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  • APTA Advocacy Sparks Medicare Advantage Beneficiary Protections for PT Services in 2015

    The Centers for Medicare and Medicaid Services (CMS) announced greater cost-sharing protection for Medicare Advantage beneficiaries receiving physical therapy services in 2015, a change adopted as a result of APTA advocacy efforts.

    The association's work to reduce copayments for physical therapist services in Medicare Advantage plans resulted in the addition of physical therapy to the list of services that will be protected by maximum out-of-pocket (MOOP) spending limits for beneficiaries. In its Advance Notice and draft Call Letter (.pdf), CMS mandates that the MOOP cost sharing for all in-network physical therapist services be set at $40. This cost-sharing requirement includes copayments, coinsurance, and service category deductibles.

    CMS has also announced that there will be cuts made to the 2015 Medicare Advantage program, although the extent of those cuts is not yet clear. According to information released in the call letter, the cuts will be based in part on projections that anticipate a 3.55% decline in the program's growth rate and an estimated 1.65% drop in per capita expenditures in 2015.

    CMS will accept comments on the call letter until March 7. APTA plans to submit comments on behalf of its membership. The final 2015 Rate Announcement and Call Letter will be published April 7.

    The association offers resources that help explain the program at its Medicare Advantage webpage.

    'Polio-Like Illness' in California Children Still a Mystery

    The "polio-like illness" found in 5 California children "appears to be very, very rare," according to the author of a study on these cases, but could point to an "emerging" infectious syndrome. In a recent press release the study's authors stated that 20–25 similar cases are now being investigated.

    The illnesses involve paralysis of 1 or more limbs with rapid onset and a peak in severity at about 2 days. Of the 5 children affected, 3 had respiratory illnesses before the polio-like symptoms began. All 5 had been vaccinated against the polio virus.

    Despite treatment, the children's symptoms did not improve, and though all are still alive none returned to normal limb function after 6 months. The children who experienced the illness were clustered in California over a 1-year period.

    Of the 5 children, 2 tested positive for enterovirus-68, which the US Centers for Disease Control and Prevention describes as a "very common" virus that tends to produce few or "very mild" signs of illness. Rarely, however, the virus can produce myocarditis, pericarditis, encephalitis, and paralysis. Providers were unable to find a cause for the illness in the other 3 children.

    The study of the 20–25 additional cases is focused on children with paralysis of 1 or more limbs and abnormal MRI scans, with no presence of botulism or Guillain–Barré syndrome—2 conditions that can also generate polio-like symptoms. The study will be discussed in detail in a case study that will be presented at the American Academy of Neurology's annual meeting April 26–May 3.

    CMS Transition Means Temporary Changes to Manual Medical Review Processes

    The Centers for Medicare and Medicaid Service's (CMS) transition to new recovery audit program contracts will temporarily change pre- and postpayment manual medical review processes for therapy services over $3,700, and will likely create delays in the typical 10-day review cycle.

    CMS is procuring the next round of recovery audit program contracts, and the agency is planning "a pause in operations" while old contracts are closed out and new ones started. The pause will have different ramifications depending on whether a particular state is subject to prepayment review or postpayment review of therapy services exceeding $3,700.

    In postpayment states, February 21, 2014, was the last day that Additional Documentation Request Letters (ADR) for postpayment review were sent to providers. In prepayment states, February 28 is the last day that Medicare administrative contractors will send out letters for prepayment reviews of therapy claims until new contracts are awarded. After February 28, prepayment reviews will not be conducted; instead all claims will undergo postpayment review after the new contracts are in place. Because of the volume of claims CMS anticipates will accumulate during the transition, the 10-day reviewing timeframe will not apply to these reviews. The new recovery auditors will review claims in the order that they were paid.

    If a provider has received an ADR letter, the provider must comply with the request and submit the records. Any records that were previously submitted to the recovery auditor will continue to be reviewed, and the provider will receive a review results letter, as usual. Providers can monitor progress of the transition at the CMS Recovery Audit Program Recent Updates webpage.