Presented by December 5, 2017
National Association for the Support of Long Term Care representing ancillary services and providers of long term and post-acute care
Total Payments by Place of Service in 2015 Same therapy, many settings: Nursing facilities, hospital outpatient departments, physicians offices, outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities (CORFs), private practice, and home health agencies. 36% 34% Medicare spent nearly $8 billion on outpatient therapy in 2015. All settings use same billing codes and are subject to the same policies. 6% 15% 9% SNF Hospital Outpatient Clinic Outpatient All Others Office Source: Moran study for AOTA 3
The Balanced Budget Act of 1997 (BBA) Created per beneficiary, per calendar year $1,500 cap for PT & SLP and an additional $1,500 cap for OT. 2006 Congress authorized an Exceptions Process that allows patients who qualify to get an exception to the cap because they need additional medically necessary therapy. 2011 CMS imposed 25% cut using Multiple Procedure Payment Reduction (MPPR). 25% payment reduction to the second and subsequent practice expense value of 44 CPT codes deemed always therapy services. 2013 Congress increased MPPR reduction to 50%. 4
2012 Congress passed Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJA), signed into law on February 22, 2012. Section 3005 imposed Manual Medical Review. Imposes a Medical Necessity review for all claims above a $3,700 threshold. CMS Implementation is highly problematic. 2015 - Congress passed Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law April 16, 2015. Section 202 changed Manual Medical review to Targeted Medical Review and prohibits RACS from conducting the review! NASL successfully lobbied for this policy. 5
Targeted medical necessity review of certain claims above $3,700 threshold for PT and SLP, and an additional $3,700 threshold for OT claims. Strategic Health Solutions is the Supplemental Medical Review Contractor (SMRC) performing this medical review on a post-payment basis. According to CMS website: The SMRC selects claims for review based on: Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA. Therapy provided in skilled nursing facilities (SNFs), therapists in private practice, and outpatient physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers. Of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day. 6
2018 The CY 2018 Medicare Physician Fee Schedule Final Rule finalized the 2018 Therapy Cap amount at $2,010. Current exceptions process expires December 31, 2017. Congress can: o Reauthorize the exceptions process by extending it for another year or two; or o Pass the discussion draft language that has been agreed to by the health care committees; or o Delay until January or February. 7
October 26 th congressional health care committee staff announced they have agreed upon discussion draft language that will repeal Therapy Cap and continue medical review. Senate Finance Committee, House Energy & Commerce Committee and House Ways & Means Committee. All have jurisdiction over Medicare Part B. Republican and Democratic staff from each committee met jointly for many months to work out and agree to the language. Therapy Cap Coalition supports the language. 8
Repeals Therapy Cap as of January 1, 2018. Continues the KX modifier indicating services are medically necessary over $2,010 (the previous therapy cap amount). Medical review process above a dollar threshold is continued. Threshold for medical review is lowered to $3,000 (currently at $3,700) for PT and SLP claims and $3,000 for OT claims. After 2028, the $3,000 threshold can increase by the Medicare Economic Index. Possible study language could be included later. 9
Tax Reform Senate now passed different version than House passed on 11/16. Could go to conference committee, or House could pass Senate version Children s Health Insurance Program (CHIP) Reauthorization states running out of CHIP money Continuing Resolution to fund the govt. Current funding through December 8 th may extend to 22 nd Deferred Action for Childhood Arrivals (DACA) -- Democrats may withhold their votes on a CR to get this included. Republicans need Democratic votes in the House and Senate to pass a new CR. Budget Caps -- Negotiations involves $180 billion in additional funding divided between defense and non-defense discretionary spending over two years. Approximately $30-40 billion in offsets could come from all sectors in healthcare. Medicare Extenders Package Includes therapy cap repeal
Congress wants to pass the Extender bill Therapy Cap policy is the lead. VERY IMPORTANT Therapy cap repeal will be included in a larger bill that will contain offsets, or additional policies that will pay for the cost of repealing the Therapy Cap. The offsets have not been identified publicly yet. SNF and/or home health sector could see cuts in this bill. While NASL supports the repeal language we need to see the entire package before we take a final position on the overall legislation. 11
Two-year straight extension of the Medicare Dependent Hospital Program and the Low-Volume Adjustment Program. Five-year straight extension of the Home Health Rural Add- On. Permanent extension of exceptions process for Medicare with the repeal of the therapy caps. Two-year straight extension of the Medicare geographic payment cost index for physician payments. Five-year straight extension of the Ground Ambulance Add- Ons and ground ambulance payment modifications. Five-year reauthorization of special needs plans (SNPs) Two-year extension of the State Health Insurance Assistance Programs (SHIP). Two-year extension of funding for consensus based entity work on quality measures.
Medicare Advantage telehealth. Medicare Advantage termination authority. Extension of the current law policy related to misvalued codes for physician services. Non-emergency transportation payment modification reduction related to end stage renal dialysis transportation. Medicare Improvement Fund rescission. Modifications to skilled nursing facility (SNF) payment. Modifications to home health agency (HHA) payment. Modification of payments for critical access hospital swing beds.
Once the discussion draft language is in a legislative vehicle, NASL and other organizations will announce a grassroots campaign to support that specific bill. Until then, we need to continue to demonstrate support for repealing the caps. Ask your Member of Congress to co-sponsor the Medicare Access to Rehabilitative Services Act (S. 253, H.R. 807). Thank your Member of Congress for their support if already a co-sponsor. Go to the NASL Issue Center for more information. https://www.nasl.org 14
CONTACT: Cynthia Morton National Association for the Support of Long Term Care (NASL) Cynthia@nasl.org 202-803-2385 15
Questions? 16
Webinar recording and handouts available later today at simpleltc.com/partb 17