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  • Where Things Stand, What APTA's Doing: Fee Schedule, SNF, and HH Rules From CMS

    The Centers for Medicare and Medicaid Services (CMS) spends much of its spring and summer churning out regulatory rules for the coming fiscal and calendar years. That means it's an equally busy time for APTA, its members, and other stakeholders to stay on top of the proposals, respond to whatever challenges emerge, and advocate for change when needed.

    This year's standout challenge: advocacy efforts around the CMS proposed physician fee schedule (PFS). The rule as proposed includes at least 2 troubling provisions that demanded a strong response—1 around how CMS would go about determining whether therapy services were delivered "in part" by a physical therapist assistant (PTA) or occupational therapy assistant (OTA), and another that proposes an estimated 8% cut to reimbursement for physical therapists (PTs) and several other professions.

    APTA has been aggressively fighting these changes through comments, creating a platform to facilitate a flood of individual member letters to CMS, multiprovider organization sign-on letters, meetings with CMS representatives, and the latest: a bipartisan letter signed by 55 members of Congress urging CMS to rethink the cuts.

    So where do things stand with CMS rulemaking, and what is APTA doing around the PFS and other developments? Here's a guide to 3 of the biggest rules issued to date in 2019, along with information on our advocacy efforts.

    Medicare Physician Fee Schedule
    Status: Proposed (comment period closed); final rule expected in early November

    Quick take
    A misguided attempt by CMS to define (and pay less) when services are delivered "in part" by a PTA or OTA, and an arbitrary 8% cut in 2021 to PT and OT services as well as similar cuts to services furnished by clinical social workers, clinical psychologists, audiologists, and other providers could have major impacts on patient access to care. The rule also includes changes to the Merit-based Incentive Payment System (MIPs) and other areas.

    Our advocacy

    Resources: CMS fact sheet; PT in Motion News stories on PTA modifier and proposed cut; recorded webinar (from August 15); upcoming "Insider Intel" phone-in session (November 20)

    Skilled Nursing Facilities (SNFs) Prospective Payment System
    Status: Final, effective October 1, 2019

    Quick take
    CMS followed through with plans to dramatically change the payment system for SNFs by adopting the Patient-Driven Payment Model (PDPM), a system based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employing a per diem system that adjusts payment rates over the course of the stay. In a win for APTA and its members around group therapy, CMS moved away from a rigid 4-person definition and adopted the association's recommendation that the definition of group therapy as 2 to 6 patients doing the same or similar activities—the same definition used in inpatient rehabilitation settings.

    Our advocacy

    • APTA comment letter
    • In-person meeting with CMS representatives
    • Multiprofession coalition sign-on letter
    • Templated comment letters for individual clinicians

    Resources: CMS fact sheet; APTA fact sheet; PT in Motion News stories on proposed and final rule; APTA SNF PDPM webpage; recorded webinar series; recorded Insider Intel session (May 22)

    Home Health Prospective Payment System
    Status: Proposed for 2020 (comment period closed), final rule expected in early November

    Quick take
    Similar to its efforts around SNFs, CMS wants to transition to a new payment system for home health agencies (HHAs), known as the Patient Driven Groupings Model (PDGM). That system moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The proposed rule would also allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist and would end the HHA split payment approach in favor of a more efficient notice-of-admission approach.

    Our advocacy

    Resources: CMS fact sheet; PT in Motion News story on proposed rule; APTA webpage on PDGM; recorded webinar (August 5)

    Other advocacy efforts
    APTA has also provided comment letters on CMS rules on outpatient payment, Medicaid access, inpatient rehabilitation facilities, and hospital payment; and signed on to multiprofession coalition letters to CMS on outpatient payment and rules around durable medical equipment, prosthetics, orthotics, and supplies.

    Stay tuned
    As APTA continues to advocate for the profession, the association also provides its members with plenty of opportunities to get up-to-speed with both proposed and final rules. Keep the following upcoming events on your radar for more insight on payment and regulation:


    • The problem with APTA's approach has long been twofold. First, we try to be co-operative and negotiate in good faith. We saw this in Michigan with BCBS. We always assumed they were negotiating in good faith (like we were). But actions speak louder than words and they never did and still don't negotiate in good faith. If you're trying to be co-operative but the party on the other side of the table is being competitive, you're always going to lose. We have to adopt a competitive rather than a co-operative strategy in order to prevail. Two, we are always on the defensive. We are always reactive rather than pro-active. Unfortunately, neither battles nor wars (and economically, this is what the situation comes down to) are never won being defensive. One must assume the offensive. Time for a major overhaul and change in strategy.

      Posted by Brian Miller on 10/2/2019 8:50 PM

    • Thank you, Dr. Sharon Dunn and APTA for helping us by swaying CMS away from its most woeful tendencies.

      Posted by Eric Lambousy on 10/2/2019 11:07 PM

    • Has APTA been involved in advocating for professionals and patients with regards to PDPM? Specifically the significant cut I’m therapy minutes by corporations, the mandating of group therapy, the dictation of which treatment codes and treatment types can be used, and the undermining of state practice acts and the authority it gives individual clinicians to most appropriately treat patients?

      Posted by Nicholas Hoening on 10/3/2019 9:03 AM

    • Over the past five years I have been suggesting to the powers at the American physical therapy Association that we take a different approach. Negotiating with CMS will never work. The only approach that will work is going directly to the public and letting them know that their benefits are being slashed and cut by the government. Most patients have no idea what’s going on. They didn’t have an idea of when the visits were limited under part B Medicare. They are confused and most are angry when they hear about it. Why not take out a major marketing campaign to the public to let them know that this is going on. Continuing to go directly to CMS will fail. The only thing Washington listens to are the constituents. If the APTA started a campaign to the public this would turn some heads. Is it that our association does not want to ruffle feathers by going around CMS? One article or an ad placed in an AARP magazine for example would begin to open some eyes. If we maintain the current approach we will continue to look like self-serving therapist begging for crumbs at the table of the Almighty federal government.

      Posted by Brian on 10/3/2019 9:33 AM

    • I applaud APTA for continuing to defend our profession and seek reimbursements that demonstrate our value. I see two major flaws that continue to occur. First, CMS and other 3rd party payers continue to ignore the impact physical therapy has on people's lives. They see the immediate dollar of the service yet neglect to see the enormous costs that incur when physical therapy is NOT implemented. The costs associated with falls and opioid addictions such as ambulance visits, hospital admissions, long-term stays just from these two issues is enormous whereas if physical therapy was implemented and followed through without reimbursement delays to reduce the risk of falls and to decrease pain, the cost on the healthcare system would be significant less. Second, we as a profession need to stand up against the 3rd party payers and say "No More." If we stand up and do not agree to thei rates or if we collectively agree to not take less than what we are worth, then perhaps the 3rd party payers will take notice because they will be losing thousands of dollars when we decided to no longer agree to their in-network terms. We as a profession must decide our value and the impact that we have in order to break this neverending cycle of fighting to get paid. What other profession provides a service and has to wait 3-6 months to get paid. It's like going through a drive thru and you owe $8.00 for a meal yet decide to pay only $1.00 and then 30 days later pay another $1.00 and then maybe 30 days later pay another $1.00. It makes no sense. A plumber gets paid the same day. An electrician gets paid at time of service. Why do we not get paid the same day of service? Why are we not fighting for that? We are Doctors of Physical Therapy. We impact live every day.

      Posted by Jeanette De Witt on 10/3/2019 9:55 AM

    • I agree with APTA trying to be cooperative instead of competitive. I feel the reason is because we want to work well with others for out patient's, but being nice doesn't always work. Thank you for all the work this group does. Virginia Bever,, PTA

      Posted by Diamantina Virginia Bevers on 10/3/2019 3:37 PM

    • I agree with Brian. This needs to be approached from a completely different angle. Patients are just as invested in this as we are and they have just as much to lose, if not more. Why not involve them?

      Posted by Devon on 10/6/2019 11:42 PM

    • The solution is to abolish Medicare. The entirety of healthcare insurance revolves around it and will forever be incompetent, stuck in the past, flat earther, unaccountable, untrustworthy and stage 5 clinger until this is done.

      Posted by Burton Ford on 10/7/2019 11:49 AM

    • whimsical, fundamentally unsound.. I could go on all day.

      Posted by Burton Ford on 10/7/2019 11:53 AM

    • I agree with Brian as well. Our patients are being short changed and our careers are in grave danger. This is pure greed for profit only, pure nonsense. We need to stand for our rights and our patients.

      Posted by Tami Hammac -> AFPZDL on 10/8/2019 8:09 PM

    • I have been a practicing physical therapist for the last 16 years. I had been at my previous job for 9 years working in inpatient Rehabilitation. Our company decided to get out ahead of the issues arising on October 1st and laid off myself and three other staff members from our rehab team. Unfortunately, where I live oh, there are not very many job opportunities for therapists right now. In all my career I never thought I would be in the situation and be struggling to find work. I am tired of having my career, and the career of all that work in physical rehabilitation, dictated by Medicare and the federal government. I'm tired of having little say in what happens.

      Posted by Christopher Greg Packard on 10/9/2019 7:51 PM

    • Only “crickets” from the APTA when us members dare to go down the road of making suggestions that require guts!!

      Posted by Brian on 10/10/2019 10:47 AM

    • We know a lot of physical therapists were laid off thanks to PDPM. APTA advocates for its members and knew that this PDPM is coming before hand, and unfortunately not able to prevent its implementation. It is not strong enough to fight for securing jobs but it boasts its DPT programs which literally means additional expenses for graduating students and current PTs. Now where can the laid off DPTs count on?

      Posted by Rafael Dela Cruz on 11/4/2019 3:04 PM

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