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  • Conference Committee Reaches Deal on SGR Update

    Late last night, the Congressional Conference Committee reached a deal on a 10-month measure that would prevent a 27.4% cut, due to the flawed Sustainable Growth Rate (SGR) portion of the fee schedule, to Medicare providers scheduled for March 1. Sources on Capitol Hill have indicated to APTA that the deal also would extend the therapy cap exceptions process for the remainder of 2012. 

    National Journal is reporting that the 10-month extension, which costs nearly $20 billion, could be paid for by pulling money from a fund earmarked for preventive medicine in the Affordable Care Act (ACA) and cutting Medicare "bad debt" payments to hospitals when beneficiaries fail to pay their copays. Significant pressure from the prevention community to defeat this legislation is expected, due to the defunding of prevention dollars included in ACA. 

    The House and Senate still must pass the measure by February 29 to avoid the return of the therapy cap without exceptions and the 27.4% payment cut for Part B outpatient physical therapy services.

    Upon its release, APTA will analyze the legislative text to see if it contains language that the association advocated for in the fall to set a path toward payment reform in therapy services.   

    Advocating on behalf of hundreds of thousands of Medicare beneficiaries who receive outpatient rehabilitation services every year, APTA, as part of the Therapy Cap Coalition, yesterday urged members of the Congressional Conference Committee to provide the longest possible exceptions extension for Medicare Part B therapy services in the committee's final agreement.

    Tri-Alliance Issues Joint Guidelines for Therapy Cotreatment Under Medicare

    APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association(ASHA) have issued guidelines to help therapists recognize appropriate opportunities for cotreatment. Cotreatment may be appropriate when practitioners from different professional disciplines can effectively address their treatment goals while the patient is engaged in a single therapy session. For example, a patient may address cognitive goals for sequencing as part of a speech-language pathology treatment session while the physical therapist (PT) is training the patient to use a wheelchair. Or, a patient may address activities of daily living goals for increasing independence as part of an occupational therapist treatment session while the PT addresses balance retraining with the patient to increase independence with mobility. 

    The guidelines contain information on proper documentation for cotreatment sessions and 3 clinical examples of 2 disciplines providing interventions during 1 treatment session. APTA has provided the document to the Centers for Medicare and Medicaid Services, as the agency had requested guidance on cotreatment therapy sessions from the 3 associations.  

    APTA will continue to work with CMS to develop additional resources for therapists, specifically in the skilled nursing facility setting, to ensure a thorough understanding of therapy coverage requirements.

    CMS Proposes Timeline for Providers to Return Overpayments

    The Centers for Medicare and Medicaid Services (CMS) yesterday proposed that providers and suppliers must report and return self-identified overpayments either within 60 days of the incorrect payment being identified or on the date when a corresponding cost report is due—whichever is later.

    The announcement is 1 in a series of steps Medicare is taking to protect taxpayer dollars, including efforts to prevent overpayments from occurring. These efforts include allowing private auditors working on behalf of Medicare to catch wasteful spending before it happens by expanding the use of Recovery Audit Contractors, testing changes to outdated hospital billing systems to help prevent overbilling, and changing processes for approving payments for medical equipment with high error rates.

    A Medicare overpayment refers to any funds that a person receives or retains under Medicare to which the person is not entitled. Examples of overpayments in Medicare include the following:

    • duplicate submission of the same service or claim
    • payment to the incorrect payee
    • payment for excluded or medically unnecessary services
    • payment for non-covered services

    Any failure to report and return the overpayment within the applicable time frame could be a violation of the False Claims Act. Providers also could be subject to civil monetary penalties or excluded from participating in federal health care programs for failure to report and return an overpayment.

    Before the Affordable Care Act (ACA) providers did not face an explicit deadline for returning overpayments. CMS has received approximately $5 million in overpayment refunds under ACA. Contractors also have received a substantial number of overpayment refunds.

    APTA is analyzing CMS' proposal and will post a summary on www.apta.org shortly.

    Also yesterday, the Obama Administration announced that the Health Care Fraud and Abuse Control Program had recovered $4.1 billion in Fiscal Year 2011 from anti-fraud efforts, while the Department of Justice opened 1,110 new criminal health care fraud investigations involving 2,561 potential defendants.

    Access the following links for APTA resources on fraud and abuse, the False Claims Act, and other compliance-related topics.