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  • Rehab Research Bill Passes Major Hurdle in Senate

    APTA's efforts to support improvements in rehabilitation research just received a major boost by way of a US Senate Committee, which has completed the "markup" phase of a bill that would bolster research efforts at the National Institutes of Health (NIH).

    Next stop: the Senate floor.

    Titled the "Enhancing the Stature and Visibility of Medical Rehabilitation Research at NIH Act," (S. 800), the bill passed through markup by the Senate Committee on Health, Education, Labor, and Pensions (HELP) with only minor changes. The Disability Rehabilitation and Research Coalition (DRRC) worked with NIH and the office of Sen Mark Kirk (R-IL), the bill's sponsor, to develop the necessary compromises. APTA is on the steering committee of DRRC, which is composed of over 40 organizations committed to promoting rehabilitation research.

    If signed into law, the bill would help better coordinate rehabilitation research across all institutes at NIH in several ways, including statutorily defining medical rehabilitation research to ensure continuity in the use of the word, and standardizing reporting mechanisms to enhance the coordination of research.

    The bill is based in part on recommendations from an NIH blue ribbon panel that was co-chaired by Rebecca Craik, PT, PhD, with members that included Anthony Delitto, PT, PhD, and Alan M. Jette, PT, PhD. The panel's recommendations, issued in 2013, were supported by APTA, with then-APTA President Paul A. Rockar Jr, PT, DPT, MS, characterizing the findings as ones that reflect APTA's "core principles," and are "critical to meeting the NIH's mission and impacting society in a positive manner."

    The bill will join a package of Senate legislation that serves as a companion of the 21st Century Cures legislation (H.R. 6) on the House side that passed last year.

    Improvements to rehabilitation research and support of NIH work in this area are among APTA's public policy priorities.

    Jimmo Message Hasn't Sunk In; CMS Needs to Do More

    When theJimmo v Sebelius settlement was announced in 2013, patient advocates applauded what they saw as a landmark change for individuals who need care to maintain their medical conditions or slow their declining health. However, 3 years later, many providers and payment adjudicators are still making coverage decisions as if they're living in a pre-Jimmo world—mostly because the US Centers for Medicare and Medicaid Services (CMS) hasn't done enough to bring them up to speed, according to an advocacy group supported by APTA.

    Recently, APTA provided a supporting declaration to the Center for Medicare Advocacy's (CMA) efforts to get CMS to do a better job of making it clear that the "Improvement Standard"—the idea that Medicare coverage can only be extended if that care will actually improve the patient's condition—is a fallacy, and that skilled maintenance care can qualify for payment.

    "There are still many providers and contractors who do not know about, understand, or trust the change in the improvement policy," CMA wrote in a December 2015 letter to APTA and other stakeholders. "We believe this is largely due to the fact that CMS' Education Campaign was insufficient to make up for the rigor with which Medicare enforced the Improvement Standard—for decades." According to CMA, CMS conducted only 1 briefing for providers and adjudicators, in early December of 2013. Since that time, CMS "has refused to do more," CMA writes.

    APTA agreed with CMA's take on the situation and submitted a declaration of support, writing that the information provided by CMS is "introductory in nature and [has] not been sufficient in educating our members."

    "Approximately 2 years after the CMS National Education Campaign, APTA is still receiving inquiries from physical therapists regarding the coverage of skilled maintenance therapy under Medicare," APTA writes. "We have found that many providers have not received any information regarding the settlement … or remain confused about the proper application of the skilled maintenance therapy benefit." The association suggests posting answers to frequently asked questions, sharing information briefs on what to do in case of denials, hosting national calls, and sponsoring regional town halls.

    Patients and physical therapists do have recourse: CMA has created a "self-help packet" for appealing denials of outpatient therapy that may have been made based on a pre-Jimmo understanding of payment policy. The webpage featuring the packet also contains background information on Medicare coverage and the "improvement myth," therapy cap exceptions, and appeals processes.

    APTA engaged in an extensive effort to educate its members on the Jimmo settlement, and maintains a webpage on skilled maintenance that includes links to a podcast series, a recorded webinar, and several pages of frequently asked questions.

    APTA Adds Physical Therapy Perspective to Senate Work Group Report on Chronic Health Conditions

    The challenges of providing care to individuals with chronic health conditions are now the focus of a bipartisan working group in the US Senate, and APTA is helping to shape the group's policy proposals.

    In December 2015, the Senate Finance Committee's Bipartisan Chronic Care Working Group issued a 30-page "policy options document," the product of a 6-month investigation of possible ways to improve care delivered to Medicare beneficiaries with chronic health conditions. The information-gathering process included over 80 stakeholder meetings and 530 recommendations, with the final document including 24 policy proposals ranging from the changes to the Medicare Advantage (MA) program to expanded education and research initiatives.

    According to the work group, the policy changes listed in the document are aimed at increasing care coordination, streamlining Medicare payment systems "to incentivize the appropriate level of care," and establishing a chronic care system that "facilitates the delivery of high quality care, improves care transitions, produces stronger patient outcomes, increases program efficiency, and contributes to an overall effort that will reduce the growth in Medicare spending."

    On the whole, APTA's comments to the proposals were supportive, with the association focusing on 12 proposals that would most directly affect physical therapy. Among them:

    Expansion of the Independence at Home demonstration project into a "permanent, nationwide program." APTA supported the idea, but advocated for a careful approach.

    Continued access to MA special needs plans. APTA asserted that "all plans have access to physical therapy services."

    Provisions that would allow MA plans to vary benefit structures to meet the needs of chronically ill enrollees. APTA supported this idea, but called for care in the definition of "non clinical" professionals.

    Telehealth provisions that would expand opportunities for use in MA, accountable care organizations (ACOs), and for beneficiaries poststroke (3 separate policy proposals). APTA supported all 3 proposals, particularly in relation to physical therapy, writing that "telehealth will not replace traditional client care, but it will give [physical therapists] and [physical therapist assistants] the flexibility to provide services in a greater capacity."

    Ensuring accurate payment for individuals who are chronically ill. APTA wrote that it was "generally supportive" of the proposal, but suggested that to truly achieve a more effective payment system, additional regulatory changes need to happen—including a full repeal of the Medicare therapy cap.

    The association also commented on proposals to increase care coordination among ACOs, the development of quality measures for chronic conditions, and a suggestion to increase transparency at the CMS Center for Medicare and Medicaid Innovation (CMMI), a center that should create more grant funding opportunities "aimed at providers such as physical therapists," according to APTA.

    APTA highlights the role of the physical therapist and physical therapist assistant in the treatment of chronic conditions through its prevention, wellness, and disease management webpage. In addition, the 2015 House of Delegates adopted the position Health Priorities for Populations and Individuals (RC 11-15) "to guide [APTA's] work in the areas of prevention, wellness, fitness, health promotion, and management of disease and disability." The priorities include active living, injury prevention, and secondary prevention in chronic disease and disability management. The topic was also the subject of a popular presentation at the 2015 NEXT Conference and Exposition.

    Also available from the APTA Learning Center: "Disease Management Models for Physical Therapists: Focus on Diabetes and Cardiovascular Disease."

    Advocacy Forum, Upgraded App: Get This Year's Efforts Off to a Strong Start

    Ready for some physical therapy advocacy? Because advocacy's ready for you.

    APTA's 2016 advocacy efforts are up and running, with plenty of opportunities for members to participate in person or by way of their handheld device of choice.

    This year's Federal Advocacy Forum is scheduled for April 3-5 at the Grand Hyatt in Washington, DC. It's your opportunity to make the physical therapy profession's voice heard loud and clear on Capitol Hill, and to network with other professionals who share your commitment.

    With the sustainable growth rate gone from the Medicare physician fee schedule, APTA government affairs staff see opportunities to focus on other important issues that deserve attention and action.

    Registration and information on housing is available at the APTA Federal Advocacy Forum webpage. Special room rates are available until March 11, and CEUs are available for the event.

    Whether or not you can make it to DC this April, you can still participate in professional advocacy through the APTA Action App, the grassroots tool that makes it easy to stay on top of issues and influence state and federal decision-makers.

    The upgraded app is even more powerful than before, and now includes state government affairs information for a growing list of states—29 and counting. Available for free, the app includes an action center to contact lawmakers in Congress and in the state legislatures, Congressional and state directories, talking points, and more.

    If you don't have it, get it. If you downloaded the app earlier, be sure to get the update. The APTA Action App is available in the Apple and Google Play app stores.

    2016 - 01 - 27 - Advocacy App

    CDC Says Nondrug Approaches 'Preferred' to Treat Chronic Pain; APTA Adds its Support

    The US Centers for Disease Control and Prevention's (CDC's) draft clinical guidelines on the use of opioids for chronic pain make it clear: nondrug approaches such as physical therapy are the "preferred" treatment path for chronic pain.

    APTA couldn't agree more.

    This week, APTA submitted comments to a new CDC document aimed at primary providers who may prescribe opioids to treat chronic pain. The guidelines attempt to rein in growing rates of opioid use disorder and opioid overdose, and to help reduce the prevalence of opioid prescriptions, which topped 259 million in 2012—"enough for every adult in the United States to have a bottle of pills," according to the CDC.

    The guidelines were developed after expert review of evidence around not only the effectiveness of opioids (and their dangers), but also the ways in which nondrug approaches can be used in treatment. After evaluating the evidence, the CDC drafted recommendations around determining when to initiate or continue opioids for chronic pain, as well as guidelines for drug selection and dosage, and risk assessment.

    Its first recommendation: "Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain."

    "Based on contextual evidence, many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, complementary and alternative therapies (e.g., manipulation, massage, and acupuncture), psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain," the draft states. "In particular, there is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip … or knee … osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2–6 months."

    In its comments to the draft, APTA applauds the recommendations, stating that approaches such as physical therapy "have been underutilized, and, therefore, can serve as a primary strategy to reducing prescription pain medication abuse and improving the lives of individuals with chronic pain."

    APTA's comments also note that referral to exercised-based interventions "is essential prior to the initiation of opioid-based therapy," and that exercise interventions "have the potential to improve health outcomes, reduce costs, and decrease the risks associated with opioid prescriptions."

    The association goes on to recommend that the CDC provide clear guidance on the patient populations that would benefit from nondrug approaches, and that more extensive patient education resources should be developed on the benefits of exercise-based interventions over opioid prescriptions. This education needs to be aimed at both the public and primary care providers, ATPA writes.

    APTA also added its support to CDC recommendations around the use of multidisciplinary approaches to management of chronic pain, such as a combination of physical therapy and cognitive-based interventions. The problem, the association points out, is that although supported by evidence, the approaches "have been challenged by reimbursement policies." APTA recommends that the use of multimodal approaches to treat chronic pain be part of a broader effort to change payment policies in ways that make them more amenable to nondrug approaches to chronic pain.

    The CDC guidelines—and APTA's comments—come at a time when the fight against opioid abuse and heroin use has gained attention at a national level. The issue was a part of President Barack Obama's final State of the Union address on January 12, and the epidemic is the subject of a White House initiative that includes APTA and other health care and corporate partners. At the state level, West Virginia—one of the states hardest hit by the opioid abuse problem—has announced the formation of a new House committee on substance abuse. That committee includes Rep Mick Bates, PT.

    Quick Quiz: When Medicare Says You've Been Overpaid

    There you are, hard at work. Your patients are making progress, you're feeling good, things seem to be going along just fine, and then—boom—you get a letter from the Centers for Medicare and Medicaid Services (CMS) saying they think they've overpaid you on a claim. It's enough to ruin anyone's day.

    Think you know your way around the overpayment process? Take this quick quiz, and then check out this CMS fact sheet for more details on the options available to you if CMS says you’ve been overpaid on a claim. (Quick tip: When it comes to the overpayment process, deadlines matter and are taken seriously. The CMS fact sheet also lays out timelines clearly—you may want to keep a copy handy.)

    Ready? Here we go.

    1. Overpayments above which amount will trigger the Medicare Administrative Contractor (MAC) recovery process?

    A. $5
    B. $10
    C. $25
    D. $50

    2. If you don't repay the alleged overpayment (or submit a rebuttal to the MAC), when does interest begin accruing?

    A. On the initial notification
    B. 30 days after notification
    C. The next quarter of the year
    D. Upon submission of a subsequent claim for reimbursement

    3. Which of the following is NOT an option if you receive an overpayment demand letter?

    A. Make an immediate payment
    B. Request that the overpayment be immediately recouped through reductions in current due or future claims you've submitted or will submit ("immediate recoupment")
    C. Request that the MAC reduce your payments on claims beginning 16 days after the demand letter was issued ("standard recoupment")
    D. Request an extended repayment schedule (ERS)
    E. Submit a rebuttal explaining why Medicare shouldn't begin recoupment
    F. Request a redetermination to appeal the overpayment determination
    G. Ignore the whole thing and binge-watch "American Gladiators"

    4. True or false: It's possible for an appeal to an overpayment determination to be decided in Federal District Court.

    5. How many days after a demand letter is sent do you have to request an appeal of the determination and stop recoupment?

    A. 7
    B. 15
    C. 30
    D. 60



    Answers: 1-C; 2-B; 3-G; 4-True; 5-C.

    Lymphedema Coverage Legislation Now in House and Senate

    Expanding Medicare coverage for lymphedema treatment, a change long-supported by APTA, may be closer to reality now that companion bills to that effect have been introduced in the US Senate and House of Representatives.

    In early December, Sen Maria Cantwell (WA), along with Sens Chuck Grassley (IA), Charles Schumer (NY) and Mark Kirk (IL), introduced the Senate version of the Lymphedema Treatment Act (S. 2373), a proposal that would expand the range of compression supplies covered by Medicare "that are the cornerstone of lymphedema treatment," according to a consumer group created to support the legislation. The version introduced in the Senate is companion legislation to a House bill (H.R. 1608) introduced in March by Rep. David Reichert (WA-8). The House bill now has 175 cosponsors.

    APTA's support for the legislation dates to 2014, when association representatives participated in a congressional hearing to educate lawmakers and staff on the bill after its introduction.

    More recently, APTA President Sharon Dunn, PT, PhD, OCS, reemphasized the association's backing for the bill in a letter to Reichert.

    "Currently, many of these items and services either are not covered or only are covered on a limited basis," Dunn wrote. "Passage of this legislation would ensure access to these supplies for individuals with lymphatic impairments and conditions." In her letter, Dunn also emphasized the role of physical therapists in manual lymph drainage, fitting patients for compression garments, and helping them engage in exercises to improve their cardiovascular health and potentially decrease swelling.

    APTA staff will monitor the legislation’s progress and update members with news and advocacy opportunities.

    UnitedHealthCare to Cover Standing Systems as Medically Necessary

    Thanks in part to expert input from APTA, beneficiaries of UnitedHealthCare (UHC) who are nonambulatory and can benefit from stationary, mobile, or active standing systems may have the cost of the system covered by their insurance. UHC has reversed its medical policy on covering the costs of standing systems (.pdf) after asking for and receiving recommendations from APTA. The new policy became effective December 1, 2015.

    Commercial payers such as UHC periodically ask professional societies to provide evidence-based guidance during reviews of their coverage policies, to ensure that policies are comprehensive, accurate, and up-to-date. APTA pulled together subject matter experts who presented evidence to UHC's Assessment Committee earlier this year; that presentation contributed to UHC changing its stance on the medical necessity of standing systems for patients who meet certain criteria. The evidence showed that enabling these patients to maintain an upright posture can increase their range of motion, reduce swelling, decrease spasticity, prevent pressure sores, improve bowel and bladder function, and maintain bone density, muscle strength, and cardiovascular endurance. Not only can these and other benefits improve the patient's quality of life, they can reduce or avoid costly medical procedures.

    Among the criteria for considering a standing system to be medically necessary for a particular individual are that the person must have been unable to accomplish his or her medical goals with current devices, equipment, or alternative treatment; and an independent review must show that the person complies with usage requirements and tolerates the system, and must show demonstrated potential clinical benefit.

    The updated policy still considers some key accessories as convenience items; however, the decision to cover these systems in general is major progress toward transforming the lives of our patients by providing them with the necessary tools to optimize their function.

    Deadline Extended on PQRS Penalty Letter Requests

    Editor’s note: After this story posted, the Centers for Medicaid and Medicare Services again extended the deadline to submit review requests. The new deadline is December 16, 2015.

    The Centers for Medicare and Medicaid Services (CMS) announced that it is extending the deadline for providers to question Physician Quality Reporting System (PQRS)-related penalty notices they may have received. Instead of a November 23 deadline, CMS will accept "informal review" requests until midnight on Wednesday, December 16.

    APTA is aware that some members have received letters related to PQRS performance during 2014. If you believe you have received a penalty notice letter in error, be sure to submit an informal review request through the CMS "QualityNet" website by the December 16 deadline.

    CMS has informed APTA that providers have been experiencing problems in reaching QualityNet over the past several days, and says that it's attempting to fix the problem. APTA is also working with CMS to ensure that physical therapists are not unduly penalized for 2014 PQRS performance.

    Questions? Problems with filing an informal review? Contact the APTA advocacy staff.

    Want more on PQRS? A recording of APTA's recent webinar, "Physical Therapy and PQRS in 2016: How to Report Successfully," will be available in the coming weeks.

    Lives Transformed by Physical Therapy Recognized at MoveForwardPT.com

    There was a point in Scott Aldridge's life when he wondered if he was about to lose the ability to walk. He was 50 years old, 520 pounds, and dealing with chronic venous wounds on his legs.

    He wasn't particularly hopeful that he could get better. But his physical therapist, Stephanie Fournier, PT, DPT, WCS, CLT-LANA, had other ideas.

    Three years, more than 300 pounds, lots of physical activity later, Aldridge has an uplifting story worth sharing—and APTA is helping that story find a wider audience.

    Aldridge's transformational story is now part of the Patient Stories section of APTA's official consumer information website, MoveForwardPT.com. Publication of the story will be followed by a podcast in which Aldridge describes his incredible improvement and Fournier's role in inspiring that change.

    Additional stories of lives transformed by physical therapy will follow every Monday into 2016—stories of people who recover from devastating accidents, regain the ability to walk, return to activities they once loved, and learn what they're capable of in the process.

    While stories such as these aren't new to physical therapists, physical therapist assistants, and students of physical therapy, their inspirational messages can enhance the public's understanding of the transformative power of physical therapy.

    To support the campaign, follow MoveForwardPT on Facebook and Twitter. Please also consider encouraging a patient whose life was transformed by physical therapy (in ways big or small) to submit their story at MoveForwardPT.com for consideration.