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  • New Medicare Conditions of Participation Guidelines for Hospital-based Outpatient Settings

    APTA currently is in discussion with the Centers for Medicare and Medicaid Services (CMS) regarding new interpretive guidelines that were issued November 18, 2011. This recent interpretation states that rehabilitation services must be ordered by a qualified practitioner who is responsible for the care of the patient and who has medical staff privileges to write orders for these services. CMS' Conditions of Participation rules apply to both inpatient and outpatient hospital-based settings and apply not only to Medicare beneficiaries but to all patients who receive services at the hospital. 

    APTA believes that this new interpretation is inconsistent with the current regulation and that it poses problems for physical therapists and their patients in hospital-based settings. The association is working diligently to get further clarification from CMS and will keep members updated as soon as more information is available.


    • I agree that this is a problem. I work at a regional hospital and we need to take PT/OT and ST referrals from large urban teaching hospitals when patients return to our isolated town.

      Posted by Mary Veale -> =GSZDF on 1/4/2012 5:17 PM

    • I agree that this is a significant issue to all regional hospitals. We frequently take PT/OT and ST referrals from larger urban teaching hospitals. This allows the patient to receive follow up care closer to home. The commute to the larger hospitals will prevent some patients from getting follow up care.

      Posted by Julie Parfitt -> =KY`EF on 1/4/2012 6:21 PM

    • Another problem with the CoP's for hospitals is the requirement that all physician orders be timed. While this is not a problem in the inpatient setting, it's a huge problem for outpatient therapy orders received from both physicians who have hospital privileges as well as those that do not. Rick Gawenda, PT President Section on Health Policy & Administration APTA

      Posted by Rick Gawenda -> =IY`?L on 1/4/2012 8:44 PM

    • This is a problem for our PT dept. at a Critical Access Hospital in Hawaii. Many of our referrals come from orthopedic surgeons who are on the island of Oahu. Patients return home from Oahu to this small island, for rehabilitation following surgery at the Oahu hospitals. Other specialists at the Oahu hospitals also refer patients to us. Most do not have privileges at our small hospital. Posted by Mary Anne Hill

      Posted by Mary Hill -> =GVaCK on 1/4/2012 9:42 PM

    • I agree that this is a very significant and serious problem for compliance, and is not needed. On the IP side, patients are already referred by physicians that are priviledged on that hospital staff. On the OP side, a significant percentage of patients are referred by physicians who are licensed to practice medicine, referred to licensed PTs, who follow all Medicare guidelines; the new law would require added cost for the patient to travel back ONLY to where they could be seen; having the patient see another (priviledged) physician locally so that the referring physician meets criteria delaying care and adding unnecessary cost). On our administrative end, we would need to make sure that the referring physician is priviledged and then maintains their priviledge- another expense. This is an example of overregulation that does not add quality or value to to the patient experience- only cost. Ed Dobrzykowski

      Posted by Edward Dobrzykowski -> >OT_D on 1/6/2012 3:20 PM

    • I think this is more then fair. Hospital based outpatient practices have all kinds of special privileges free-standing clinic don't, the greatest of which is no cap restrictions because they are hospital based, whether their location is any were near the hospital. Regulating care to that hospital's participants is at least attempting to level the playing field. I don't think any care not referred directly from a hospital stay should be allowed at hospital based outpatient practices. Why else do they have special privileges with regard to cap exemption directly related to hospital based status.

      Posted by Trevor Harting on 1/6/2012 4:10 PM

    • This would be another needless burden for both the patient and the provider. The Joint commission looks to see if we check the licensure of every non facility credentialed referral source. If this were to stand, the attending staff would not be able to handle the volume and patients would go without their care. Question...does this apply to all non rehab outpatient services as well?

      Posted by Jim Dunleavy PT, MS on 1/6/2012 4:51 PM

    • Do hospital based outpatient clinics have any advantage because we are exempt from the reimbursent caps? It seems to me that the effect of the cap exemption is to ensure that our case mix is predominantly medicare (who reimburses well below what private insurers reimburse). We average around 40% medicare at our clinic while our competitors can refuse to accept medicare patients and fill their schedules with better paying insurers. Maybe I'm all wet Trevor, but I don't see the advantage of the cap exemption the way that you do. This issue is about putting unnecessary burden on the clinics who will be seeing the majority of these patients. I hope that the APTA can get this wording changed.

      Posted by Joe Falls PTA on 1/6/2012 7:32 PM

    • Keep in mind as well, all OP hospital based clinics must be within a 35 mile radius from the main hospital, have to follow the JCAHO standards that the private clinics do not- they are reviewed as part of the hospital JCAHO review; All settings (private and hospital based) must be ADA compliant; but in the hospital based world they also must have the state dept of public health come in and approve the setting and set up with their standards prior to operations and this must be maintained- subject to reviews as well; They are much more heavily regulated then the private clinics. There is a significant cost to that.

      Posted by mjacobson, PT on 1/7/2012 10:37 AM

    • Is this not just a blatant attempt by CMS to have another avenue for denials for non-compliance? Otherwise it makes no sense. I work in a small to medium sized town in a hospital based OP clinic, where we probably have over 100 local and county PCPs that don't have priveledges at our hospital. There aren't enough private practices to handle the amount of business that we would have to turn away until we came up with some type of credentialling process to serve the public. I think Trevor is very short sighted, is it about a playing field or helping people?

      Posted by Jim Estes, PT on 1/8/2012 12:17 PM

    • Patient autonomy is the real loser in this ruling. I work for a hospital based OP clinic, but do not want to choose a PT or any other healthcare professional based on where I initially sought medical care. Just as with any business with competition, some hospitals are better at others in areas of care, but patients should not have their continuum of care dictated to them based on previous treatment. This is a very poor ruling and will hurt patient care in the end. Let's fight this as colleagues no matter what our setting.

      Posted by Josh Farley, DPT on 1/9/2012 10:44 AM

    • In rural hospitals this would be the kiss of death for hospital based outpatient clinics, that receive the bulk of their referrals from larger teaching hospitals. The patients would be forced to drive long distances to get their care. This is another example of the federal government's attempt to silo healthcare to specific areas. I think the APTA needs to fight hard to change the wording of this law. The federal government is trying to decrease utilization every way they can, unfortunately it will lead to poor health outcomes for our elderly.

      Posted by Ellis Hall on 1/9/2012 11:00 AM

    • My answer to Ellis Hall is perhaps the federal government is trying to decrease the over utilization of therapy services. Too many therapists still treat to the end of insurance, struggling to find real need for continuing treatments until the money stops..

      Posted by martha propst on 1/9/2012 3:47 PM

    • It is absurd that legislators or bureaucrats make rules like this one. The license to practice in good standing is all that should matter.

      Posted by Tom Reeves DPT ATC on 1/9/2012 3:51 PM

    • As P.T. and a Manager of a Rehab department in a small hospital (both in and outpatient), I see this as a major detriment for the Medicare population accessing Physical Therapy in the outpatient setting and having the CHOICE of location, as many of our patients live in the vicinity, are limited by access to transportation, the trend in my area of closure of other hospital outpatient clinics, OR freestanding clinics not taking Medicare patients.

      Posted by Heidi Endert on 1/10/2012 5:54 PM

    • Talking about leveling the playing field: Ad to this the restriction that all medical staff can ONLY refer to a hospital based clinic( does this change the taste?). This is one of the most absurt proposed rules I have seen in a long time!

      Posted by Sednanre,P on 1/12/2012 11:11 AM

    • 482.54 of the CoP speaks to Outpatient Services, and it does not contain such restrictive language for limiting referrals to only those that come from the hospital's medical staff physicians. That said, we can only hope that 482.56(b) speaks to "Inpatient" Rehabilitation, which seems to make more sense.

      Posted by Sid Hsu on 1/12/2012 4:04 PM

    • I see this as a problem. I am a lymphedema therapist in a large,urban hospital based outpatient setting. I receive referrals from physiacians all over the state since most small towns don't have lymphedema therapists. Many of my patients drive quite a way to see me for treatment, but are so thankful for the treatment. Now they won't be able to receive qualified treament for this difficult diagnosis.

      Posted by Ginger Stover on 1/15/2012 3:42 PM

    • So, is anyone following this currently? We also have several therapist who are certified in many different areas including lymphedema & vestibular rehab. Many physicians refer to us specifically for those purposes. Is anyone turning patients away due to this?

      Posted by Tammy Rouse on 1/16/2012 12:09 PM

    • I am the manager of a PM&R Department (inpt and outpt) and we have not changed practice...yet. I just learned of the proposed changes yesterday and I am hoping the APTA provides direction in short order. Has anyone taken steps to follow this guideline?

      Posted by Keith Hammerschmidt on 1/20/2012 10:12 AM

    • Is there any additional information about this ruling?

      Posted by Michael Duchaj -> =OS`EG on 1/23/2012 6:38 PM

    • I have just searched all websites and Medicare for updates or fruther explanation but find none. We have reached out to our hospital state organization for assistance.

      Posted by Lynne Holland on 1/25/2012 9:38 AM

    • I have not and CANNOT change our practice. I am the director of a hospital department in northern Arizona. We serve people who live in rural areas, including the surrounding reservations. While there are several other PT practices in our city, they may not accept the state Medicaid or IHS. We also provide many services not offered by others such as wound care, lymphedema management and PT is integrated with other disciplines which is necessary for many of our patients. I am disturbed that some of the comments mention leveling the playing field and the importance of assuring all PTs in private practice get an adequate number of patients. These comments ignore the real needs of the people we are entrusted to serve. I appreciate the work the APTA is doing to address this tranmittal and look forward to direction as to how the membership can best help.

      Posted by Lori Pearlmutter on 1/25/2012 11:41 PM

    • I am also concerned over the exclusion of nurse midwives. We have found that there is an enourmous amount of need and demand for pelvic floor PT. The primary area of need and referral sources are the nurse midwives in the area. There are no private PT's offering this service within a 3 hour drive of our rural location. This exclusion will create significant barriers to care and leave a large population of individuals without available treatment.

      Posted by Douglas Keith on 1/26/2012 9:00 AM

    • I agree with Lori in AZ. I am Director of Rehab in a smaller community hospital. We provide multi-discipline services to Medicare and Medicaid patients that they cannot receive in the other private clinics in the area. Many of our Medicare patients cannot drive far or depend on others for transportation. Copays are different for freestanding vs. hospital-based, and we try to alert our patients so they don't end up spending way more than they have to. Instead of fighting turf wars with each other, we should be working together to meet the needs of all of our patients. Besides, Medicare is looking at putting the cap in place in hospital OP. Let's hope that doesn't happen.

      Posted by Sue Dupont on 1/26/2012 6:30 PM

    • Crazy interpretation. Where is patient choice in this decision? So if you are holding a valid PT referral and you want to see the PT Guru in your town who happens to work for a hospital you can't unless your referring physician has privileges there. So now in order to see that PT you need to visit a physician with hospital privileges to obtain a referral. Along the way everyone is billing Medicare for the visits, and we wonder why our healthcaresystem is going broke......

      Posted by Ryan Grella on 1/26/2012 10:29 PM

    • As a followup our state organization has reached out to AHA. AHA is drafting up a comment/clarification letter and has been talking to CMS about this issue.

      Posted by Lynne Holland on 1/27/2012 1:47 PM

    • Today we started implementing a plan to comply with this ruling. This applies to all outpatients not just Medicare outpatients. I am a rehab director for a small rural hospital with 4 outpatient clinics, two of which are in areas with limited access to services, one is in an areas where there are no hospitals or private practices. As far as I am concerned this ruling is worse than the cap because at least with the cap a patient has a choice where they can go for care for a limited amount of time, with this there is no choice. I agree with Sid Hsu, it sounds more like Inpatient Rehabilitation language than outpatient language. Until it changes, we don't have a choice but to comply. If we don't comply we are putting our hospital's at risk. I too, am grateful for the APTA's efforts in resolving this issue and once I get our patient's taken care of, I plan on writing my legistlators about the negative effects of this ruling on their constituents.

      Posted by Sandy Myers on 1/27/2012 3:47 PM

    • This is great news as the hospitals have been buying up physician practices for years and prohibiting them from referring to less costly private practice outpatient centers. If the physician does refer to a place outside the hospital based facilty their charts are flagged.

      Posted by George Herbig on 2/3/2012 9:43 AM

    • Mr. Herbig, While I understand your concern and I think the practice you speak of occurs, I don't think it is widespread (to that extent). I don't have proof of this, but I think that is besides the point. We are very careful to expouse the benefits of returning to our hospital for OP therapy, but CLEARLY reinforce that it is up to the patient. The issue at hand is that CMS appears to be intending one thing (one, referral by qualified clinicians, and two, improved continuity of care by assuring close contact of the referral source and the treating therapist). There is merit in these intentions but the unintended consequences are the problem. My program provides multidisciplinary therapy services. Only 2-3 other programs exist in my medium size city. We also provide specialty programs such as Lymphedema, Wound Care, Vital Stim therapy etc. While we get many in house referrals, there are many docs that refer to us from private practice that don't have privelages at our hospital. Where will those patients go? This could drive down program development significantly. There are also non-hospital affiliated private practices that do great work, have lower overhead, and thus lower cost. Why can't patients go there? Its up to the PT/OT/SLP to collaborate with the referring MD no matter where he/she writes an order from. This is already part of Medicare standards. By the way, I don't understand why hospitals (including mine)are exempt from the cap and so, I could support that changing, as long as the exceptions process is made permanent. And why in the world should CMS be able to dictate where non-Medicare/Medicaid patients go for services?! We provide pediatric therapy, most Pediatric MDs in our town only have privelages at the Children's Hospital, so there patients now HAVE to go there?! As for that last part, frankly I don't see that clause when I read the transmittal, but the APTA says it applies to all payors. Perhaps its elsewhere in the regs?

      Posted by Jeremy Ramage -> >GP]EO on 2/7/2012 3:44 PM

    • Thank you for sharing this article that contains this kind of serious concern.

      Posted by MD Premier on 10/9/2015 3:02 AM

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