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  • CMS Announces New Approach to Manual Medical Reviews

    To the surprise of APTA and other organizations that were expecting to get more information and provide input on the plan, the US Centers for Medicare and Medicaid Services (CMS) has moved ahead with a system for manual medical reviews for physical therapy and other services that exceed the therapy cap.

    Last week, CMS announced that it has contracted with Strategic Health Solutions to serve as a supplemental medical review contractor (SMRC) to conduct a "targeted review process" for claims that exceed the $3,700 cap for physical therapy and speech-language pathology combined, and $3,700 for occupational therapy services. Unlike previous years, in which reviews were conducted for all claims exceeding the thresholds, the new approach allows Strategic Health to select only certain claims for review.

    According to CMS, Strategic Health will pay particular attention to 2 main areas: providers with "a high percentage" of patients receiving therapy beyond the thresholds compared with peers; and "therapy provided in skilled nursing facilities, therapists in private practice, and outpatient physical therapy or speech-language pathology providers … or other rehabilitation providers." CMS writes that an evaluation of the number of units or hours of therapy provided in a day will be "of particular interest."

    The new approach is required as part of changes adopted in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

    The announcement was made with little warning from CMS, and was apparently developed without input of any stakeholders, including APTA, which made numerous requests to meet with CMS on the subject. The association has requested more information on the new process, and will provide members with details as they become available.


    • It is unfortunate, and will probably be regrettable for all involved that CMS has decided to move ahead without any input from the providers (or, doubtless the consumers). It is particularly troublesome and unfair that they have chosen to single out one type of provider from another. It appears to fly in the face of transparency and even democracy.

      Posted by Burke Gurney on 2/17/2016 3:54 PM

    • Thank-you for the information. This is a disturbing announcement, and I hope all PT's understand the meaning behind a report such as this. CMS continues to function autonomously, with little regard for our profession or our patients. The statistical package they have employed to review our activities has served the purpose of instilling fear into all PT's, as evidenced by the current average billing which , in the majority of cases, doesn't exceed the KX modifier level. This was the intent of the statistical package, which has been rolled out as an offensive weapon without regard for their subscribers. The MMR, to date ( based on my limited knowledge of the situation ) has been mostly a rubber stamp claiming that the notes don't reflect medical necessity. A third party reviewer will necessarily understand that they are to deny most claims and if they don't, it's likely CMS will find another review group. It's also likely that our profession will continue to seek guidance regarding the specific language and content that CMS will need to extend a patient's treatment beyond the $3,700 limit. So, we are paid very little for our work, we are threatened with legal, or at least financial repercussions if our statistics aren't in line with the new averages and we possess the knowledge that we must discharge patients quickly to stay under the radar. At what point do we begin to lobby Congress for relief? At what point do we consider our legal rights and those of our patients? How long do we continue to tolerate specific caps and tolerate the joining of our services with Speech Pathology? How long will it be before we decide that we can't generate enough revenue to keep the doors open or to justify the cost of PT school?

      Posted by Brian P. D'Orazio on 2/17/2016 6:55 PM

    • So, according to this article states the PT and speech combined cap is $3,700. I thought the cap was $1,900 for PT and speech combined. Has it changed for the better?

      Posted by Steve on 2/18/2016 8:42 AM

    • Just goes to show everyone, how little respect CMS has for ancillary services. And to Brian P O'razio, Well said, I share your frustration. Jason

      Posted by Jason H on 2/18/2016 6:17 PM

    • Cheers and ditto, Brian..... I'm so disappointed we continue to share meager reimbursement caps with a virtually unrelated service like SLP. Further, I'm disgusted with the Gcode requirement which has no validity or substance, as shown in the recent 2015 article from PT Journal. Likewise, PQRS reporting is bookkeepers' work and should come first and foremost from the referring docs who not only collect most of this redundant data to begin with but certainly gain more payment for procedures. Why is it that our PAC and lobbyists fail again and again to fight these mandates? Isn't it baffling that OT is valued at a higher amount, yet PT remains the primary rehab discipline for most major inpatient or SNF care? Moreover, I can't recall many services offered by OT that can't be covered to a degree through PT, whether it's wheelchair or other DME fitting, home safety and ergonomics, return to work, energy conservation, planning and structuring a daily routine, improving occular and vestibular function, upper extremity treatment, ADL training and adaptation, wound and lymphedema care, or sensory and motor reintegration..... though I've heard OT's are uniquely trained for these.... seems to me we PT"s should go on strike for the cases we share, and see how well goals are met without us. Of course, our patients would suffer the consequence and most of us have strong ethics prohibiting such ideas. But ironically, aren't they limited already by our tolerance to such discrimination?

      Posted by Kate Humphrey on 2/21/2016 4:56 PM

    • Thanks Kate! Every PT in this country should be up in arms. There should be a million posts, but most have given up, feel helpless and are just holding their nose hoping to survive until they can retire. Years from now, patients won't even remember that their right to good healthcare has been abrogated. Many PT's ( especially those starting in practice after 2005 ) already don't understand that we once could provide the kind of care that we could be proud to call our own. Now, we cut off care to protect ourselves. Now, we can't delegate care to aides, when it is reasonable to do so, to provide a more comprehensive approach to treatment. CMS has taken great advantage of the change in our practice act...a practice act that we crafted! Now, a profession that has been underpaid for decades is at risk of being forced into hospital or long-term rehab units in order to survive...the same conditions we found ourselves in through the 50's, 60's and largely the 70's. So how is it that we have failed every attempt to fight back against this scurrilous attack? Or, have we unwittingly been the cause by failing to understand our profession and it's needs? We are being marginalized as part of a focused attack to cut spending at all costs. It began in 1997 and accelerated in 2005. Now, we face a per diem payment crafted on the backside of a divisive campaign by CMS to statistically leverage us into limited care which reduced billing and has led to a greatly reduced average treatment charge that will now be used to justify further draconian cuts while OIG and the FBI hold the sword of Damocles as a warning against caring too much about our patients. When do we marshal our time, talents and money to educate the public and our elected representatives about this abuse? It should have begun in earnest years ago, but if not now then we will not recognize the remains of our profession in 10 years.

      Posted by Brian P. D'Orazio on 2/26/2016 4:24 PM

    • Well said Brian and Kate. Nothing new to add, but some of my personal frustrations. Physical Therapy services are the most cost effective healthcare available. What other healthcare professional do you get to spend an hour with for reimbursement that has not really increased in a decade? Considering the inflation index it has decreased considerably. Most recently we have seen reduction in payments due to sequestration, multiple procedures and losses in productivity by PT's while providing extensive additional documentation required by CMS. PQRS must be performed, documented and compiled to avoid further reduction in reimbursement and G/C codes, that is far to broad to be meaningful must be determined and added to billing in order to get paid at all. PT's were not included in the meaningful use EMR incentives, though we were included in the mandate. However, our office would be challenged to fulfill CMS extensive reporting requirements if we had not joined a network or purchased an EMR. CMS has continued to encourage unreasonable restriction of PT treatment by refusing to support "direct access" and limiting treatments with an arbitrary dollar amount that was determined and combined with SLP in 1997 (nearly 20 years ago). Other insurance companies have jumped in line with CMS, restricting treatments much more aggressively in order to increase their profits. In Hawaii, "Medicare Advantage/Medicare Part C" patients have been limited to approval of 4 treatments during their 1st month, followed by an occasional 2 extra treatments during the next month and then denied for "minimal progress". For these 6 treatments spread over 2 months, the senior has had to pay monthly insurance premiums in addition to standard Medicare payment deducted from their Social Security check and a $40 - $50 copay for each. CMS poorly monitors these profiteering insurance companies they have outsourced to and has been very dismissive regarding complaints about these questionable practices. Responding always with the term "actuarial equivalency" that apparently covers any and all concerns. Now CMS has quietly chosen another company to outsource to for MMR, with the intention of saving money on PT/SLP, OT services (Big Pharma, Corporate Hospitals or DME reviews wouldn't save much). It is of course a certainty that in order for CMS to save and a middle entity to profit it is necessary to deny, deny, deny Therapy services regardless of the medical professionals expertise or the patients needs.

      Posted by Betty Fackler on 2/27/2016 2:34 AM

    • Glad to see all the outrage. Having been through an audit recently with Optum on behalf of United Healthcare all I can say is it's a very distressing and disturbing trend to make PT's so distracted by the heavy hand of the overseers. I won my audit of 40 therapy dates but it doesn't make me feel safe from others. I try to have every note read as showing the justifiable and skilled nature of the therapy. I do fear CMS and minutia rules. I wonder if there are teams of "Dolores Umbridge" types like that mean petty person in the Harry Potter series. Rachel Katz

      Posted by Rachel Katz -> ?IX]> on 3/9/2016 11:34 PM

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