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  • Final Home Health Rule Cements PDGM, Allows PTAs to Perform Maintenance Therapy

    When it comes to its most talked-about provisions, the US Centers for Medicare and Medicaid Services' (CMS) final rule for home health payment under Medicare isn't much of a change from the proposed version released earlier this year, meaning that an entirely new payment system will indeed be rolled out beginning January 1. But other parts of the rule have been tweaked—and in several areas, those tweaks represent wins for the physical therapy profession and the patients it serves in home health settings. [In addition to the lengthy final rule, CMS also offers a fact sheet summary.]

    It's official: PDGM is on for 2020.
    There wasn't much debate about whether this would happen, but the final rule eliminates any doubt: the Patient-Driven Groupings Model (PDGM) will be the system under which CMS pays home health agencies (HHAs). It's a big change, and APTA offers extensive information on the details of the model, but the bottom line is that the PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The system classifies episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. CMS says it will monitor how HHAs are operating under the PDGM, including the provision of therapy services.

    Overall payments will increase by 1.3%.
    CMS projects an annual increase of about $250 million in payments related to home health.

    "Behavioral adjustments" will still be used—but they won't be as large as proposed.
    In anticipation of the possibility that HHAs will alter their practices to maximize payment under the PDGM, CMS had proposed a "behavioral adjustment" that reduced payments by 8.01%. The final rule lowers the negative adjustment to 4.36%.

    PTAs will be able to perform maintenance therapy under the home health benefit.
    The final rule follows through on an APTA-supported proposal to allow physical therapists assistants (PTAs) and occupational therapy assistants (OTAs) to perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the PTA or OTA, the qualified therapist still would be responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days.

    A question about pain still will be available to patients.
    In addition to removing a quality-reporting measure on to pain interfering with activity from the Quality Reporting Program, CMS also proposed eliminating a home health consumer survey question about whether the patient and provider had discussed pain in the past 2 months. APTA and other organizations pressed for that question to remain, and CMS relented. The pain interfering with activity quality measure has been removed, however.

    Split payments are going away, and Requests for Anticipated Payment (RAPs) will be gone by 2022—but a modified RAP process will be in place beginning in 2021.
    CMS is phasing out the split percentage payment approach beginning in 2020. The split percentage payment amount, paid in response to a RAP, will shift from an upfront 60%-initial, 50%-subsequent payment for each 60-day period to 20% for both initial and subsequent 30-day periods of care. Then, beginning in 2021, there will be no upfront payment made in response to a RAP; however, all HHAs will be required to submit a "no-pay” RAP every 30 days to alert the claims processing system that the beneficiary is under a home health period of care. HHAs must submit the “no-pay” RAP within 5 calendar days of each 30-day period or be subject to a late penalty. Beginning in 2022, CMS will eliminate RAPs and instead require HHAs to submit a Notice of Admission (NOA) every 30 days; agencies must do so within 5 calendar days of each 30-day period or be subject to a payment penalty. CMS says that because they are removing upfront payment associated with the RAP, the agency is relaxing the information needed to submit the “no-pay” RAP and subsequent NOA.

    Want more on PDGM? Sign up for the November 20 APTA "Insider Intel" phone-in session, where the home health system will be discussed along with the final Medicare physician fee schedule.

    UnitedHealthcare to Expand Program Waiving Copays, Deductibles for Physical Therapy for LBP

    Momentum around better insurer coverage of physical therapy continues to build at UnitedHealthcare (UHC), which announced that it's moving ahead to expand a pilot project that waives copays and deductibles for 3 physical therapy sessions for patients with new-onset low back pain (LBP). The pilot follows a multiyear collaboration between APTA, OptumLabs®, and UHC.

    The program is targeted at UHC enrollees in employer-sponsored plans who experience new-onset LBP and seek care from an outpatient in-network provider. The program fully covers up to 3 visits to a physical therapist (PT) or chiropractor in addition to visits normally covered. When the program was rolled out in June, it was limited to plans sponsored by employers of more than 50 employees in Florida, George, Connecticut, North Carolina, and New York. The expanded pilot, which begins January 1, 2020, will extend to self-funded plans with 2 to 50 employees in Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia.

    APTA has been working with UHC and OptumLabs to investigate both the efficacy of physical therapy as a first treatment option for LBP and the effects insurer payment policies have on patient access to more conservative approaches to the condition. Those efforts yielded 3 research articles: a study affirming that higher copays and payer restrictions steer patients away from conservative LBP treatments; an analysis that found lower odds of early and long-term opioid use among patients who see a PT first for LBP; and an investigation that linked unrestricted direct access to a PT for LBP to lower health care utilization and costs than would occur with provisional access to physical therapy. APTA cosponsored all 3 studies.

    "The evidence supporting the use of physical therapy as a first-line, widely accessible treatment for low back pain continues to grow, and insurers like UnitedHealthcare are paying attention and moving from analysis into action," said Carmen Elliott, APTA's vice president of payment and practice management. "APTA's collaboration with UHC and Optum has helped UHC establish some on-the-ground changes that we hope will pave the way for a true sea change in the way insurers think about the value of physical therapy."

    House, Senate Legislation Could Lead to Major PT Telehealth Opportunities in Medicare

    Physical therapists (PTs) have tended to be largely left out of opportunities to provide telehealth services through Medicare, but that could change significantly if federal lawmakers support APTA-supported legislation recently introduced in the US Congress.

    This week, legislators on Capitol Hill announced the introduction of companion bills in the US Senate and House of Representatives that could open the doors to wider use of telehealth in Medicare, including use by PTs. Known as the "CONNECT for Health Act of 2019" (CONNECT), the bills now in the House (HR 4932) and Senate (S 2741) would remove many current restrictions on telehealth in Medicare and give the Secretary of Health and Human Services (HHS) broad authority to waive others. The legislation was introduced by members of the Senate and House telehealth caucuses, with Sen Brian Schatz (D-HI) and Rep Mike Thompson (D-CA) leading the efforts in their respective chambers.

    While the bill covers a lot of ground, it's the provisions allowing the HHS Secretary waiver power that should be of particular interest to PTs, according to Baruch Humble, APTA senior specialist for congressional affairs.

    "If this bill is successful, starting on January 1, 2021, the HHS Secretary could waive telehealth restrictions and open up opportunities for therapists to be reimbursed for telehealth services as long as those services don't limit or deny coverage and can reduce spending without sacrificing quality of care," Humble said. " That's a big step forward for Medicare."

    Baruch added that the waiver rules even have exceptions—namely, that even if a service doesn't reduce spending and maintain quality, a waiver could still be granted if the service was targeted at a high-need health professional shortage area. The waiver process would also be subject to an annual public comment process, and include regular data collection and reviews of waivers conducted no more frequently than every 3 years.

    The CONNECT Act includes another potential opportunity for PTs to participate in telehealth by way of programs created through the Center for Medicare and Medicare Innovation (CMMI).

    Provisions in the bill would direct CMMI to identify services that could deliver both outcome- and cost-effectiveness through telehealth. Physical therapy is among the services that could be reviewed by CMMI, which could design and test delivery models that could be adopted by Medicare, Medicaid, or the Children's Health Insurance Program.

    According to a summary created by the bills' sponsors, current Medicare restrictions that limit telehealth to certain rural areas, clinical sites, and types of providers create "barriers" to a service delivery method that "increases access to care in areas with workforce shortages and for individuals who have barriers to accessing care."

    The legislation is endorsed by more than 120 organizations, including AARP, the American Medical Association, and Kaiser Permanente. APTA not only endorsed the legislation but worked in collaboration with the American Occupational Therapy Association and the American Speech-Language-Hearing Association to advocate for their respective professions as the legislation was being drafted.

    "The CONNECT act is a win for the profession, not just because it opens the opportunity for telehealth by PTs beginning as early as 2021, but because it establishes a way for the profession to demonstrate, through data and outcomes, how a PT's use of telehealth could make a very real contribution to improved health," Humble said. "PTs using telehealth can play an important role on several health care fronts, particularly in terms of efforts to combat the opioid epidemic by reaching rural and underserved communities with nonpharmacological options to chronic pain."

    APTA government affairs staff will continue to track the progress of the legislation. Stay tuned for opportunities to advocate in support of the bills.

    APTA offers a summary of research on telerehabilitation's effectiveness and a collection of PT testimonials supporting the use of telehealth. The legislation is just one of several bills and issues APTA is advocating on during this session of the US Congress, which includes APTA-supported legislation aimed at addressing administrative burden and prior authorization (HR 3107), PT student loan debt (HR 2802/S. 970), home health payment issues (S 433 / HR 2573), the Medicare fee schedule, self-referral, and more.


    Senate sponsors of the CONNECT Health Act, led by Sen Brian Schatz (HI, at microphone) have introduced a bill that could provide opportunities for greater use of telehealth by PTs.