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  • Now Available to Members: Highlights of the Proposed 2017 Medicare Physician Fee Schedule

    Get up to speed on 1 of the most extensive changes to physical therapy coding in years: APTA members can now access highlights of the 2017 proposed Medicare physician fee schedule rule, a guide that includes an explanation of the Centers for Medicare and Medicaid Services' proposal to implement a 3-level physical therapy initial evaluation code system.

    In addition to information on the new system for current procedural terminology (CPT) coding, the highlights prepared by APTA federal regulatory affairs staff touch on all of the other elements of the proposed rule that affect physical therapists, including payment rate updates, CMS' continued review of potentially misvalued codes, and proposed adjustments to physician self-referral rules and accountable care organization (ACO) quality measures.

    To access the highlights, visit the APTA Medicare fee schedule webpage, scroll down to APTA summaries, and click on the related highlights link. For a live conversation on the proposed rule, be sure to sign up for the next APTA Insider Intel live phone-in event, scheduled for August 17 2:00 pm-2:30 pm, ET.

    A final rule will be issued later in the year. APTA intends to comment on the proposed rule by the September 6 deadline.

    Bill That Adds Protections for PTs Traveling With Sports Teams Moves in House

    A bipartisan bill that helps to protect physical therapists (PTs) and other health care providers who travel across state lines with sports teams is on its way to the floor of the US House of Representatives.

    The Sports Medicine Licensure Clarity Act (HR 921/S 689) aims to provide added legal protections for sports medicine professionals when they're traveling with professional, college, or national sports teams by extending the provider's "home state" malpractice and professional liability insurance to any other state the team may visit. This week, the House Energy and Commerce Committee approved the bill for full House consideration.

    Originally, the bill's coverage was restricted to only physicians and athletic trainers. Advocacy staff at APTA worked closely with the office of sponsor Rep Brett Guthrie (R-KY) and ECC subcommittee staff to get PTs added to the list. The bill also opens the possibility of coverage for physical therapist assistants who are under the direct supervision of a PT.

    In addition to Guthrie, cosponsors include Rep Cedric Richmond (D-LA) in the House, and Sens John Thune (R-SD) and Amy Klobuchar (D-MN) in the Senate.

    Senate Committee Hearing on Stark Law Touches on Self-Referral Loophole for Physical Therapy, Other Services

    Though there are plenty of political distractions out there, some members of the Senate have not forgotten about problems with the so-called "Stark law" intended to counter abuses of physician self-referral. At a hearing of the Senate Finance Committee this week, legislators talked about how certain provisions of the law, including exceptions that allow for self-referral to physical therapy, may not be in the best interests of Medicare's shift to value-based models.

    The hearing (viewable here) was called by chair Orrin Hatch (R-Utah) to look at the entire breadth of the Stark law, which he characterized as "the embodiment of good intentions muddled with complex execution." That law prohibits physicians from referring Medicare patients for services or facilities in which the physician has a financial interest, but it contains a loophole for referrals for "in-office ancillary services" (IOAS)—physical therapy, anatomic pathology, radiation oncology, and advanced diagnostic imaging. APTA has long advocated for the elimination of this loophole.

    The bulk of the hearing focused on the big-picture issues associated with the law, particularly around the ways it might be unintentionally impeding the development of value-based health care models that call for greater integration of services. Though not a major focus of the hearing, the IOAS exception was mentioned in testimony, and characterized by all 3 witnesses as 1 of the more "contentious" issues in the law.

    "Many stakeholders have singled out the IOAS exception as 1 of the most abused in the law, because it ultimately promotes the very conduct that the Stark law was intended to prevent—overutilization of services and unnecessary self-referrals of health care services," said Troy Barsky, an attorney representing the American Society for Radiation Oncology, in written remarks.

    While Barsky had recommendations for possible limits on the exceptions, he acknowledged that Congress would need to provide the Centers for Medicare and Medicaid Services with additional authority before any major reforms could be accomplished. Still, he argued, adjustments could be made that "would stop the increasing rate of unnecessary utilization due to IOAS and promote value-focused arrangements among providers."

    Elimination of the IOAS exceptions remains a central public policy priority of APTA, which is a member of the Alliance for Integrity in Medicare, a coalition of organizations that has been advocating for closing the loophole. APTA submitted comments to the Senate Finance and House Ways and Means committees in early 2016, and provided a separate set of comments specific to this week's hearing, writing that "care furnished under the IOAS exception is often degraded, raising serious quality concerns."

    The IOAS exemptions are also the subject of possible discussion in the House of Representatives, where Rep Jackie Speier (D-CA14) reintroduced the "Promoting Integrity in Medicare Act," a bill that would end the IOAS loopholes.

    According to various news reports, Hatch has stated that he hopes to see legislative action on the Stark Law by the end of this year. It's unclear if that action would include changes to the IOAS exceptions.

    Highlights of New Home Health Agency Claims Program Posted

    Now available to members through the APTA website: highlights and resources to help members prepare for big changes to home health agency (HHA) Medicare claims coming to 5 states.

    Beginning with Illinois on August 1, 2016, the Centers for Medicare and Medicaid Services (CMS) will require HHAs to submit supporting documentation for services while beneficiaries still are receiving care. CMS will review the pre-claim and make a review decision. The other 4 states—Florida, Texas, Michigan, and Massachusetts—will be phased into the program during the rest of the year and into 2017. The final version of the program was announced in June.

    The new APTA highlights (look under "APTA Summaries") provide the basics on how the system will work, including information on making submissions, the process for resubmission of a claim that is not affirmed by CMS, and penalties for claims submitted without pre-claim review. Links to CMS resources are also included.

    APTA is monitoring the implementation of this program and needs your input. If you have any administrative issues, unreasonable delays in responses, or unfair denials under this demonstration, please submit your issue to advocacy@apta.org. Be sure to include “Home Health Demonstration” in the subject line of your email.

    New Rules for ACOs Aim to Encourage Participation

    Accountable care organizations (ACOs) participating the Medicare Shared Savings Program (MSSP) will begin operating under some new rules designed to incentivize participation in the program while continuing the Centers for Medicare and Medicaid's (CMS) evolution toward value-based payment.

    Under the new rule, ACOs that sign up for a second or subsequent contract period will be subject to a benchmarking process based on regional rather than national spending data—a move aimed at acknowledging the fact that health care costs aren't the same across the country. Also, so-called Track 1 ACOs (which share in savings but are not responsible for losses) that are approved for renewal will be allowed more time to transition to a risk-based Track 2 or 3 model by way of a 1-year deferment.

    The rule also sets up a 4-year window for appeals and reopenings of reviews of savings or losses—the first time CMS has offered specifics on the process.

    APTA has developed summary of the rule and offers a webpage dedicated to ACOs. Also, the APTA Learning Center includes a recorded webinar on ACOs and the role of physical therapists.

    "Today's changes will encourage more physicians to improve patient care by joining [ACOs], while also refining how the program measures success, so that current participants are better rewarded for quality," said CMS Acting Administrator Andy Slavitt in a news release.

    The rule will be implemented in phases beginning January 1, 2017.

    CMS Will Shift Home Health Agencies to a 'Pre-Claim Review' Model in 5 States

    In a step that it hopes will help educate home health agencies (HHAs) and prevent improper payment, the Centers for Medicare and Medicaid Services (CMS) will soon require HHAs in 5 states to participate in a pre-claim review process for their Medicare patients.

    Beginning with Illinois on August 1, 2016, CMS will require HHAs to submit supporting documentation for services while beneficiaries are receiving care. CMS will review the pre-claim and make a review decision "generally within 10 days," according to a CMS fact sheet. The other 4 states—Florida, Texas, Michigan, and Massachusetts—will be phased into the program during the rest of the year and into 2017.

    According to CMS, the documentation will be "the same type of documentation [HHAs] currently gather for payment, only HHAs will submit it earlier in the process." The new program does not change eligibility standards, and CMS states that it will allow HHAs to submit additional pre-claim documentation to support the claim should CMS find the initial submission lacking. HHAs can receive initial payments before CMS makes its pre-claim review decision, and if a claim is not approved during the pre-claim process, the HHA can appeal.

    Once the program has been operational for 3 months in a demonstration state, HHAs that submit a claim without a pre-claim review may still receive payment, but at a 25% reduction of the full claim amount—if they they are approved at all. These claims will go through the same pre-claim review process and may be subject to denial.

    The new program is an attempt to tighten up an HHA claims process that reached a 59% improper payment rate in 2015, with a large proportion of those improper claims linked to insufficient documentation. "The pre-claim review demonstration will help educate HHAs on what documentation is required and encourage them to submit the correct documentation," CMS states.

    The project is also designed to shift CMS away from a "pay and chase" approach that forces the agency to demand repayment of money already spent and toward a more preventive model. According to CMS, "most" of the 5 states targeted for the demonstration project have been identified as at "high risk" for improper payment.

    APTA will monitor implementation of the program to evaluate its effects on access to physical therapy, and will work with other stakeholders to ensure that CMS does not unfairly penalize all HHAs and the physical therapists who practice in home health settings.

    Improved Direct Access to PTs Now Law in Louisiana

    After a sometimes-contentious struggle, individuals in Louisiana now have improved direct access to physical therapist (PT) services.

    On June 6, Louisiana Gov Bel Edwards signed SB 291, which allows PTs to treat without a referral or previous medical diagnosis for up to 30 calendar days, a significant improvement over what had been one of the most restrictive direct access laws in the country. After 30 days, a direct access patient must be referred to a physician, dentist, podiatrist, or chiropractor if there is no measurable or documented functional improvement of the patient. The legislation was sponsored by state Sen Fred H. Mills Jr (R) and advocated by the Louisiana Physical Therapy Association (LPTA).

    All physical therapists who have a DPT or 5 years of clinical practice experience are eligible for direct access.

    The win for citizens and Louisiana PTs was not an easy one: opponents of the bill, led by the state's orthopedic surgeons association, launched an active campaign to block passage, arguing that direct access would put patients at risk should a PT miss a health condition that would require attention from a physician. In the end, the bill passed in both the Louisiana House and Senate by wide margins.

    “The passage of SB 291 and allowing the citizens of Louisiana to choose physical therapy directly was by far the most widely debated bill of the 2016 legislative session," said Cristina Faucheux PT, LPTA legislative chair. "Its passage paves the way for the citizens of Louisiana to have unparalleled services and be in the driver’s seat of their health care dollars."

    PTs Added to Bill That Protects Providers Traveling With Sports Teams

    A bipartisan bill that helps to protect health care providers who travel with sports teams now includes physical therapists (PTs) in its list of covered professions, and is poised to move on for consideration by the full Energy and Commerce Committee (ECC) and, eventually, the floor of the US House of Representatives.

    The Sports Medicine Licensure Clarity Act (HR 921/S 689) cleared an important hurdle this week when it was reviewed and approved in a markup session of a subcommittee of the ECC. The bill aims to provide added legal protections for sports medicine professionals when they're traveling with professional, college, or national sports teams by extending the provider's "home state" malpractice and professional liability insurance to any other state the team may visit.

    Originally, the bill's coverage was restricted to only physicians and athletic trainers. Advocacy staff at APTA worked closely with the office of Rep Brett Guthrie (R-KY) and ECC subcommittee staff to get PTs added to the list. The bill also opens the possibility of coverage for physical therapist assistants who are under the direct supervision of a PT.

    In addition to Guthrie, cosponsors include Cedric Richmond (D-LA) in the house, and Sens James Thune (R-SD) and Amy Klobuchar (D-MN).

    Upcoming 'Insider Intel' Program Gives You the Latest on Manual Medical Review, MACRA, IMPACT, and More

    APTA's popular "Insider Intel" call-in program returns on June 15 to deliver need-to-know information on hot topics in policy and payment.

    Free and limited to APTA members only, the upcoming session will focus on the proposed Medicare and Chip Reauthorization Act (MACRA) highlights, the new therapy cap-targeted manual medical review process, and payment reform for postacute care providers established through the Improving Post-Acute Care Transformation Act (IMPACT). APTA regulatory affairs staff will provide the latest information on the changes now in place as well as the ones to come, and callers will also have the opportunity to ask questions.

    The 30-minute call-in program will begin at 2:00 pm, ET. To register for a spot in the session, email advocacy@apta.org with "June 15 Call" in the subject line. Don't wait—space is limited, and the sessions typically fill up quickly. "Insider Intel" is free to members of APTA.

    If you're unable to participate live, recordings of the calls will be posted on a special Insider Intel page on the APTA website.

    APTA 2016 House of Delegates Election Results Announced

    The following members were elected to APTA's Board of Directors and Nominating Committee on Monday at the House of Delegates in Nashville, Tennessee.

    Roger Herr, PT, MPA, was elected secretary.

    Stuart Platt, PT, MSPT, was reelected vice speaker.

    Carolyn Oddo, PT, MS, FACHE, and Sue Whitney, PT, DPT, PhD, NCS, ATC, FAPTA, were reelected director and Kip Schick, PT, DPT, MBA, was elected director.

    Holly Clynch, PT, DPT, MA, GCS, and Chris Petrosino, PT, PhD, were elected to the Nominating Committee.

    These terms become effective at the close of the House of Delegates on Wednesday.