Taking Part B Therapy Beyond the $3,700 Threshold New Manual Medical Review Process Effective date October 1, 2012

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1 Taking Part B Therapy Beyond the $3,700 Threshold New Manual Medical Review Process Effective date October 1, 2012 Presented by: Leigh Ann Frick, PT, MBA Vice President of Clinical Services Heritage Healthcare

2 Agenda Therapy Cap Review & History Outpatient Hospital-Based Inclusion Continued Use of KX Modifier Manual Medical Review Process National Provider Identifier (NPI) Requirement Next Steps 2

3 History of Therapy Caps Statutory Medicare Part B outpatient therapy caps for 2012: OT: $1,880 Combined PT & SLP: $1,880 Medicare Part B Outpatient Therapy Cap Exceptions Process extended through December 31, 2012 Middle Class Tax Relief and Job Creation Act of 2012 Medicare allowable charges counted toward cap Includes Medicare payments to providers & beneficiary coinsurance 3

4 Therapy Caps Applies to all Part B outpatient therapy settings & providers, including: Private Practices Part B Skilled Nursing Facilities (SNFs) Home Health Agencies (TOB 34X) Outpatient Rehab Facilities (ORFs) Rehabilitation Agencies Comprehensive Outpatient Rehabilitation Facilities (CORFs) Hospital Outpatient Departments (HOPDs) beginning October 1 through December 31, 2012 Claims paid for outpatient therapy services since January 1, 2012 will be included in caps accrual totals 4

5 Therapy Caps Exceptions Process Exceptions process allows cap to be exceeded, IF therapy services: Are reasonable & medically necessary Require the specialized skills of a medical professional Are justified by supporting documentation in the patient s medical record KX modifier MUST be included on the claim once cap is exceeded Attests that the requirements for an exception to the therapy cap have been met 5

6 Manual Medical Review Process Required per Section 3005 of the Middle Class Tax Relief & Job Creation Act of 2012 Establishes a pre-approval process for therapy services that exceed the following thresholds: OT: $3,700 Combined PT & SLP: $3,700 6

7 New Manual Medical Review Process Applies to all Part B outpatient therapy settings & providers, including: Private Practices Part B Skilled Nursing Facilities (SNFs) Home Health Agencies (TOB 34X) Outpatient Rehab Facilities (ORFs) Rehabilitation Agencies Comprehensive Outpatient Rehabilitation Facilities (CORFs) Hospital Outpatient Departments (HOPDs) beginning October 1, 2012 until December 31, Thresholds will accrue for claims with dates of service from January 1, 2012 through December 31,

8 Phase-In of Review Process Review process being phased-in: Phase I October 1 December 31, 2012 Phase II November 1 December 31, 2012 Phase III December 1 December 31, 2012 Providers assigned to phases based on CMS analysis of providers billing practices & MAC s workload CMS mailed letters to providers notifying them of the phase to which each had been assigned Details posted to CMS website: Information/ucum-64-bit NPIs listed for providers assigned to either Phase I or II Providers are in Phase III if NPI is not listed 8

9 Q & A on Phase-In Q If I am in Phase III, what happens to my claims during the timeframe of October 1, 2012 to November 30, 2012? A Phase III is scheduled to begin for services expected to be furnished on or after December 1, Claims furnished for services furnished before this time will be treated in the same manner as claims for services below the $3,700 threshold. 9

10 Coverage & Policy Guidelines MAC will use coverage & payment policy requirements as outlined in Section 220 of the Medicare Benefit Policy Manual, as well as any local coverage decisions (LCDs) in the decision-making process for approvals. Guidance/Guidance/Manuals/downloads/bp1 02c15.pdf 10

11 Manual Medical Review Process Requests for OT services exceeding $3,700 threshold or PT/SLP services exceeding $3,700 need to be approved in advance No automatic exceptions MAC will not approve more than 20 treatment days at one time 11

12 Information Required in Pre-Approval Request Beneficiary Last Name Beneficiary First Name Beneficiary Middle Initial Beneficiary Medicare Claim Number (HICN) Beneficiary Date of Birth Beneficiary Address & Telephone Number Name of Provider Certifying Plan of Care Address of Provider Certifying Plan of Care Telephone & Fax Number of Provider Certifying Plan of Care 12

13 Information Required in Pre-Approval Request continued Provider Number of Physician/ non-physician practitioner (NPP) Certifying Plan of Care Name of Performing Provider Address of Performing Provider Performing Provider Number Telephone & Fax #s of Performing Provider Number of treatment days requested Expected date range of services Date of Submission 13

14 Information Required in Pre-Approval Request continued A cover/transmittal sheet containing the following information & documentation: Cover sheet Justification Evaluation or reevaluation(s) for Plan(s) of Care Certification(s) of the Plan(s) of Care, where available Objectives, measurable goals & any other documentation requirements of the Local Coverage Determinations (LCDs) Progress reports Treatment notes Any orders, if applicable, for the additional therapy services Any additional information requested by the Medicare contractor 14

15 Exception Approval Process Submission by US Mail or fax, according to MAC s instructions MAC has 10 business days from the time it receives all necessary documents to approve or deny the request Recommend providers retain proof of receipt by MAC (i.e., fax confirmation & cover sheet that specifies date/time of submission, return receipt or certified mail) MAC will inform the provider & beneficiary of the decision by telephone, fax or letter (must be postmarked by the 10th day) Providers must monitor this closely Phase I submissions accepted beginning September 16 15

16 Exception Approval Process continued MACs will inform providers of tracking mechanism being used for preapproval requests & how to submit claims If request is denied, provider may submit a new request if it has additional information for consideration Each MAC has defined the process it uses for pre-approval Check your MAC s website for specific instructions 16

17 Exception Approval Process continued Providers instructed in the transmittal to use the HIPAA Eligibility Transaction System (HETS) to determine whether a patient is approaching the $3,700 threshold As a reminder, the Common Working File (CWF) does not reflect all of the claims at any given time 17

18 Out of Sequence Claims Medicare has a 12 months claims filing limitation Claims may be received and processed in a sequence different than that of the services provided Contractor is not required to conduct post payment review on claims that would have been subjected to the $3700 manual medical review threshold had the claims been received & processed in the order provided 18

19 Out of Sequence Claims continued Example: Beneficiary in SNF receives PT services under Part B totaling $3600 (all dates of service before October 1, 2012). Beneficiary discharged from the SNF & received therapy services from an independently practicing PT totaling $1,800. The independent PT bills in November 2012 for services provided after October 1, The MAC receives the claims & processes them. After these claims are processed the MAC receives the SNF Part B claims totaling $3,600 & processes them. Had the SNF Part B claims been received in advance of the independent PT services, the independent PT would have been required to have the services approved in advance. In circumstances such as this example, the contractor is not required to perform post-payment review on the $1,800 provided by the independent therapist. 19

20 Pre-approval What does that mean? Pre-authorization is not a guarantee of payment Claims receiving pre-approval still subject to retrospective review 20

21 Therapy Cap Determination In applying the caps after October 1, 2012, claims paid for outpatient therapy services since January 1, 2012 will be included in the caps accrual totals. The threshold is determined by the Part B totals billed from January 1, 2012, including hospital outpatient therapy that was provided. If an exception is not requested in advance of any treatment beyond the $3,700, payment will stop & a request for medical records will be sent to the provider for a prepayment review.

22 CMS Communication with In September, CMS sent letters to beneficiaries for whom Medicare has paid at least $1,700 for therapy services in 2012 Letters described beneficiary s financial liability for services provided above the $1,880 cap if the exception requirements are not met Beneficiaries 22

23 CMS Communication with Beneficiaries continued Letter stated: Even if your therapist or doctor asks for an exception, this isn t a guarantee that you won t have to pay for costs above the $1,880 therapy cap amounts. If Medicare decides at any time that your therapist or doctor didn t show enough proof that your therapy services were medically necessary, you may have to pay for the total cost of the services above the $1,880 therapy cap amounts. 23

24 CMS Communication with Beneficiaries continued Letters to beneficiaries do not mention the $3,700 threshold or potential beneficiary liability if the services are not pre-approved through the manual medical review process 24

25 Information & Education Use of the voluntary Advanced Beneficiary Notice of Noncoverage (ABN) is not required, but CMS strongly recommends using it when the provider believes Medicare may not cover the services. 25

26 Additional Changes NPI Beginning October 1, 2012, the National Provider Identifier (NPI) of the physician (or non-physician practitioner (NPP), where applicable) certifying the therapy plan of care is to be reported on all claims for therapy services 26

27 Next Steps? Communication/dialogue with residents/ members? Use of Voluntary ABN? Communicate your phase in date with Rehab Manager/Director of Rehab Review your MAC s website for further instructions Establish tracking mechanisms & procedures to integrate this process into current systems Ensure business office has NPIs for all physicians & NPPs Communicate with business office on Part B dollars for patients near $3,700 threshold Run a therapy cap report & determine who will need an exception submitted Business Office Manager to check the CWF to see where patients are in regard to the caps this does not yet show the total dollars paid or the amount compared to the threshold. 27

28 PHASE I MACs were able to begin conducting pre-approval request reviews on September 16, Providers that have not submitted pre-approval requests should submit pre-approval requests ASAP and contact their MACs 28

29 Summary What phase were you assigned to for implementation of the manual medical review process? What are your MAC s requirements? Who is responsible for what task? Communicate: Make certain that the entire team (including the beneficiary) knows and understands the rules. Re-evaluate systems and processes in light of new requirements. 29

30 Source Documents Middle Class Tax Relief & Job Creation Act of 2012 CMS Manual System Change Request 8036/ Transmittal 1117 MLN Matters Number MM8036, August 31, 2012 CMS Requests for Exceptions to the Therapy Threshold: Manual Medical Review Process CMS Therapy Cap Sheet CMS Medicare Claims Processing Change Request 7785/Transmittal #2457 CMS Special Open Door Forum August 7, 2012 Transcript 30

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32 Thank you for joining us. NASL & AHCA/NCAL thanks today s presenter: Leigh Ann Frick, PT, MBA Heritage Healthcare, Inc. lfrick@heritage-healthcare.com Webinar sponsored by: National Association for the Support of Long Term Care (NASL) American Health Care Association & National Center for Assisted Living (AHCA/NCAL) 32