for outpatient therapy claims that exceed $3,700.     

From October 1, 2012, through December 31, 2012, CMS used a prior approval process at $3,700 under which providers would submit a request to their Medicare Administrative Contractors (MAC) for approval of up to 20 visits. With the request, providers would include information from the patients' medical record (eg, progress reports, daily notes, plan of care) to support the need for the additional visits.      

For 2013, CMS has replaced the prior approval process with prepayment review, at least for the interim. Under prepayment review, when the patient reaches $3,700 in outpatient therapy services, the MAC will send the provider an additional development request (ADR) asking him or her to submit documentation so that the MAC can determine whether the services are medically necessary. Typically under Medicare, MACs have 60 days to make a determination. However, CMS has requested that with regard to the therapy cap manual medical review process, MACs decide within 10 days of receipt of the documentation whether the services exceeding $3,700 will be paid.

CMS currently is working on a long-term strategy for the manual medical review process. 

Physical therapists should consult their MACs' websites for specific information about submitting documentation in response to an ADR.  

The Royal Dutch Society for Physical Therapy (KNGF) has made PTJ its official journal. KNGF members will have access to PTJ Online as one of its member benefits. Editor in Chief Rebecca Craik, PT, PhD, FAPTA, notes in her February editorial, "I am delighted to be entering into this relationship with our Dutch colleagues, [who have] made significant contributions to our understanding of the use of measurement tools to examine clinical effectiveness …, advanced our understanding of clinical practice guideline development and clinician adherence to guidelines, as well as our understanding of professional issues such as direct access, continuing education, and physical therapist consultation in primary care." Philip Van der Wees, PT, PhD, who is affiliated with the Scientific Institute for Quality of Healthcare at Radboud University Nijmegen Medical Center and with Maastricht University, was nominated by the Royal Dutch Society and appointed by Craik to serve on PTJ's Editorial Board; he will share his expertise in clinical practice guideline development and in examining clinician adherence to practice guidelines. Read more at http://ptjournal.apta.org/content/93/2/126.full.

APTA's newly established Scope of Practice Task Force is seeking members to develop recommendations to the Board of Directors on the appropriate role and authority of APTA in decisions on scope of practice in physical therapy and recommend a consistent process and criteria to establish current and future physical therapist scope of practice. Those who are interested should respond to the call by completing a volunteer interest profile found on the Volunteer Interest Pool webpage. The first step is creating a "profile" for service. After developing a profile, to be considered for this task force members must then access the "current opportunities for service page" and respond to the questions specific to this task force. The deadline to respond to this call is March 7. For more information on this task force, click on the link above or contact Karen Jost, PT, MS, senior payment specialist, payment and practice management.

Yesterday, the Department of Health and Human Services (HHS) finalized provisions in the Affordable Care Act ensuring that health plans offered in the individual and small group markets, both inside and outside of health insurance marketplaces (also called "exchanges") offer a core package of items and services, known as essential health benefits (EHB).

Beginning in 2014, all nongrandfathered health insurance coverage in the individual and small group markets, Medicaid benchmark and benchmark-equivalent plans, and basic health programs (if applicable) will cover EHB, which include items and services in 10 statutory benefit categories, including rehabilitation and habilitation services and devices. These benefits will be equal in scope to a typical employer health plan.

The final rule defines EHB based on a state-specific benchmark plan. States can select a benchmark plan from among several options, including the largest small group private health insurance plan by enrollment in the state. The final rule provides that all plans subject to EHB offer benefits substantially equal to the benefits offered by the benchmark plan.

The final rule also includes standards to protect consumers against discrimination and ensure that benchmark plans offer a full array of EHB benefits and services.

Substitution within EHB categories is still permissible to provide greater choice to consumers and promote plan innovation through coverage and design options. The requirement that any substitution must be actuarially equivalent is retained in the final rule. It is up to each state to set criteria for substitution.

HHS does not provide a federal definition of habilitative services in this final rule. If habilitative services are not yetcovered by the EHB-benchmark plan, then states have the first opportunity to determine which habilitative benefits must be covered by their benchmark plan. States may choose either the definition used by the National Association of Insurance Commissioners or Medicaid. If states have not chosen to define habilitative benefits, the health plan issuers' will determine the benefit. This is a transitional policy, and HHS intends to monitor available data regarding coverage of habilitative services. 

HHS also finalizes actuarial values (AVs), also called "metal levels," to assist consumers in comparing and selecting health plans by allowing a potential enrollee to compare the relative payment generosity of available plans. Nongrandfathered health insurance plans must meet 1 of 4 specific AVs: 60% for a bronze plan, 70% for a silver plan, 80% for a gold plan, and 90% for a platinum plan. 

APTA was highly involved in the processes that determined how EHBs should be defined. The association submitted comments to HHS in response to a December 2011 guidance bulletin, the Center for Consumer Information and Insurance Oversight's January 2012 bulletin, and the Institute of Medicine's report Essential Health Benefits: Balancing Coverage and Cost. APTA also took part in all public stakeholder meetings. Throughout the development of EHB, APTA urged HHS' secretary not to overly define the categories so that practitioners have the flexibility to provide both the type and frequency of care that is medically necessary for each individual.

APTA will post a comprehensive summary on the final rule shortly.