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  • CMS to Expand List of DMEPOS Requiring Prior Authorization

    Physical therapists (PTs) who are providers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) take note: the US Centers for Medicare and Medicaid Services (CMS) is adding 31 codes to its list of devices that require prior authorization under Medicare. The additional codes will go into effect on September 1 of this year.

    The codes, all related to power wheelchairs, already were subject to prior authorization in 18 states as part of a demonstration project aimed at reducing improper payment. With that demonstration project set to end on August 31, CMS decided to expand the requirements to all states and fold the list into its broader DMEPOS demonstration project launched in 2015.

    CMS offers a webpage focused on the DMEPOS prior authorization program and has published a notice and list of the 31 codes to be added. A full list of DMEPOS requiring prior authorization (minus the 31 codes to be added in September) is also available from CMS. APTA offers more resources at its DMEPOS webpage as well as through a clinical mobility device documentation guide.

    CMS Reports High Levels of Participation in MIPS; Will It Be Expanded to PTs in 2019?

    Things are looking good for the Merit-Based Incentive Payment System (MIPS), according to the US Centers for Medicare and Medicaid Services (CMS). According to CMS, participation in MIPS—which could be required of physical therapists (PTs) as early as next year—was just above 90% during its first year of operation.

    The 91% clinician participation rate was slightly better than the CMS goal of 90%, and included particularly strong performance from accountable care organizations and physicians in rural areas, which reported at rates of 98% and 94%, respectively, according to a blog post from CMS administrator Seema Verma. Beginning in 2019, clinicians can earn Medicare payment increases or face penalties based on quality reporting data provided through the program.

    MIPS is part of a broader effort by CMS to shift toward value-based payment systems through the Quality Payment Program (QPP). Under QPP, providers can choose 1 of 2 paths: reporting through MIPS, or participating in an Advanced Alternative Payment Model (AAPM). MIPS requires reporting in 4 performance categories—quality, promoting interoperability, clinical improvement activities, and cost. Providers earn points in each category, producing a total annual MIPS score, which in turn determines whether the providers earn a payment incentive, remain neutral in payment, or be subject to a penalty. Several of the data points must be reported electronically through certified EHR vendors or registries like APTA’s Physical Therapy Outcomes Registry.

    Although PTs are not yet required to report outcomes through MIPS, they can participate voluntarily—an option strongly encouraged by APTA, given that all indications point to PTs being required to participate in MIPS or APMs as early as 2019. CMS is expected to make its decision on the inclusion of PTs in MIPS in early July 2018.

    According to Verma, while CMS presses for broader participation in MIPS, it will remain "committed to removing more of the regulatory burdens that get in the way of doctors and other clinicians spending time with their patients" through its "Patients Over Paperwork" initiative.

    "We’re also eager to improve the clinician and patient experience through our Meaningful Measures initiative so that clinicians can spend more time providing care to their patients and improving the quality of care their patients receive," Verma writes. "Within MIPS, we are adopting measures that improve patient outcomes and promote high-quality care, instead of focusing on processes."

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care in general and MIPS in particular, including a readiness self-assessment quiz, a podcast series, a video, a frequently-asked question page on MIPS, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the PTOR to submit their data to CMS.

    AMA: Drop in Opioid Prescription Rates Good News; More Nonopioid Pain Treatment Needed

    The American Medical Association (AMA) is applauding new data showing that opioid prescriptions fell dramatically in 2017—and using the news as an opportunity to promote access to "affordable, non-opioid pain care."

    In its report, AMA cites statistics from IQVIA Institute for Human Data Science, which found that opioid prescription rates fell by 10% in 2017, the steepest drop in 25 years. All 50 states reported decreases in prescriptions of 5% or more. Additionally, the report states that physicians are increasing their use of prescriptions drug monitoring programs and expanding their treatment capacity through certifications to administer in-office buprenorphine, a drug used in the treatment of opioid use disorder.

    That's all good news, the AMA report says, but more needs to be done, both in terms of the nation's addiction treatment efforts and the health care system's overreliance on opioids in the treatment of pain. Among AMA recommendations: a call for "all public and private payers… [to] ensure that patients have access to affordable, non-opioid pain care."

    “While this progress report shows physician leadership and action to help reverse the epidemic, such progress is tempered by the fact that every day, more than 115 people in the United States die from an opioid-related overdose,” said Patrice A. Harris, MD, MA, chair of the AMA Opioid Task Force in an AMA news release. “What is needed now is a concerted effort to greatly expand access to high-quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end.”

    APTA has made the opioid crisis a priority in its public education and advocacy efforts through the #ChoosePT opioid awareness campaign and participation in multiple multiorganization initiatives, including a National Quality Partners "Opioid Playbook" that offers actions that can be taken to shift health care away from the overuse of opioids for treatment of noncancer pain. Earlier this year, APTA hosted a live Facebook-broadcast panel discussion titled "Beyond Opioids: Transforming Pain Management to Improve Health."

    CMS Hopes to Reboot 'Pre-Claim Demonstration' Proposal for HHAs in 5 States

    The US Centers for Medicare and Medicaid Services (CMS) plans to revive a home health agency (HHA) "pre-claim demonstration" project it shelved in 2017 due in part to criticism that the program created significant administrative burdens and reduced access to care. The reconstituted project will be implemented in 5 states and is described as "optional," though HHAs that choose not to participate would face a 25% cut in payments.

    The demonstration project will be carried out in Florida, Illinois, North Carolina, Ohio, and Texas, and would offer HHAs 3 paths in seeking payment for Medicare beneficiaries: submit documentation for 100% of Medicare patients while they are receiving care (a "preclaim review"), submit 100% of all claims for a postpayment review, or opt out entirely and swallow a 25% payment cut with the possibility of review by a recovery audit contractor. The previous version of the project included only the preclaim review provisions; according to a statement from CMS administrator Seema Verma, the new plan "offers new flexibility and choice for providers."

    CMS' earlier attempt at the project was implemented in Illinois but was suspended after some HHAs were forced to close their doors, pointing to the program's administrative burdens as part of the cause. Federal lawmakers requested that the program be shut down until a better plan could be developed.

    Like its earlier version, the project is aimed at reducing what CMS has identified as high rates of Medicare fraud among HHAs. CMS stated that although it will limit the project to 5 states initially, it may consider expanding the project to other states in the Palmetto/JM jurisdiction—mainly southern states as well as New Mexico, Indiana, and Kentucky. CMS has not yet set a start date for the program.

    APTA will provide comments to CMS within the 60-day window triggered by publication of the proposal in the Federal Register, and will share information on how individuals can provide comments at the APTA federal advocacy webpage.

    Major Overhaul of VA Choice Could be On the Way—But Health Net Won't Be Around For It

    Some big changes may be in store for Veterans Affairs (VA) patients and providers, as Congress moves toward approval of an expansion of care options for VA patients and the VA announces that it's ending a relationship with Health Net Federal, a major contractor for the VA Choice program.

    The most far-reaching decision is the advancement of a bill named the VA Mission Act. That bill, already approved in the US House of Representatives and likely to pass in the US Senate, would commit $52 billion to the creation of a new program that would overhaul VA Choice, the program created in 2014 to increase access and reduce wait times for VA patients by allowing greater use of non-VA providers.

    The VA Choice program faced criticism that it has fallen short of its aims, and is set to run out of money in late May or early June 2018. If signed into law, the Mission Act would provide funding while the program is retooled. The Trump administration has already indicated support for the legislation.

    Once up and running, the new program would allow veterans to access private sector care in instances in which long travel times, long wait times, or a VA facility's poor service prevent the patient from receiving adequate care. The program would also allow up to 2 walk-in visits per year at non-VA clinics, according to a report in the Military Times.

    In another move related to VA Choice, VA announced that it will be allowing its contract with Health Net Federal to expire on September 30, 2018. The company is the contractor for VA Choice services in regions that include all or portions of 37 states

    VA has not announced a new contractor for the regions now served by Health Net, nor has it provided any guidance on what providers currently contracted with Health Net should be doing to prepare for the change. For its part, Health Net issued a statement that it will "remain focused on program performance improvements" and "will continue to work collaboratively with VA to ensure providers receive prompt and timely payments during this period of transition." The company stated that it will provide updates on the transition on its Veterans Affairs webpage.

    ATPA regulatory affairs staff will continue to monitor the progress of the legislation and transition from Health Net, and will share updates through PT in Motion News and other resources.

    CMS Offers Alternative Dispute Resolution for Some Providers With Unresolved Medicare A or B Appeals

    Providers with Medicare Part A or B appeals that have been waiting for a decision are being offered the possibility of resolving those appeals through a new alternative dispute resolution program from the US Centers for Medicare and Medicaid Services (CMS). However, the requirements around just who can qualify for the service, and under what circumstances, are a bit complex—that's why CMS is urging interested providers to review online resources and register now for a May 22 conference call that will attempt to explain the details.

    Called the "Settlement Conference Facilitation" (SCF) program, the initiative is aimed at providers and suppliers who have claims appeals awaiting decisions in the Office of Medicare Hearings and Appeals (OMHA) or Medicare Appeals Council (Council). In the SCF, "a facilitator uses mediation principles to assist the appellant and CMS in working toward a mutually agreeable resolution" to a claims appeal, according to CMS. The facilitator can't make rulings on the merits of a claim, nor can the facilitator serve as a fact-finder; instead, says CMS, the facilitator "may help the appellant and CMS see the relative strengths and weaknesses of their positions."

    To qualify for the program, a provider must have a National Provider Identifier, cannot have or have had False Claims Act litigation pending against them, and cannot have filed for bankruptcy or expect to do so.

    But those are just the provider qualifications. Determining which appeals would qualify for the program is another somewhat more complicated matter, involving the total number of appeals pending, the dollar amounts involved in those appeals, and the codes used in the initial claim, among other requirements.

    To help make things clearer, CMS offers a webpage on the SCF program and urges interested providers to join a conference call on May 22 at 1:30 pm ET. That call requires free advance registration, which closes at noon on May 22 or earlier if spaces fill up. Questions about the SCF can be emailed to OMHA.SCF@hhs.gov.

    This program is separate from the Low-Volume Appeals Initiative CMS announced in February of 2018.

    APTA-Supported VA Change Will Expand Use of Telehealth for PT Services

    In a potentially game-changing win for physical therapists (PTs), physical therapist assistants (PTAs), and many other health care providers, the US Department of Veterans Affairs (VA) is following through on a proposal to dramatically expand the use of telehealth services across state lines for VA beneficiaries in all US jurisdictions The change, strongly supported by APTA, would also allow these services to be conducted in nonfederal sites, including the homes of VA patients.

    As noted in its final rule released on May 10, VA took this sweeping action because interstate barriers were limiting VA's ability to fulfill its federal mandate.

    "In an effort to furnish care to all beneficiaries and use its resources most efficiently, VA needs to operate its telehealth program with health care providers who will provide services via telehealth to beneficiaries in states in which they are not located, licensed, registered, certified or otherwise authorized by the state," VA writes in its rule. "Without this rulemaking, doing so may jeopardize these providers' credentials…because of conflicts between VA's need to provide telehealth across the VA system and some states' laws or requirements for licensure, registration, certification, that restrict the practice of telehealth."

    In addition to providing comments in strong support of this change when it was proposed in October 2017, APTA met with VA representatives to advocate for the expanded use of PT and PTA services provided via telehealth.

    "Our combined efforts with APTA have helped to create a change that will make a huge difference in the lives of VA patients," said Mark Havran, PT, DPT, president of the Federal Physical Therapy Section. "The patients who will benefit from this new rule are some of VA's most in-need, with many living far from provider facilities or experiencing mobility issues that make travel difficult. Now PTs and PTAs will be better able to provide the services those patients require."

    Some important things to understand about the new rule:

    The rule doesn't expand authority or scopes of practice.
    VA providers must continue to abide by federal law and the practice acts of the provider's state of licensure.

    The rule applies only to VA-employed providers—not to contracted providers such as providers in the Veterans Choice program.
    The limitation to VA-employed providers was necessary to create protections from any actions that might be taken by state professional licensing boards.

    Copays for telehealth services will go away.
    Congress authorized VA to waive copay requirements for telehealth services, which VA did.

    The rule doesn't go into effect immediately.
    The changes will go into effect 30 days after publication in the Federal Register, which hasn't happened yet. Don't expect that publication until sometime in December at the earliest.

    The rule won't solve all the issues with telehealth service delivery.
    VA acknowledges that the change addresses only 1 challenge to telehealth services, and has resolved to continue to work on technical elements that interfere with effective delivery, including patients' and providers' access to technology.

    Telehealth services currently are allowed in the VA system, but only if both the provider and patient live in the same state. Additionally, many VA medical centers restrict telehealth activities to federal property—for both the patient and the provider. The new rule would make it possible for the facilities to lift those restrictions.

    "This rule is a significant step forward in the recognition of therapy services provided through telehealth," said Justin Moore, PT, DPT, CEO of APTA. "APTA was happy to support this change, because we believe VA's vision and leadership in this important component of health care will help to shape the future of patient access."

    CMS Wants to Drop Functional Measure, 2 Quality Reporting Measures From IRF Requirements

    The US Centers for Medicare and Medicaid (CMS) is continuing its trend toward easing administrative burdens and eliminating what it believes may be duplicative quality-reporting activities—this time, by way of a proposed rule for inpatient rehabilitation facility (IRF) payment that would do away with a longstanding functional assessment and 2 outcome measures.

    The assessment slated for possible elimination is the Functional Independence Measure (FIM), part of the IRF Patient Assessment Instrument. According to a CMS fact sheet on the proposed rule, data collected through the FIM are being captured in other parts of the assessment instrument. The use of the FIM dates back to 1987; its use would end October 1, 2019.

    Also up for possible elimination: measures related to methicillin resistant staph aureus (MRSA) infection and the percent of patients assessed and given the seasonal flu vaccine. CMS describes both measures as ones in which costs of reporting outweigh the benefits. The reporting changes would be implemented October 1, 2018.

    Other changes in the proposed rule include:

    • A 0.9% payment increase for FY 2019—about the same percentage increase as in 2018
    • Elimination of reporting requirements related to the rehabilitation physician conducting team meetings remotely
    • Allowance for the postadmission physician evaluation to count as one of the required face-to-face physician visits
    • Removal of requirements for admission order documentation—but not the requirement for admission orders themselves

    Also included in the proposed rule is a general call for feedback on several topics, including ideas for achieving better electronic sharing of data between providers, the possibility of allowing the rehabilitation physician to determine whether a particular patient assessment could be conducted remotely, the training of nonphysician providers relevant to IRFs, and ways that nonphysician IRF provider roles could be expanded.

    APTA will submit comments on the proposed rule by the June 26 deadline.

    Special Olympics Looking for PT, PTA, Student Volunteers

    Calling all physical therapists (PTs), physical therapist assistants (PTA), and physical therapy students: your service is needed at the upcoming Special Olympics US National Games in Seattle July 1-6, 2018.

    The Special Olympics Healthy Athletes program has issued a call for PTs, PTAs, and students interested in participating in the FUNfitness screening event, which provides an opportunity for athletes to be examined in a range of areas including flexibility, functional strength, aerobic conditioning, and balance. The FUNfitness screen was developed as a collaboration with APTA and Special Olympics and is a cornerstone of an APTA-Special Olympics partnership.

    Screening events are open at various times throughout the Olympics, and are preceded by training sessions for volunteers. For more information on FUN fitness, contact Vicki Tilley, Special Olympics global clinical advisor. To register as a volunteer, contact Frank Sebastian or visit the volunteer webpage.

    CMS Proposes Major Change in SNF Payment System

    The payment world could change dramatically for skilled nursing facilities (SNFs) as early as October of next year if the US Centers for Medicare and Medicaid Services (CMS) follows through on a proposed rule.

    On April 27, CMS unveiled its proposed SNF rule for 2019, which includes plans to replace the existing SNF case-mix methodology, known as Resource Utilization Groups Version IV (RUG-IV) with an entirely new system dubbed the Patient-Driven Payment Model (PDPM). CMS believes the new model will save money and improve care by reducing administrative burden and tying payment to patient conditions rather than services provided. The new system would go into effect on October 1, 2019.

    Under the PDPM, payments would be based on a resident's classification among 5 components—physical therapy, occupational therapy, speech-language pathology, nursing, and "non-therapy ancillary services," a category mostly related to drugs and medical supplies. Payment would be calculated by multiplying the case-mix index for the resident's group with each component, first by a base payment rate and then by days of service received. The payment calculations for each component would then be added together to create a resident's total per diem rate.

    The big picture: CMS believes the new system would shift payment away from the focus on volume-based services associated with RUG-IV and toward "incentives to treat the whole patient." That shift also would come with "significantly" reduced administrative burdens, according to a CMS fact sheet on the proposed rule.

    The new model is itself an overhaul of sorts of a case-mix methodology system CMS floated last year. That model, known as the Resident Classification System (RCS-I), met with heavy criticism from a wide range of stakeholders, including APTA. The association argued that the plan was based on an inadequate set of patient characteristics and a poor understanding of the impact of comorbidities, and likely would reduce therapy for patients most in need. Initial analysis of the PDPM reveals that CMS may have listened to that criticism, creating a system that it says "puts the unique care needs of the patient first."

    To ensure that SNFs are delivering the kind of care envisioned, CMS would add 2 new therapy reporting requirements to the discharge assessment—the first aimed at documenting therapy minutes and each therapy mode used, and a second focused on days for each discipline and mode of therapy. CMS hopes that monitoring both minutes and days will allow it to get a better handle on the daily intensity of services provided—something that's difficult to do under the current RUG system. In addition, the new system would limit concurrent and group therapy to 25% for each discipline.

    Other elements of the proposed SNF rule:

    • Overall payments to SNFs would increase by 2.4%, or $850 million.
    • The reporting window for the public display of SNF outcome measures would be expanded from 1 to 2 years, a change that CMS believes will require more SNFs to participate and is in line with current requirements for inpatient rehab facilities and long-term care hospitals.
    • Beginning as early as 2020, CMS would begin publicly displaying data related to changes in self-care and mobility during SNF care and at discharge.
    • CMS would add a cost-benefit analysis as an additional factor when considering potential outcome measures to remove from its list of requirements.

    And while no actual changes are being proposed, CMS is using the release of the proposed rule to remind SNFs that beginning in October 2018, SNFs could receive increased or reduced payments depending on their performance on the SNF value-based purchasing program's readmission measure. The measure, based on all-cause 30-day hospital readmissions, doesn't require SNFs to report additional information, since CMS will use existing claims information to make the assessment.

    APTA regulatory affairs staff are reviewing the rule and will draft comments for submission before the deadline of June 26, 2018.