AMRPA Magazine December 2017 by AMRPA

December 2017 â&#x20AC;¢ Vol. 20, No. 12

In this Issue: CY 2018 Final Rules Coverage 15TH ANNUAL EDUCATIONAL CONFERENCE SUMMARY: MEDICAL REHABILITATION: TRANSFORMING THE FUTURE OF POST-ACUTE CARE

Volume 20, Number 12

Contributors Bruce Gans, MD Chair, AMRPA Board of Directors, Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation, and National Medical Director for Rehabilitation, Select Medical Martha Kendrick, JD Partner, Akin Gump Strauss Hauer & Feld LLP Peter Thomas, JD Counsel to the AMRPA Consumer and Clinical Affairs Committee, Principal, Powers Pyles Sutter & Verville, PC

Letter from the Chair........................................................................................... 3 AMRPA Legislative Update................................................................................. 4 HHS Proposes Greater Role for States in Regulating Health Plans Under the ACA ............................................................................. 8 Writing an Effective Appeal Letter .................................................................. 10 AMRPA Holds 15th Annual Educational Conference in Chicago; Highest Attendance Ever! ........................................................... 12

Lisa Werner, MBA, MS, SLP Director of Consulting Services for FlemingAdvanced Outcomes Design

CMS Issues CY 2018 Final Rule for Outpatient/Ambulatory Surgical Center Payment Systems .................................................................. 15

Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA

MedPAC to Recommend Within-Setting Payment Redistribution for Post-Acute Care ................................................................ 17

Jonathan M. Gold, JD Regulatory and Government Relations Counsel, AMRPA

CMS Issues Final Report On Initiative to Improve Care and Reduce Cost among Long-Stay Nursing Facility Residents .......................... 19

Mimi Zhang Policy and Research Associate, AMRPA

CMS Updates the Physician Fee Schedule for CY 2018 and Expands Diabetes Prevention Program ................................... 21

Lovelyn Robinson Editorial and Research Assistant, AMRPA

CMS Issues Final Rule for Second Year of Quality Payment Program ......... 24 CMS Finalizes CY 2018 Home Health Rule Without New HHGM Payment Model ........................................................... 29

AMRPA Magazine, Volume 20, Number 12. AMRPA Magazine is published monthly by the American Medical Rehabilitation Providers Association (AMRPA). AMRPA is the national voluntary trade association representing inpatient rehabilitation hospitals and units, hospital outpatient departments and settings independent of the hospital, such as comprehensive outpatient rehabilitation facilities, rehabilitation agencies and skilled nursing facilities. SUBSCRIPTION RATES: Member institutions receive the AMRPA magazine as part of their membership dues. Individuals who are employees of member institutions may subscribe to the magazine for $100 annually. Nonmember individual subscriptions are $500 per year. Send subscription requests to AMRPA, 529 14th Street, NW, Washington, DC 20045 USA. Make checks payable to AMRPA.

Highest-Cost Patients Are Generating Most of Medicare’s Potentially Preventable Spending Study Finds ........................... 31 Pulmonary Rehabilitation Should Be Among “First Line” Therapies for Patients with Lung Fibrosis, Study Says .................................. 32 Study Underscores Need for Proactive Partnerships Between Hospitals and Providers in Reducing Patient Harm........................ 33 CMS Transmittals of Interest for Medical Rehabilitation Providers ............. 35

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AMRPA Magazine December 2017

LETTER FROM THE CHAIR

Letter from the Chair Bruce M. Gans, MD, Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation and National Medical Director for Rehabilitation, Select Medical bgans@kessler-rehab.com

So long, and thanks for all the fish…

his is my final Chairman’s message of the year, and of four years of service to our association as chair. Some of you will recall that I had a “final” message about six years ago when I was also your elected chair and handed over the keys to Marsha Lommel. What a privilege and honor it has been to represent the field and speak out on behalf of those whom we serve! Thank you to all who have made my time so enjoyable (if not hectic). Our association is in excellent hands with Rich Kathrins assuming the role of Chairman and CEO as of January 1, Robert Krug, MD, moving into the role of Vice Chairman, David Storto taking over for the fantastic work of Doug Baer as Treasurer, and Anthony Cuzzola continuing his service as Secretary. Our Executive Committee will be rounded out by Mark Tarr and Kathleen Yosko as Members at Large, and I will continue on the Executive Committee as Immediate Past Chairman.

New this year, I will also be named to the role of Chief Policy Officer, a voluntary position that the Board decided to establish (so I can continue to help tormenting our members of Congress and their staff, I suppose). I am most grateful for this opportunity to continue to try to make a difference and both change the world in positive ways and prevent adverse changes from happening. AMRPA is an innovative and effective entity that serves our members and our patients very well. I am proud and excited to continue to be a part of this effort, and look forward to continuing to work with each of you over the coming years to preserve and protect access to our services for the people who will need us, but just don’t know it yet. By the way, “so long, and thanks for all the fish” is a literary allusion you may want to look up if you aren’t already familiar with it.

AMRPA LEGISLATIVE UPDATE

By Martha M. Kendrick, Esquire, Partner, Akin Gump Strauss Hauer & Feld LLP

Permanent Repeal of Therapy Caps Also Has Stakeholder Support

n October 26, Congressional leaders of the House Energy and Commerce Committee, House Ways and Means Committee and the Senate Finance Committee announced they reached a bipartisan policy agreement on a permanent therapy caps repeal. The policy will repeal the therapy caps, but require an appropriate modifier to be included on claims submitted over the new $3,000 threshold, in order to ensure that the therapy services are medically necessary, and continue targeted medical review of

• • • • •

Tax Reform Begins in Earnest Now that Congress has approved a unified FY18 Budget Resolution, the instructed

followed by a week-long Committee markup beginning on November 6. As we go to print, Republican Leaders in both the House and Senate are intent on passing a major tax bill that is not without controversy. On November 2, 2017, the House Ways and Means Committee released its muchanticipated plan for reforming the tax code for businesses and individuals, entitled the Tax Cuts and Jobs Act of 2017 (TCJA). The bill marks the beginning of what Republican leaders hope will be a speedy

Congress continues its heavy workload with a goal of wrapping up the first session of the 115th Congress by December 15. Tax reform debate begins along with efforts to provide disaster relief and stabilize health care markets. Republicans are intent on moving a major tax bill rapidly through both Houses of Congress. On October 26, a bipartisan and bicameral agreement on a permanent therapy caps repeal was announced. The “payfor” remains unknown at this juncture. After receiving heavy opposition from Congress and stakeholders, CMS pulls the Home Health Groupings Model (HHGM) from the CY 2018 Home Health Payment Final Rule. CHIP Reauthorization legislation begins to make its way through Congress, as states continue to pressure lawmakers for relief before they leave for the Thanksgiving recess.

claims established by the Medicare Access and CHIP Reauthorization Act (MACRA). AMRPA has led an effort with the Therapy Caps Coalition, to develop additional legislative language that requires a study on the impact of the new policy changes on Medicare beneficiary access. The study specifically calls for a review of all claims above the $3,000 annual threshold, as the highest utilizers of outpatient therapy services are often medically complex, 4

suffering from multiple chronic conditions. Leaders of the Senate Finance Committee also circulated a bipartisan discussion draft that addresses several expired or expiring Medicare extenders, including permanent repeal of the therapy caps. The Senate discussion draft did not include any “payfors,” and offsets, as well as some specific Medicare extender policies, are still under discussion with the House.

Congressional Committees can begin work on tax reform legislation using the reconciliation process, which allows legislation to pass the Senate chamber with a simple majority rather than the enhanced majority required for most bills. Even before the House passed the Budget Resolution, House Ways and Means Committee Republicans announced that they would release their tax reform reconciliation draft bill in early November

and successful race to enactment by the end of 2017. The plan makes significant changes to all aspects of the corporate, pass-through, international and individual sections of the tax code. The proposal eliminates the medical expense deduction, which is estimated to increase revenues by $1,261.3 billion over 2018-2027. The Ways and Means Committee began its markup of the legislation on November AMRPA Magazine December 2017

6, and it is expected to finish consideration of the bill by Thursday, November 9. While this would require a quick turnaround post-markup, House Speaker Paul Ryan (RWI) has confirmed that he plans to put the bill on the House floor for a vote the week of November 13.

and the differences between the two bills will be worked out in a conference committee in December. Republican leaders have been adamant about meeting their ambitious deadline of sending a tax reform bill to the President’s desk before adjourning for the holidays.

The Senate Finance Committee released its version of tax reform on November 9, with a markup planned for the week of November 13. The Chairman’s Mark is a conceptual draft, describing the changes in narrative format per Committee tradition. Finance Committee Members will file amendments leading up to the planned mark-up that will begin on November 13. The mark-up could extend throughout the week with final passage as late as Friday, November 17. The House is expected to debate and vote on H.R. 1 on the House floor at the same time, with a vote likely on Thursday, November 16. Senate Republican leaders have indicated the week of November 27 is possible for floor consideration of its version of tax reform. Senate rules for a reconciliation bill require 20 hours of floor debate followed by a rapid-fire amendment series known as vote-a-rama.

House Ways and Means Committee Chairman Kevin Brady (R-TX) confirmed that he is working with Democrats on a deal to delay some Affordable Care Act (ACA) taxes, including the medical device tax and the health insurance tax. Chairman Brady stated that a bipartisan agreement may also include changes to health savings accounts (HSAs). These changes, he suggested, would move separately from tax reform as part of a year-end spending deal along with reauthorization of the Children’s Health Insurance Program (CHIP). Both the medical device tax and the health insurance tax were delayed previously and are set to take effect in January.

The expectation is that the House and Senate will both appoint conferees quickly

CHIP Reauthorization and IPAB Repeal Legislation Passes House On November 3, 2017, the House voted 242-174 to pass legislation that renews Children’s Health Insurance Program (CHIP) funding for five years and extends other public health programs. The

CHAMPIONING HEALTHY KIDS Act (H.R. 3922) was passed over the objections of Democrats, who oppose the offsets identified in the measure. The House bill would be paid for through cuts to the ACA’s Public Health and Prevention Fund, changes to Medicaid third-party liability policies and tightening Medicaid asset rules with regard to lottery winnings. The CHIP reauthorization legislation also would eliminate $2 billion in reductions for disproportionate share hospital (DSH) allotments for FY 2018 and offset the cost of the policy by extending DSH reductions through FY 2026 and FY 2027. The Senate Finance Committee advanced its own CHIP bill on October 4. It hews closely to the House bill but does not include any offsets. Debates over pay-fors will likely continue into December. On November 2, the House voted 307111 to pass H.R. 849, legislation to repeal the Independent Payment Advisory Board (IPAB). Seventy-six Democrats joined with Republicans to pass the measure. It is unclear how the Senate will proceed. The Congressional Budget Office (CBO) has estimated IPAB repeal would cost about $17.5 billion over 10 years. Interestingly, the legislation passed without pay-for offsets!

CMS Pulls HHGM from Home Health Payment Rule On November 1, the Centers for Medicare and Medicaid Services (CMS) released a final rule updating the home health prospective payment system (HH PPS) payment rates. Most notably, CMS decided not to finalize the Home Health Groupings Model (HHGM), which would have cut almost $1 billion in payments to home health providers in 2019. CMS had proposed to implement this new model, which would replace 60-day episodes with 30-day periods and place patients into clinical categories, in a non-budget neutral way. It is quite possible that Congress will move forward with an alternative HHGM model in a moving year-end bill. CMS Publishes Several Final Payment Regulations On November 1, CMS released a final rule with comment period revising the Medicare hospital outpatient prospective payment system (OPPS). CMS is updating OPPS payment rates by 1.35 percent for 2018. The change is based on the hospital market basket increase of 2.7 percent minus both a 0.6 percentage point adjustment for multi-factor productivity and a 0.75 percentage point adjustment required by law. CMS is also finalizing a policy to pay for drugs purchased through the 340B Program at the average sales price (ASP) minus 22.5 percent rather than ASP plus 6 percent. CMS also removed knee replacement surgeries from its “inpatient only” list and will allow physicians to decide whether the procedure can occur in outpatient settings.

On November 2, CMS issued the final rule setting the policies for the second year of the Quality Payment Program under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The regulation aims to increase flexibility and reduce the reporting burdens for physicians. For example, the rule makes several changes to the performance categories under the Merit-based Incentive Payment System (MIPS), including raising the low-volume threshold to $90,000 in Medicare revenue or fewer than 200 Medicare patients, and allowing for the establishment of virtual groups by small or solo practitioners to combine their performance reporting and payment adjustments. CMS on also issued a final rule updating the Medicare physician fee schedule and other Medicare Part B payment policies, in which the agency moved forward with a 20 percent reduction to the current Physician Fee Schedule rate for services provided in certain off-campus hospital outpatient provider-based departments as a way to ‘level the playing field for competition between hospitals and physician practices.” 2019 Proposed Exchange Rule Mirrors Repeal and Replace Policies On October 27, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule setting forth 2019 payment parameters and provisions related to the risk adjustment and risk adjustment data validation programs; cost-sharing parameters and cost-sharing reductions; and user fees for federally-facilitated exchanges and state-based exchanges on the federal platform. The regulation includes policies similar to the proposals

considered within the “repeal and replace” bills that were debated in the House and Senate, including providing states with new flexibility to set essential health benefits, loosening requirements for small business exchanges, increasing the rate review threshold, eliminating standardized plan options and the “meaningful difference” standard. Comments were due on November 27, 2017. *** Legislative activity over the next several weeks will remain intense, and is expected to continue through the upcoming holidays as several “must pass” bills still need to reach the President’s desk by the end of the year. As members look for last-minute offsets, we cannot stop worrying that there may be a late Ways and Means Committee push to add its post-acute care ValueBased Purchasing proposal on one of the moving legislative vehicles as a potential pay-for, so we must continue to be vigilant. As noted above, we are also concerned Congress will use a HHGM-like policy as an offset. Therefore, we urge you to reach out to your members of Congress and let them know your concerns and the impact such policies will have on patients who need and depend on rehabilitative care. AMRPA also remains diligent in advocating for full repeal of the arbitrary therapy caps. Your support in sending similar messages to your lawmakers will make a difference as we move into the uncertainty of end-ofthe-year legislating!

AMRPA Magazine December 2017

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HHS PROPOSES GREATER ROLE FOR STATES IN REGULATING HEALTH PLANS UNDER THE ACA NEW STATE AUTHORITY COULD IMPACT BENEFITS PROVIDED, COSTS OF COVERAGE

n October 27, 2017, the Centers for Medicare & Medicaid Services (CMS) at the Department of Health and Human Services (HHS) issued their annual proposed benefit and payment notice under the Affordable Care Act (ACA). This is the same regulation that in prior years established important regulations granting access to the essential health benefits category of “rehabilitative and habilitative services and devices.” In a shift from prior years, HHS proposes a larger role for the states in defining what benefits must be provided and what plans can be offered on the exchanges. As a result, the impact of the proposal will largely depend on what states decide to do with their expanded flexibility and discretion. The proposed rule is also consistent with President Trump’s January 20 Executive Order instructing all executive departments and agencies to “exercise all authority and discretion to waive, defer, grant exemptions from or delay the implementation of any provision or requirement” of the ACA. Essential Health Benefits The ACA mandates that all small group and individual health insurance plans must cover an essential health benefits (EHB) package that includes 10 categories of benefits, including rehabilitative and habilitative services and devices. In prior rulemaking, HHS set up a process that each state was required to use in establishing the EHB package available in their state, referred to as a “benchmark plan.” In the past and in light of financial incentives set up by the federal government, most states chose the largest small group plan by enrollment in their state as their benchmark plan for the ACA EHB package. As anticipated, HHS has exercised its regulatory authority in this proposed rule to change the options that states have 8

for establishing their benchmark plans, essentially allowing states to relax their standards and weaken EHBs. Starting in plan year 2019, a state may change its EHB benchmark plan by: 1. Selecting an EHB benchmark plan used by another state; 2. Replacing one or more of the EHB categories of benefits in the state’s benchmark plan with the same category (or categories) of benefits from another state’s benchmark plan; or, 3. Rewriting their own benchmark plan, provided the plan does not exceed the generosity of the most generous of a comparable set of plans, including the state’s own benchmark plan used for the 2017 plan year. Under the proposal, states would be allowed to change their EHB benchmark plans annually. If a state does not select a new benchmark plan, then the benchmark plan selection from the prior year would continue to apply. HHS is also considering establishing a federal default definition of EHB, while still allowing states the flexibility to adopt their own EHB benchmark plans (but states would be required to defray the costs of any benefits that exceeded the federal default). States would still be required to adopt benchmark plans that cover the 10 categories required by the ACA, including rehabilitative and habilitative services and devices. States would also still be required to take into account the healthcare needs of diverse segments of the population, including persons with disabilities, when selecting a benchmark plan. However, HHS admits that people with “specific health needs” may be impacted by the proposal. This is because, depending on the benchmark plan selection made by the state, consumers with less comprehensive plans may no longer have coverage for certain services.

Qualified Health Plan Certification and Provider Network Adequacy The proposed rule makes a number of changes, discussed below, regarding which plans can be offered on an exchange and which standards those plans must meet. HHS believes that this expanded authority would allow states to promote greater competition on the exchanges. Under the ACA, only qualified health plans (QHPs) can be offered on the exchanges. HHS is required to establish minimum criteria for provider network adequacy

ABOUT THE AUTHORS

Peter W. Thomas Counsel to the AMRPA Denials Management Committee and the Consumer and Clinical Affairs Committee

Christina Krysinski Associate, Powers Pyles Sutter & Verville, PC AMRPA Magazine December 2017

that a health plan must meet to be certified as a QHP. The proposed rule would have states play a much larger role than they previously have in certifying that QHPs meet network adequacy requirements. HHS proposes that, starting in plan year 2019, the federally facilitated exchanges (FFEs) and state-based exchanges that are hosted on the federal platform (SBEFPs) rely on state reviews of network adequacy standards, so long as the state has been found to have an adequate review process. The proposed rule would also get rid of the requirement that SBEFPs enforce FFE network adequacy and essential community provider standards. Instead, SBE-FPs would be allowed to determine how to implement these standards on their own. Under the current rules, an exchange health plan must also have enough doctors and other providers of care in its network to guarantee patients “reasonable access.” Starting in plan year 2019, HHS proposes to defer to the states reviews of reasonable access with the authority to enforce standards that are at least equal to the current federal reasonable access standard. For states that do not have the authority to conduct sufficient network adequacy reviews, HHS proposes reliance on an issuer’s accreditation from an HHSrecognized accrediting entity. The current regulations also require that a plan be “meaningfully different” from all other QHPs offered by the same issuer of that plan within a service area and level of coverage in an exchange. This requirement is meant to better allow consumers to compare different health plans offered by the same insurer. HHS proposes eliminating the meaningful difference standards for QHPs offered through a FFE or SBE-FP. HHS’ position is that this requirement is no longer necessary due to fewer issuers participating in the exchanges and the availability of fewer plans for consumers to choose from. Risk Adjustment Transfers Risk adjustment is one of the most important issues to consider when it comes to nondiscrimination and equal access to care for people with disabilities and chronic conditions. In the private insurance market, insurers prefer to

attract young and healthy enrollees and repel older and sicker potential enrollees in order to reduce their risk profile. With a lower risk profile, there is a greater chance that the insurer will be more profitable after paying out health care claims. In order to counteract this, the current regulations implemented the risk adjustment program to support health insurance issuers that attract higher risk populations. Under the risk adjustment program, funds are transferred from insurers who attract lower risk enrollees to insurers who attract higher risk enrollees. States or the federal government (depending on which one is operating the exchange in the state) assess charges on plans that experience lower than average actuarial risk and use such funds to make payments to plans that have higher than average actuarial risk. In response to requests from state regulators, HHS proposes to provide states with more flexibility regarding risk adjustment transfers in their markets. The Proposed Rule would permit states to request a reduction in the average premium used to calculate risk adjustment transfers in the small group market in order to minimize burden on certain insurers. This means that less money would be transferred from lowerrisk plans to higher-risk plans in the small group market in those states. Medical Loss Ratio The medical loss ratio (MLR) is a financial measurement that encourages health plans to provide value to enrollees. For example, if an insurer spends 80 cents of every premium dollar on medical claims and improvement in the quality of care (as opposed to using those funds to cover overhead expenses), the insurer would have an MLR of 80 percent. The ACA requires health insurers to provide rebates to enrollees if they do not achieve specified MLR thresholds. The current MLR standard established by the federal government is 80 percent, with certain exceptions.

destabilize the individual market in the state. The proposed rule would allow for adjustments to a state’s MLR standard if the state demonstrates that a lower MLR standard could help stabilize its individual market. This means that a state could change the percentage of premium dollars paid to cover claims if the state could demonstrate that the change could help stabilize its individual market. HHS believes that this would provide states with an additional tool to help stabilize and provide relief in their individual markets. Rate Review Under current regulations, if an insurer plans to increase its rates by more than 10 percent, the insurer must justify the increase through a “reasonableness review.” Reasonableness reviews examine how a rate increase was determined, ensure that the rate increase is supported by evidence, and determine whether a rate increase will not unfairly discriminate against certain insured individuals. HHS proposes to raise the threshold for reasonableness review of rate increases from 10 percent to 15 percent. The proposal would also increase state flexibility for rate review programs by allowing states to set different rate filing deadlines and allowing states to post rate filing information on a rolling basis. Conclusion In light of stalled Congressional efforts to repeal and replace the ACA, the administration will likely continue to use its executive and administrative authority to weaken ACA requirements and allow states further discretion to implement the Act. The administration believes that these actions will expand competition and reduce health insurance prices. HHS accepted comments on the proposed rule through November 27. AMRPA is working with its partners in the Coalition to Preserve Rehabilitation (CPR) as these important developments continue to occur and plans to comment to HHS by the deadline.

HHS proposes to make it easier for states to change the MLR standard in their state. The current regulation only allows a state to be granted an adjustment if there is a reasonable likelihood that application of the 80 percent MLR standard may 9

WRITING AN EFFECTIVE APPEAL LETTER By Lisa Werner, MBA, MS, CCC-SLP

s you are all well aware, CMS and its contractors are auditing inpatient rehabilitation claims and consistently denying much of what they review. These contractors and the items they focus on during an audit have been covered in previous months. However, in this article, I would like to address how to conduct appeals for both technical and subjective denials, providing you with the tools necessary to successfully challenge any and all denials you may receive. The first step in this process is an Additional Documentation Request. When preparing your chart, make sure to thoroughly review the entire document and verify that all necessary items are included and easily identifiable. The easiest denial to avoid is one where the auditor cannot find the necessary documentation in the chart. If you feel that your charts make items difficult to find, include a table of contents or a short letter indicating the name and placement of each required item. Be as specific as possible. Do not allow an auditor to deny a claim because of a simple oversight. They can, and will, deny any claims that do not meet their criteria. The next step in the appeals process is redetermination. For redeterminations, the same auditor who initially reviewed your charts will revisit them in their entirety. Because of this, I highly recommend including an appeal letter. Make sure the letter provides solid arguments as to why the patient’s rehabilitation stay was both reasonable and necessary. Make sure to specifically refute the reasons for denial included in the initial denial letter. If the auditor upholds the denial despite your efforts, you will then move on to the next step: reconsideration.

During reconsideration, the provider will appeal directly to the Qualified Independent Contractor (QIC). The provider’s Medicare Administrative Contractor (MAC) forwards the record to the QIC, but the provider (you) will need to submit additional documentation in support of payment. This additional documentation can be either an appeal letter or additional documentation that was omitted from the original appeal. These initial steps all have one item in common: the appeal letter. Because of this, I want to focus specifically on what to include in this letter so you can construct the most effective document possible. If an auditor denies your claim because the pre-admission screening (PAS) lacks specific information, or does not meet signature timeframe criteria, consider using these arguments in your letter: •

Discuss the process for reviewing potential admissions.

•

Make sure the medical director reviews each admission and signs the PAS form. If a signature is not present, look for documented evidence that the medical director did review information regarding the potential admission (emails, texts, etc.).

•

Make sure the screening is filed in the medical record before the chart is closed. If it was not sent to the auditor initially, make sure it is sent along with the appeal.

•

Identify and emphasize the medical necessity that initially justified the patient’s stay and place it conspicuously in the letter. If the auditor argued his/her case by pointing out missing elements, create

a comprehensive overview of the admission and argue that, regardless of the specific criteria set out for admissions, this rehabilitation stay was still medically necessary. If an auditor denied your claim because the post-admission physician evaluation (PAPE) lacked specific information, or did not meet the timeframe criteria for completions, consider these arguments: •

If you are missing the statement verifying the concurrence of the findings in the PAS and the patient’s presentation during the postadmission assessment, discuss how the physician typically reviews the PAS as part of initial patient assessments. Note how the physician would handle changes to the patient’s presentation and how these changes would be documented.

•

If your PAPE was completed greater than 24 hours after admission, look for a note with a plan written within 24 hours. The purpose of this guideline was to make sure teams had an initial plan of care from which to work. Identify how this process is demonstrated in your record regardless of the status of your PAPE.

•

If the physician extender wrote the PAPE, your defense will need to demonstrate how the physician and the extender collaborated on the case. Identify and emphasize where the physician documented his faceto-face visits, collaborated with the extender, and completed all other required elements of the PAPE.

•

If the denial was justified because of missing elements in the PAPE, comb through your initial documentation to identify examples of the patient’s AMRPA Magazine December 2017

prior levels of function, their social history, their active and chronic comorbidities, and the plans to address all conditions that require physician oversight. List as many examples as you can find. If an auditor denies your claim because the individualized overall plan of care lacks specific information, or does not meet the timeframe criteria for signatures, consider these arguments: •

•

If the overall plan of care was completed outside of the four-day window, look for a documented team conference within the first four days of the patient’s stay. Look for evidence that the plan was addressed and finalized in a timely manner. If you did not adhere to the original plan or the original scheduled interventions, look for documentation of missed therapy sessions and any other medical explanations that can justify altering the plan. Provide specific references to these notes in your appeal letter. Provide examples of how the physician’s documents are in agreement with the therapist’s treatment plans, interventions and goals. Discuss how these conclusions are communicated to the team and what role the physician plays in that process.

If an auditor denies your claim because your team conferences lack specific information, do not meet the completion timeframes, or are missing signatures for required attendees, consider these arguments:

•

If a team member was missing from a team conference, focus your explanation on how information and ideas from each discipline are conveyed during the conference. Look for information that provides reasons for absences and address whether another team member covered for the missing person.

In your appeal letter, emphasize prior levels of function, compare levels of function at admission and discharge, indicate incremental gains, and provide information on outcomes.

•

The most effective way to justify intensity, even if time was missed, is to focus on accomplishments made by the patient.

•

Many denials result from errors in counting group and concurrent minutes. To circumvent this, focus your argument on the outcomes of the therapy, not the specific therapies provided.

If an auditor denies your claim because of doubt surrounding the medical necessity of the stay, consider these arguments: •

•

Provide details and examples from your documentation that show adherence to the seven criteria of medical necessity. -- Medical Supervision -- Rehabilitation Nursing -- Relatively Intense Level of Services -- Multidisciplinary Approach -- Coordinated Care Plan -- Significant Practical Improvement -- Realistic Goals

•

Focus your appeal letters on patient successes.

•

Make sure to specifically address the reasons for denial noted by the auditor and thoroughly refute each point.

•

While technicalities should by no means be ignored, when it comes to medical necessity, it is always important to focus on the overall medical necessity of the rehab stay instead of dwelling too long on small errors.

If team conferences do not occur once every seven days, look for evidence of documented team meetings between conferences.

If an auditor denies your claim because of doubt surrounding the intensity of your therapy services, consider these arguments: •

defining factors used to justify the necessity of rehab services.

Every appeal letter should address the patient’s medical condition at admission, as this is one of the

Writing appeal letters is labor intensive, but, at the end of the day, they are absolutely worth the time and effort needed to do them correctly. If we do not diligently fight these denials, not only are we jeopardizing our reimbursements, but, by extension, we are jeopardizing access to necessary services. It is of the utmost importance that we defend the right for people to receive the treatment they need and to benefit from an inpatient rehabilitation stay.

AMRPA HOLDS 15TH ANNUAL EDUCATIONAL CONFERENCE IN CHICAGO; HIGHEST ATTENDANCE EVER! By Carolyn C. Zollar, MA, JD, Executive Vice President of Government Relations and Policy Development, AMRPA

he American Medical Rehabilitation Providers Association (AMRPA) held its 15th Annual Educational Conference and Expo in Chicago, October 23-25. The conference’s theme was Medical Rehabilitation: Transforming the Future of Post-Acute Care. More than 450 people attended and chose between five tracks of educational programming: •

Business Development, Operations and Financial Management

•

Regulatory Compliance and Coding

•

Research and New Advances in the Delivery of Rehabilitation Services

•

Program Evaluation

•

Safety and Quality

The sessions focused, for example, on the many problems rehabilitation providers are facing with audits and denials from the Medicare Administrative Contractors (MACs), Supplemental Medicare Review Contractors (SMRCs), and the Certified

Error Rate Testing (CERT) contractors. Other sessions highlighted member and non-member experiences with the new service and delivery models, and how they are affecting their operations. For example, one session focused on the extremely diverse experiences of three providers participating in Accountable Care Organizations (ACO). Another presenter discussed their success in participating in the local Comprehensive Care for Joint Replacement (CJR), and one presenter shared their multiyear experience with the Bundled Payment Care Initiative (BPCI). The meeting featured two exemplary keynote presentations: Thomas Demetrio, JD, and Josh and Shelly Buck. In 2012, Thomas Demetrio won a $1 billion settlement against the NFL and NHL by players and their families in a groundbreaking concussion class action lawsuit. Currently, he represents the passenger pulled off the United Airlines flight that consumed the news media for weeks. He gave his views on medical rehabilitation and the intersection of risk with quality

Highlights: • •

Highest Attendance Yet! Successful Networking Opportunities

and safety issues in healthcare. Josh and Shelly Buck described their history of tragedy, crisis, healing and victory over their years together. After a spinal cord injury left him paralyzed from the chest down, Mr. Buck battled back with the help of intensive medical rehabilitation. Their heartwarming and inspiring story reminds those of us in the field why and how medical rehabilitation saves and changes lives. The morning session addressed the current environment for medical rehabilitation providers, including the newest regulations, their potential impact and the effect of changes being made by the new administration. Martha Kendrick, JD, outlined the current political landscape and what it means for the

AMRPA Magazine December 2017

medical rehabilitation field. Bruce Gans, MD, AMRPA Board Chair, addressed the state of AMRPA and presented the AMRPA Leadership Excellence Award. There were three awardees this year: •

Mary Beth Walsh, MD, Former CEO and Executive Medical Director, Burke Rehabilitation Hospital, Inc., White Plains, New York, and AMRPA Board of Directors Member;

•

Noel Rao, MD, Residency Director of Marianjoy Rehabilitation Hospital, Wheaton, IL;

•

Nathaniel Mayer, MD, Founding Director of the Drucker Brain Injury Center at MossRehab, Elkins Park, PA.

than 40 percent of the field’s discharges. Dan Walter of Walter Consulting presented the status of the field for today and tomorrow and concluded that he is bullish on the future of medical rehabilitation. Attendees enjoyed networking breaks in the exhibit hall area and networking receptions on Monday and Tuesday evening. On Tuesday morning, there was a networking breakfast and educational roundtables. The roundtables focused on marketing, unit manager special issues, legislative and regulatory issues, nursing and medical directors. Come join us next year in Boston, September 24-26, 2018!

In addition, Richard Kathrins, PhD, AMRPA Board Vice Chair, presented Bruce Gans with a plaque recognizing his years of leadership with AMRPA. Dr. Kathrins is the incoming AMRPA Board Chair starting in January 2018. Additionally, Sam Fleming, President of eRehabData®, gave an overview of the current trends in the field based on the information collected from eRehabData®, which represents more 13

H E L P M OV E O U R F I E L D F O R WA R D

one vote at a time.

Mary Free Bed is on a mission to raise the profile of our field. Rehabilitation is one of only four specialties in the U.S. News Best Hospitals rankings to be rated on reputation rather than quality. Weâ&#x20AC;&#x2122;re asking physiatrists to select which metrics best reflect excellence in our field. Help us Rehab the Vote. Visit www.maryfreebed.com/doc-survey (password: survey) to learn more. 14

AskForMary.com AMRPA Magazine December 2017

CMS ISSUES CY 2018 FINAL RULE FOR OUTPATIENT/AMBULATORY SURGICAL CENTER PAYMENT SYSTEMS By Mimi Zhang, Policy and Research Associate, AMRPA

n November 1, 2017, the Centers for Medicare and Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period which updates the 2018 payment rates and quality provisions, and includes other policy changes. Perhaps the most controversial aspect of the rule is CMS’ finalization of a policy that will dramatically reduce Medicare Part B reimbursement amounts for separately payable outpatient drugs purchased under the 340B Drug Discount Program. In response to this policy, several parties have publicly stated that they intend to pursue litigation over the 340B components of the rule as of this article’s printing. CMS also finalized its proposal to remove total knee arthroplasty (TKA) from the inpatientonly procedure list (thereby allowing the procedure to be paid for under the OPPS), and is reinstating a moratorium on enforcement of the direct physician supervision policy for outpatient therapeutic services for certain providers for CYs 2018 and 2019. This article summarizes the major provisions of the final rule. OPPS and ASC Payment Update Based on policies finalized in the rule, the OPPS payment rates will increase by 1.35 percent for 2018. The change is based on the hospital market basket increase of 2.7 percent minus both a 0.6 percent adjustment for multi-factor productivity and a 0.75 percent adjustment required by law. CMS estimates an overall impact of 1.4 percent payment increase for providers paid under the OPPS in CY 2018. CMS projects total ASC payments to increase

approximately 3 percent in 2018 after including enrollment, case-mix and utilization changes. The 2018 final update factor is 1.2 percent, reflecting a 1.7 percent increase in the Consumer Price Index minus a 0.5 multi-factor productivity adjustment. Inpatient Only List The Medicare inpatient-only (IPO) list includes procedures that are typically only provided in the inpatient setting and therefore are not paid under the OPPS. For CY 2018, CMS is removing total knee arthroplasty (TKA, CPT code 27447) from the IPO list. AMRPA submitted comments to CMS supporting the code’s removal, but also recommended that CMS bolster the Hospital Outpatient Quality Reporting Program to monitor TKA beneficiaries’ outcomes and also ensure that patients who elect to have the procedure in outpatient settings continue to have access to medically necessary post-acute care. To address stakeholders concerns regarding site of service audits and reviews, CMS is precluding the Recovery Audit Contractors (RACs) from reviewing TKA procedures for “patient status” as an inpatient or outpatient (i.e., site of service) for a period of two years. However, CMS clarified that RAC reviews of TKA procedures described by CPT code 27447 will continue to be permitted for issues other than patient status, such as those for underlying medical necessity. Changes to the 340B Drug Pricing Program The 340B Drug Pricing Program allows some hospitals and other health care providers to purchase certain outpatient drugs at discounted prices from drug manufacturers. These covered drugs include prescribed drugs and biologics other than vaccines. In the CY 2018 OPPS proposed rule, CMS expressed concern about the growth in the number of

Highlights: •

•

In 2018, OPPS payment rates will increase by 1.35 percent in 2018 and ASC payment rates will increase by 3 percent CMS finalizes a policy to cuts payments for certain drugs purchased under the 340B Drug Discount Program upwards of 22.5 percent

providers participating in the 340B program and the high and increasing prices of several drugs covered under Part B. CMS sought feedback on whether it is appropriate to continue paying 340B hospitals the current rate of average sales price (ASP) plus 6 percent. Furthermore, it proposed to cut what it pays 340B hospitals for non-pass-through drugs that are separately payable under the OPPS at a rate of ASP minus 22.5 percent. CMS states that it derived the 22.5 percent figure from a Medicare Payment Advisory Commission (MedPAC) report to Congress in May 2015 on the 340B program. Interestingly however, in MedPAC’s comments in response to the 2018 proposed rule, the Commission recommends that CMS instead adopt a rate of ASP minus 5.7 percent, which MedPAC first recommended in its March 2016 Report to Congress on Medicare payment policy. In this final rule, CMS finalized its proposal to pay for separately payable, non-pass-through drugs and biologicals (other than vaccines) purchased through the 340B program at the ASP minus 22.5 percent effective January 1, 2018. Certain hospitals will be excluded from this policy, including rural sole community hospitals, PPS-exempt cancer hospitals and 15

children’s hospitals. Drugs not purchased under the 340B drug program will continue to be paid for at a rate of ASP plus 6 percent. CMS selected the reimbursement rate of ASP minus 22.5 percent based on previous analysis by MedPAC. CMS is implementing this policy in a budget neutral manner. It estimates the projected decrease in drug payments of $1.6 billion and will redistribute an equal amount for nondrug items and services across the OPPS. Specifically, CMS will increase the non-drug OPPS conversion factor for all hospitals in 2018 by 3.2 percent, estimating that the overall OPPS payment increase in 2018 will be 1.4 percent (1.3 percent urban; 2.5 percent rural). Effectively, 340B hospitals will face substantial decreases in drug reimbursement, and these dollars will be allocated to all hospitals. The policy will be effectuated by mandatory modifiers: nonexempt hospitals must report modifier “JG” on all OPPS claims for drugs purchased under the 340B program, and exempt hospitals must report modifier “TB” for all 340B-acquired drugs (excluding critical access hospitals [CAHs]). CMS states that it may revisit these policies for CY 2019 and is interested in exploring policies addressing the needs of safety net hospitals. Supervision of Hospital Outpatient Therapeutic Services In the 2009 OPPS final rule, CMS instituted a policy for direct physician supervision for hospital outpatient therapeutic services that 16

are furnished in hospitals, CAHs, and in hospital provider-based departments (PBDs). Since then, and due to hospitals concerns, the policy was revised to allow non-physician providers (NPP) to provide direct supervision, i.e., must be immediately available to furnish assistance and direction. From 2010 through 2013, CMS prohibited its contractors from enforcing the direct supervision policy. Congress has extended this enforcement moratorium every year since 2014, with the latest moratorium on enforcement expiring on December 31, 2016. In this final rule, CMS is reinstating and essentially extending the non-enforcement of direct supervision requirements for outpatient therapeutic services for CAHs and small rural hospitals having 100 or fewer beds for CYs 2018 and 2019. (Providers should note that the direct supervision policy is still enforced through the end of CY 2017.) Hospital Outpatient and ASC Quality Reporting Programs The Hospital Outpatient Quality Reporting (HOQR) and the ASC Quality Reporting (ASCQR) Programs are pay-for-reporting quality reporting programs under which providers must submit data on quality measures and meet certain program requirements to avoid a 2 percent reduction to their annual payment updates. For both programs, CMS is delaying the mandatory implementation of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) beginning with the CY 2018 data collection.

In the CY 2018 OPPS/ASC final rule, CMS is finalizing the removal of six measures for the HOQR setting beginning with the CYs 2020 and 2021 payment determination years. They are: •

OP-21: Median Time to Pain Management for Long Bone Fracture

•

OP-26: Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures

•

OP-1: Median Time to Fibrinolysis

•

OP-4: Aspirin at Arrival

•

OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional; and

•

OP-25: Safe Surgery Checklist Use

CMS is adding two measures to the ASCQR program regarding hospital events following specified surgical procedures beginning with the CY 2022 payment determination year. The measures are ASC-17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures, and ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures. CMS is also removing three measures beginning with the CY 2019 payment determination year. The 2018 OPPS/ASC final rule was published in the November 13, 2017, edition of the Federal Register.

AMRPA Magazine December 2017

MEDPAC TO RECOMMEND WITHIN-SETTING PAYMENT REDISTRIBUTION FOR POST-ACUTE CARE By Mimi Zhang, Policy and Research Associate, AMRPA

he Medicare Payment Advisory Commission (MedPAC) met in early November to discuss the topic of “Increasing the equity of payments within each postacute care setting.” The impetus for this meeting was to address a reoccurring commission concern: Given the importance and potential impact of the broader recommendations on the unified post-acute care prospective payment system (PAC PPS), how can MedPAC take more immediate action and incorporate those reforms into its annual payment recommendations for PAC providers?

to provider settings and makes its recommendations for payment updates and other policies in its March Report to Congress on Medicare Payment Policy. The Commission has two stated goals in this evaluation: to assess the level of payments, and to consider whether the payment system needs to be revised to more closely match payments to the cost of treating beneficiaries with different care needs. Over several years, the Commission has raised several concerns with regard to Medicare’s PPSs for post-acute care, including:

In the session, MedPAC staff presented a policy approach to redistribute payments within each post-acute care (PAC) setting prior to the implementation of a unified PAC PPS. The meeting concluded with commissioners in support of including this payment redistribution approach in its December 2017 discussion on payment adequacy and recommendations for PAC settings.

•

The redistribution policy would have the effect of raising payments to low-margin providers lowering payments to highmargin providers. However, MedPAC staff provided limited technical details on the methodology that would be used to recalculate and redistribute payments and were asked by Commissioners to provide more clarity and transparency on the topic in future meetings to order to better inform the Commission’s discussion. Background and MedPAC Staff Presentation Every year, the commission evaluates the adequacy of Medicare’s payments

•

The level of Medicare payments is high and well above the cost of care;

•

-- Prefer to treat some types of patients and avoid medically complex patients; -- Extend lengths of stay to avoid short-stay payments, or, in the case of SNFs, to increase payments; and/or -- Code clinical conditions and frailty to raise payments. •

Providers’ financial performance varies widely depending on provider type (hospital-based/freestanding) or ownership status (nonprofit/forprofit);

•

Similar patients are treated across home health agencies, skilled nursing facilities, inpatient rehabilitation facilities and long-term care hospitals; Separate PPSs establish different payments for similar patients;

MedPAC develops a new approach to calculating postacute care payments that would redistribute dollars from highmargin providers to low-margin providers within each care setting. The Commission will consider including the policy in its 2018 recommendations to Congress on post-acute care payments.

•

Lack of evidence-based guidelines to base decisions about the need of PAC; and

•

Medicare per capita spending varies more for PAC than for any other covered services.

The current PPSs encourage providers to: -- Furnish therapy services unrelated to care needs;

•

Highlights:

Borne out of the Improving Medicare Post-Acute Transformation (IMPACT) Act of 2014, the unified PAC PPS aims to correct these perceived shortcomings. MedPAC’s prototype for a PAC PPS would redistribute payments across patient conditions, increasing payments for medically complex patients and decreasing payments for rehabilitation care that is unrelated to a patient’s diagnosis. The redistribution would narrow the relative profitability across conditions, and as a result, providers would have less incentive to admit certain types of patients over others, according to MedPAC. A Within-Setting Redistribution Approach Commissioners have previously asked the staff to investigate how MedPAC’s annual payment adequacy recommendations could be used to bring the current PAC 17

payment systems more in line with the dynamics of a unified PAC PPS. Hence, the staff developed a policy approach that would increase the equity of payments by redistributing payments within each setting based on patient characteristics and in a budget-neutral manner. Specifically, within each setting, payments would be recalculated using a blend of current setting-specific patient case-mix adjusters and the patient case-mix adjusters of the unified PAC PPS. As a result, the resulting payments would shift within each setting by the patient treated by providers. Total payments to each setting would remain at the level recommended by MedPAC, as dollars are not being

redistributed among the PAC settings. The image above represents the design of a prospective payment system. MedPAC’s new payment calculation approach would retool the relative weights feeding into Case-Mix Adjusters, thus resulting in a different end payment. Examples of relative weights that could be used include primary reason to treat, age, comorbidities, severities. However, the staff did not go into detail about the relative weights analyzed nor about the methodology by which the weights would be applied to a payment calculation. As such, one of the Commissioners requested that the staff provide more clarity and transparency in future meetings.

Provider Impact The new weighing system would redistribute Medicare payments within each setting based on the mix of conditions providers treat, how their costs compare to the average provider cost, and their current therapy practices. The redistribution would in effect increase payments to those providers who have low margins under the current PPSs, and lower payments to high-margin providers. Specially, MedPAC’s preliminary modeling has found that payments would rise for nonprofit providers and hospital-based providers, and decrease for for-profit facilities and freestanding providers. MedPAC staff reported however that these shifts reflect the mixes of patients treated by providers and provider practices, not ownership or provider type per se. Implementation Timeline MedPAC staff reported that this approach could being in 2019 and 2020 and serve as an incremental step to the transition period to the unified PAC PPS, which MedPAC has recommended begin in 2021. Their conceptual timeline is summarized in the graphic on the lower left of this page. The redistributional approach discussed here would occur in 2019 and 2020 (green vertical arrows). Again, it is settingspecific would not adjust payment among settings. The unified PAC PPS would begin implementation with a three-year transition period that begins in 2021 (yellow horizontal arrow). During the transition period, payments among settings would change and would reflect the case-mix of patients treated in each setting. Essentially, the redistrbutional period would function as a transition to the PAC PPS-transition period. Next Steps The redistribution policy will be included as part of MedPAC’s payment adequacy discussion in December and January. After that, the Commissioners will vote as to whether it should be included in MedPAC’s formal recommendations to Congress issued in March 2018. For more information and access to the meeting materials, see www.medpac.gov.

AMRPA Magazine December 2017

CMS ISSUES FINAL REPORT ON INITIATIVE TO IMPROVE CARE AND REDUCE COST AMONG LONG-STAY NURSING FACILITY RESIDENTS By Lovelyn M. Robinson, Research and Editorial Assistant, AMRPA

he Centers for Medicare and Medicaid Services (CMS) Medicare-Medicaid Coordination Office (MMCO) released its final independent evaluation report for the first phase of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, focusing on the 2014-2016 period. Hospital readmissions for longstay nursing facility residents are often potentially avoidable and detrimental to patients and costly to Medicare and Medicaid. CMS launched the Initiative in 2012 with the primary goals of reducing potentially avoidable hospitalizations, improving quality of care, and decreasing health care spending. The final report provides an overview of the Initiative and the evaluation methods, describes the Initiative implementation across participating states and discusses common features of the models and the range of model components, and implementation approaches. It also includes state-specific analyses; for each state the results are integrated across multi-method evaluation approaches to present a clear picture of each ECCP’s accomplishments, challenges and the evaluation results. The report also includes aggregated expenditure results and analyses of the overall probability that net savings were achieved and that reductions in expenditures on hospitalizations, and potentially avoidable hospitalizations, were achieved.

Background Long-stay nursing facility residents often experience potentially avoidable inpatient hospitalizations. These hospitalizations

are expensive, disruptive and disorienting for seniors and people with disabilities. Long-stay facility residents are especially vulnerable to the risks that accompany hospital stays and transitions between long-stay facilities and hospitals, including medication errors and hospital-acquired infections (HAIs). Many residents are enrolled in both the Medicare and Medicaid programs (Medicare-Medicaid enrollees). CMS research on Medicare-Medicaid enrollees in long-stay facilities found that approximately 45 percent of hospital admissions among individuals receiving either Medicare skilled nursing facility (SNF) services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005. Under the Initiative, CMS supported organizations that partnered with a group of long-stay facilities to implement evidence-based clinical and educational interventions that improved care and lowered costs. From 2013 to 2016, the Initiative tested a series of clinical interventions focused on long-stay facility residents who were dually enrolled in Medicare and Medicaid programs, with the goals of: •

Reducing avoidable inpatient hospital admissions;

•

Improving care quality; and

•

Decreasing health care spending for the Medicare-Medicaid enrollees participating in the Initiative.

The Initiative involved seven ECCPs that applied to participate across seven states:

Highlight: •

The Initiative led to statistically significant reductions in 10 of the 13 Medicare utilization and expenditure measures.

1. Alabama Quality Assurance Foundation – Alabama 2. CHI/Alegent Creighton Health – Nebraska 3. HealthInsight of Nevada – Nevada 4. Indiana University – Indiana 5. The Curators of the University of Missouri – Missouri 6. The Greater New York Hospital Foundation, Inc. – New York 7. UPMC Community Provider Services - Pennsylvania Each ECCP developed unique models to support 15–30 participating nursing facilities within its respective state. These models included staff education, facility leadership and physician engagement, and/or clinical assessment and treatment of residents who experienced a change in condition. Overall, the Initiative sought to identify and treat residents whose conditions could be managed effectively within the nursing facility, rather than relying on hospital transfers for most or all changes in resident condition. The seven ECCPs interventions sought to:

implemented

•

Reduce the frequency of avoidable hospital admissions and readmissions among long-stay nursing facility residents.

•

Improve resident health outcomes. 19

•

Improve transitions between inpatient hospitals and nursing facilities.

•

Reduce overall health care spending without restricting access to care or choice of providers.

Findings Reduction in Utilization The estimated Initiative-wide intervention period (2014–2016) effect saw a 2.6 percent average annual net reduction in the probability of all-cause hospitalizations from the test facilities, which was statistically significant. This represented a relative reduction of 9.5 percent from the annual average rate of all-cause hospitalizations during the period. For the probability of a potentially avoidable hospitalization, the Initiative-wide average annual effect was a statistically significant reduction of 2.0 percent, or a relative reduction of 17.0 percent. Reduction in Medicare Expenditures For total Medicare expenditures (including CMS grants awarded to the ECCPs), there was an estimated a 21 percent probability that the Initiative was cost-saving. The estimated probability of any reduction in total Medicare expenditures from the trust funds, not accounting for CMS grants, was 92 percent. For Medicare expenditures on inpatient services, for both allcause hospitalizations and potentially avoidable hospitalizations, the estimated probability of spending reductions, not accounting for the grants, was greater than 99 percent. The evaluation determined that all seven sites reduced hospitalizations, with six of the seven achieving statistically significant improvement in either allcause hospitalizations, potentially avoidable hospitalizations, or both. Total Medicare expenditures were reduced in six of the seven sites, with statistical significance in four. If the intervention cost is taken into account, four of the seven sites achieved Medicare expenditure reductions in excess of costs, though overall the difference was not statistically significant. The analysis showed substantial variability in the effects of the Initiative 20

on reducing utilization and expenditures both across the ECCPs and across measures, as shown in Table ES-4 above. Strongest improvements in both cost and quality were shown at the test sites with a full-time nurse at each facility providing direct care to residents. Test sites where nurses did not provide direct care, or where nurses rotated across multiple facilities, showed less consistent effects. The effectiveness of the Initiative interventions was enhanced by the consistent presence of ECCP nurses who provided a knowledgeable extra set of hands in facilities, particularly when assisting with clinical care. Overall, the findings provided evidence of the Initiative’s effectiveness in reducing hospital inpatient admissions, ED visits, and hospitalization-related Medicare expenditures.

For more information on the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents, visit the CMS Medicare-Medicaid Coordination Office webpage.

AMRPA Magazine December 2017

CMS UPDATES THE PHYSICIAN FEE SCHEDULE FOR CY 2018 AND EXPANDS DIABETES PREVENTION PROGRAM By Jonathan M. Gold, JD, Regulatory and Government Relations Counsel, AMRPA

n November 15, the Centers for Medicare and Medicaid Services (CMS) published the final rule updating the Physician Fee Schedule (PFS) for calendar year (CY) 2018. The PFS is continuing to undergo a number of transitions since the Medicare and CHIP Reauthorization Act of 2015 (MACRA) created the Quality Payment Program (QPP), which replaces many of the quality and value-based aspects of the Physician Fee Schedule. AMRPA’s Outpatient and Therapies Committee developed formal comments to the proposed rule for CY 2018 and submitted them to CMS. These comments are available on the AMRPA website. The overall update to payments under the PFS based on the finalized CY 2018 rates will be an increase of 0.41 percent. After applying adjustments, and the budget neutrality adjustment to account for changes in values, the final 2018 PFS conversion factor, which is the base amount a code value is multiplied by to determine payment, is $35.99. This is an increase to the 2017 PFS conversion factor of $35.89. Valuations of Newly Created and Revised Codes When updating the value and corresponding payment rates for Medicare claims, CMS, in consultation with stakeholders, undertakes an annual process in which it identifies potentially misvalued codes and also makes adjustments to align with the Current Procedural Terminology codes (CPT codes), which are determined by a third party outside of CMS’ control. This year, CMS proposed to alter the

value of several therapy codes that it had identified as misvalued. CPT codes 97112 (neuromuscular reeducation), 97113 (aquatic therapy), 97116 (gait training), 97533 (sensory integrative techniques), 97537 (community/work reintegration training), and 97542 (wheelchair management) will all see small changes in their value in CY 2018, which are the result of suggested adjustments from professional clinical organizations. All of these except for 97113 (aquatic therapy) will be increases for CY 2018. Due to the deletion and creation of CPT codes, there are value updates to some orthotics and prosthetics codes. The CPT editorial board has now defined 97760 (orthotic management and training, including assessment and fitting) and 97761 (prosthetic training) to be used only to report initial encounters, whereas previously it was used to describe both initial and subsequent encounters. The board has created a new code, 97763, to be used for any subsequent encounter pertaining to orthotics or prosthetics. The CPT board has deleted 97762, which was used for assessment and fittings for orthotics or prosthetics when the code was not bundled in with another billed code or service. Due to these changes, 97760 and 97761 will see increases in CY 2018, and the newly created 97763 has approximately the same value of now deleted code 97762. CMS also finalized value changes to a code pertaining to Cognitive Function Intervention. CPT code 97532 (cognitive skills development) is scheduled to be deleted for CY 2018 and replaced by CPT code 97127. A major difference is that 97532 is reported per 15 minutes whereas

Highlights: • •

Changes in value to therapy codes finalized. MACRA patient relationship codes to be elected on voluntary basis.

the new code will only be reported per session. Claims data indicate that CPT code 97532 was most often billed in four units, but recommended a value for CPT code 97127 which is only 3.4 times greater the predecessor code. Since this may create a reduction in payments for many providers, CMS is finalizing its plan to maintain the current coding and valuation for 97532 by creating a new a G-Code, G0515, which will maintain the descriptor and values from the soon to be deleted CPT code 97532. New CPT code 97127 will be given a procedure status of ‘‘I’’ (Invalid for Medicare), which means providers must use the G0515 when billing Medicare. MACRA Patient Relationship Codes As part of its larger data collection efforts, MACRA seeks to facilitate the attribution of patients and episodes to one or more clinicians, and required the development of patient relationship categories and codes that define the relationship between a clinician and a patient at the time of furnishing a service. Originally, CMS proposed that the use of these codes would be mandatory beginning in 2018. However, in the proposed rule for CY 2018, CMS instead proposed to make these codes voluntary for the upcoming year. CMS had previously finalized the five patient relationship categories to include in this effort, and in this rule finalized the 21

code modifiers that correspond to those categories and that will be used in claims for CY 2018 on a voluntary basis. More instructions on how to use these codes can be found on the CMS website, and CMS says it will be conducting outreach to familiarize clinicians with these codes. The proposed code modifiers are:

Telehealth and Remote Patient Monitoring Codes CMS is finalizing its proposal to add several codes to the list permitted telehealth services, and will begin paying providers for a code describing remote patient monitoring. The newly approved telehealth codes include:

1. Proposed HCPCS modifier X1: Continuous/broad services. For reporting services by clinicians who provide the principal care for a patient, with no planned endpoint of the relationship. 2. Proposed HCPCS modifier X2: Continuous/focused services. For reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed for a long time. 3. Proposed HCPCS modifier X3: Episodic/broad services. For reporting services by clinicians who have broad responsibility for the comprehensive needs of the patients, that is limited to a defined period and circumstance, such as a hospitalization. 4. Proposed HCPCS modifier X4: Episodic/focused services. For reporting services by specialty focused clinicians who provide timelimited care. 5. Proposed HCPCS modifier X5: Only as ordered by another clinician. For reporting services by a clinician who furnishes care to the patient only as ordered by another clinician.

•

HCPCS code G0296 (visit to determine low-dose computed tomography (LDCT) eligibility);

•

CPT code 90785 (Interactive Complexity);

•

CPT codes 96160 and 96161 (Health Risk Assessment);

•

HCPCS code G0506 (Care Planning for Chronic Care Management); and

•

CPT codes 90839 and 90840 (Psychotherapy for Crisis).

The new code that CMS will be allowing under remote patient monitoring is CPT code 99091 (Collection and interpretation of physiologic data, digitally stored and/or transmitted by the patient and/or caregiver to the physician). In the final rule, CMS specifically mentions a list of physical and occupational therapy codes that they will not be adding to the list of telehealth codes. The agency states they are not adding these codes because therapists were not among the statutorily prescribed provider types that are permitted to provide telehealth services.

Medicare Diabetes Prevention Program The final rule includes an expansion of the Medicare Diabetes Prevention Program (MDPP) for CY 2018. The MDPP is a clinical intervention program that consists of a minimum of 16 intensive “core” sessions of curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. CMS has instituted a performancebased system that pays providers a flat rate for the initial core sessions, but then provides higher payment after the initial sessions based on how much weight loss the patient achieves or maintains, as well as how often a patient attends sessions. CMS has also clarified eligibility requirements so that if a patient receives a diagnosis during, but not before, participation in the program, they remain eligible for the program. CMS is also altering the structure of the initial program, so now clinicians provide MDPP services for a total period of two years, consisting of one year of core and core maintenance sessions followed by up to one year of ongoing maintenance sessions. CMS also considered allowing for the program to be provided virtually using tele-technology, but has finalized that the services must be furnished in-person, except for limited virtual make-up sessions. The final rule is printed in the November 15, 2017, edition of the Federal Register.

AMRPA Magazine December 2017

2 O 18 Spring Conference & Congressional Fly-In March 11-13, 2018 Embassy Row Hotel â&#x20AC;˘ Washington, DC

Registration is Open Visit us at www.amrpa.org The 2018 Leadership Forum and Congressional Fly-In event offers rehabilitation industry leaders a unique opportunity to hear directly from federal agency officials and Washington, DC influencers. Likewise, it gives our elected officials a chance to hear from us about key issues of importance to the medical rehabilitation industry. In addition to the Leadership Forum, the Medical Directors Symposium will provide your physician leadership with the knowledge and networking opportunities they need to stay informed on the latest issues in the field. Finally, the Rehabilitation Administrators Workshop is the perfect opportunity for your operational leadership to cover the basics of regulations for inpatient medical rehabilitation hospitals and units. Questions? Contact Samantha Schwarz, AMRPA Staff Associate, at sschwarz@amrpa.org or by calling 202-207-1132. 23

CMS ISSUES FINAL RULE FOR SECOND YEAR OF QUALITY PAYMENT PROGRAM By Jonathan M. Gold, JD, Regulatory and Government Relations Counsel, AMRPA

n November 16, the Centers for Medicare and Medicaid Services (CMS) published the final Quality Payment Program (QPP) rule for calendar year (CY) 2018 in the Federal Register. AMRPA submitted formal comments on the Proposed Rule in August of this year, which are available on the AMRPA website. Background This calendar year is the first performance year for the QPP, after the Medicare and CHIP Reauthorization Act of 2015 (MACRA) repealed the sustainable growth rate (SGR) formula that was used to update payments under Medicare Part B. The QPP replaces several existing programs, including the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program, often referred to as “Meaningful Use.” Physicians and other clinicians currently covered by the QPP fall under two tracks. Either they participate in the Merit-based Incentive Payment System (MIPS) and are considered MIPS-eligible clinicians (MECs), or they are Qualifying Providers (QPs) in an Advanced Alternative Payment Model (Advanced APM). Under MIPS, physicians and other eligible clinicians are evaluated across four performance categories: (1) Quality; (2) Cost (resource use); (3) Improvement Activities; and (4) Advancing Care Information (ACI), a replacement of the EHR Incentive Program. Clinicians receive a total score based on the reporting categories, which will result in a positive, neutral or negative payment adjustment. 24

The payment adjustment currently ranges from an adjustment in either direction of up to 4 percent of total payments, and is set to increase annually as the program advances until leveling off at plus-orminus 9 percent. Similar to other CMS programs, MIPS generally uses a two-year delayed payment system so that services and scores achieved in Calendar Year (CY) 2018, referred to as performance year 2018, will be used to adjust payments for 2020, referred to as payment year 2020. Advanced APMs are essentially an alternative track to MIPS, and QPs participating in an Advanced APM are eligible to receive a five percent bonus payment in a payment year. CMS has adopted several notable proposals in the final rule pertaining to MIPS, including a significant elevation of the low-volume exclusions thresholds and further adjustments to the weighting of scoring categories. CMS is also finalizing a plan to allow clinicians who are facilitybased to use their facility’s score for parts of their MIPS score but with a one year delay. The agency also finalized updates to Advanced APMs as it moves closer to implementing All-Payer Advanced APMs. Finally, the agency has begun to finalize details on how it plans to implement those models that would provide more options for clinicians to be exempt from MIPS and eligible for the Advanced APM incentive payments. Despite AMRPA’s urging, CMS did not include information on how other types of clinicians, such as therapists, will be incorporated into the QPP in future years.

Highlights: •

•

Significantly more clinicians will be excluded under new lowvolume threshold. CMS provides little information on inclusion of more types of clinicians in the program.

Currently only a limited number physician extenders, in addition to physicians who meet Medicare patient thresholds, are eligible for the QPP. By statute, CMS is permitted to begin including other types of clinicians in year 3 (CY 2019) of the program. The final rule provided an estimate of the rule’s impact on various specialties, including Physical Medicine and Rehabilitation (PM&R), which showed the PM&R specialty anticipated to fare below average in payment adjustments. CMS estimates that approximately 93.2 percent of PM&R specialists can expect a positive or neutral payment adjustment, which is below the total average for all eligible clinicians of 97 percent. CMS says the PM&R specialty can expect a 0.4 percent overall increase in payments, which is also notably below the national average of 0.9 percent. Included below is more in-depth information on some the key policies in the final rule. Performance Categories Weighting CMS finalized a proposal in CY 2017 that made a MEC’s Composite Performance Score (CPS), the final score a MEC receives to determine their payment AMRPA Magazine December 2017

adjustment, heavily dependent on Quality performance (60 percent), with the rest of the CPS divided between Advancing Care Information (ACI) performance (25 percent) and Improvement Activities performance (15 percent). The Cost Performance category was weighted at zero percent for the initial “transition year” (2017) so that MECs would have time to understand the category. Although CMS said in the CY 2018 proposed rule that they were considering continuing to weight Cost at zero percent, in the final rule CMS stated that it will instead finalize Cost at 10 percent. CMS stated that since it is statutorily obligated to weight that category at 30 percent by CY 2019, continuing to weight Cost at zero percent would create a sharp change from one year to the next for CY 2019. With this change, Quality is being reduced to 50 percent and ACI and Improvement Activities will remain at 25 and 15 percent respectively for CY 2018. The table below displays the final changes in category weighting, as well as CMS’ preliminary plans for how it will weight categories in future years.

In the CY 2017 proposed and final rules, CMS discussed adding a requirement for MECs to report at least one cross-cutting measure and solicited feedback on the idea. In CY 2018 proposed rule, CMS again solicited feedback in the idea, but did not add any requirements pertaining to crosscutting measures in this final rule. For MECs reporting as groups, they will continue to be permitted to use patient feedback as one quality measure through the Consumer Assessment of Healthcare Provider and Systems Survey (CAHPS) tool, which also qualifies as a high-priority measure. Further, groups of 16 or more MECs will have the All-Cause Rehospitalization metric applied to their scores, if they have at least 200 cases to provide. CMS proposed to lower its previously established data completeness threshold for individual MECs to 50 percent from 60 percent. However, CMS is backtracking on its proposal and will now require a data completeness level of 60 percent for CY 2018. CMS is finalizing its proposal that those MECs who do not meet the

TABLE 28. Weights by MIPS Performance Category Performance Category

Transition Year

2020 MIPS Payment Year

2021 MIPS Payment Year and Beyond

60%

50%

30%

Cost

10%

30%

Improvement Activities

15%

Advancing Care Information*

25%

Quality

Quality Performance Category Criteria and Reporting CMS finalized limited changes to the Quality Performance Category criteria and data reporting requirements. For CY 2018, MECs will continue to be required to report six quality measures, including at least one outcome or other “high-priority” measure. Alternatively, MECs may choose one MEC specialty set to report. Regardless of the makeup of the specialty set, the MEC must still report one outcome measure, or, if no outcome measures are available in the measure set, the MEC will report another high priority measure, such as an appropriate use, patient safety, efficiency, patient experience or care coordination measure.

threshold will receive only one point per quality measure submitted, except for small practices, who will receive three points. For CY 2017, MECs received three points for data submitted that did not reach the threshold. There are a number of new quality measures as well as changes to quality measures within the PM&R specialty set for CY 2018. These finalized changes can be found in Table B.15 of the final rule. Cost (Resource Use) Performance Criteria and Reporting As previously noted, Cost will be worth 10 percent of the MIPS final score for CY 2018. For CY 2017, Cost performance is

determined by two metrics: the total per capita costs for all attributed beneficiaries (Total Per Capita Cost) measure, and the Medicare Spending Per Beneficiary (MSPB) measure. CMS also included 10 episode-based measures from the Supplemental Quality and Resource Use Reports (QRURs) for CY 2017. However for CY 2018, CMS is finalizing its proposal to eliminate the episode-based measures and will rely solely on the Total Per Capita Cost and MSPB measure for CY 2018. CMS states it will work with experts to develop more comprehensive episode-based measures for future use. As with this year, the Cost measures will be determined through claims data, so no reporting will be required of MECs for this category in CY 2018. Improvement Activities Performance Category Criteria and Reporting CMS is making minimal changes to the Improvement Activities performance criteria, which will continue to count as 15 percent of the CPS in CY 2018. One change of note is that CMS finalized adoption of a subregulatory process for submitting new improvement activities. It will be similar to the process used during the transition year where experts could nominate proposals through the CMS website. MECs will continue to self-certify the activities completed or have a contractor certify on their behalf. The performance period will continue to be 90 days for Improvement Activities, so a MEC may structure the activity in any way they choose, so long as it occurs for a minimum of 90 consecutive days. MECs will need to achieve 40 points total by selecting from a combination of high-weighted activities (20 points) or medium-weighted activities (10 points). CMS is finalizing a number of new activities and making changes to others, which can be found in Tables F and G of the final rule. Advancing Care Information (ACI) Performance Category Criteria and Reporting CMS is finalizing a number of changes to the ACI category scoring, which will be weighted at 25 percent for those MECs not exempted, just as it was for CY 2017, and as required by statute. CMS backed off from its proposal to require MECs use the 2015 CEHRT and will allow for MECs 25

to continue using 2014 CEHRT. However, CMS will award 10 bonus points for MECs who report measures using only 2015 CEHRT. In CY 2018, CMS will award 10 points for reporting to any single public health agency or clinical data registry. CMS previously only awarded points for reporting to the Immunization Registry. Further, MECs will receive five bonus points per additional public health registry that the MEC reports to, up to 10 points total. CMS will also continue to allow up to a 10 percent bonus for MECs who report pre-approved improvement activities using CEHRT.

MIPS Requirements for Participants in Alternative Payment Models (MIPS APMs) CMS has developed modified requirements for MECs who participate in APMs with Medicare. It is important to distinguish participation in MIPS through an APM with those clinicians who are exempted from MIPS for participating in Advanced Alternative Payment Models (Advanced APMs). That system is discussed separately in this article. Generally, all MIPS requirements will continue to apply for APM participants unless they are specifically modified for participants in that APM. As in previous years, the Cost performance category will be weighted to zero for APM participants and MECs will not need to submit any

Facility-Based Scoring CMS is now allowing clinicians it defines as “facility-based” to have the option to use their facility’s Hospital Value-Based Purchasing Program (VBP) scores as a total substitute for the MIPS Quality performance category and Cost performance score. To be considered a facility-based MEC and eligible to use a facility’s VBP score, a MEC must furnish 75 percent or more of services at POS codes (as used in HIPAA standard transactions) 21 (inpatient hospital) or 23 (emergency room).

The VBP score will be translated to the Quality and Cost score for the MEC under MIPS using a percentile calculation. To CMS is also finalizing changes to its account for the harsher scoring under exemptions under the ACI performance the VBP, the MEC will be awarded the category. It will extend a hardship percentile in which the facility falls in exemption to small group the VBP, so if a MEC works MECs (15 or fewer MECs), and at a facility that scores in the reweight their ACI performance 75th percentile in the VBP, he to zero percent. Hospital-based or she will receive the score CMS acknowledged AMRPA’s MECs – those who furnish 75 corresponding to the 75th percent or more of their services percentile in the Quality and comments in response to the at Point of Service (POS) Codes Cost performance measures proposed rule suggesting that 21 (inpatient hospital), 22 (onfor that CY. MECs that use the clinicians who practice in an inpatient facility-based measures will campus outpatient hospital) or 23 (emergency room) – will rehabilitation facility (IRF) should not qualify for certain bonuses, also have their ACI scored including for reporting also have their scores reweighted. reweighted to zero, unless they additional quality measures However, CMS only said it would choose to submit ACI measures. and end-to-end electronic take it under advisement for future Further, CMS is amending its reporting. definition of a hospital-based rulemakings, and did not include the MEC to also include POS 19, The rule only permits for metrics concept in its final rule. which is defined as an offfrom the Hospital Value-Based campus outpatient hospital. Purchasing Program to be Due to the 21st Century Cures used. Since this is a program data on cost. The other measures, quality, Act, CMS will also reweight Ambulatory for general acute care hospitals, and not improvement activities and ACI, will all be Surgery Center (ASC) based MECs’ (POS IRFs, it does not appear clinicians who are weighted differently depending on which Code 24) ACI score to zero, including IRF based will be eligible for this option. APM the MEC is participating with. retroactively for the CY 2017 performance CMS explains that it chose the VBP year, unless MECs choose to submit ACI because it believes the VBP program to be Performance Thresholds measures. Finally, CMS also included a the most analogous to the MIPS program For CY 2017, CMS set a performance hardship exemption for clinicians who had in its focus on quality because it operates threshold floor that a MEC was required to their EHR decertified, so that their ACI as pay for performance rather than a pay meet in order to earn a neutral or positive score will be reweighted to zero. for reporting program. AMRPA had urged payment adjustment. On the 0-100 scale CMS to consider including IRF-based the threshold for the transition year was CMS acknowledged AMRPA’s comments in clinician in its definition of a facility-based three points. CMS has raised the threshold response to the proposed rule suggesting clinician, and allow those clinicians to use to 15 points for CY 2018, which CMS that clinicians who practice in an inpatient the IRF Quality Reporting Program as a describes as a gradual increase that still rehabilitation facility (IRF) should also have surrogate, but CMS rejected the idea. allows multiple pathways to meet. Further, their scores reweighted. However, CMS CMS has held the performance threshold only said it would take it under advisement Low-Volume Exclusion at 70 for CY 2018, which is the minimum for future rulemakings, and did not include During the transition year CMS excluded score to make MECs eligible to share in a the concept in its final rule. MECs with equal to or less than $30,000 pool of $500 million, on top of their other in Part B allowed charges or equal to or payment adjustments. less than 100 Part B beneficiaries during a

AMRPA Magazine December 2017

determination period. For year two, CMS is significantly expanding the threshold so that MIPS will exclude MECs with equal to or less than $90,000 in Part B allowed charges or equal to or less than 200 Part B beneficiaries during a determination period. While CMS is finalizing the higher low-volume threshold, it chose not to finalize the option for low-volume MECs to opt-in to MIPS if they exceed one of the thresholds. CMS stated they need more feedback on how this could be accomplished with minimal burden, and how it could avoid self-selection skewing the performance pool. Reporting Mechanisms For the transition year, MECs had a full array of reporting mechanisms available to them within all four performance categories. However, MECs were required to use only one submission mechanism per performance category, with very narrow exceptions. CMS had proposed to revise this policy so that in CY 2018 MECs could submit information via multiple mechanisms for the Quality, Improvement Activities and ACI categories for CY 2018. However, due to operational concerns, CMS states it will delay this policy change until CY 2019 so it is better prepared to accept submissions in this manner. Virtual Groups CMS is finalizing a new method of participation in MIPS for CY 2018 called Virtual Groups. These Virtual Groups may be composed of solo practitioners or groups who come together under this clause in order to create efficiencies. In order for solo practitioners to be eligible to join a Virtual Group, they will need to meet the definition of a MEC and not be excluded from MIPS. In order for groups to be eligible to participate in MIPS as part of a Virtual Group, groups will need to exceed the low-volume threshold at the group level and consist of no more than 10 MECs. A group that is part of a Virtual Group may include clinicians who do not meet the definition of a MEC or are

excluded from MIPS. If the group chooses to join or form a Virtual Group, all clinicians under the TIN will be part of the Virtual Group. The Virtual Groups will be assessed collectively under MIPS and subject to a payment adjustment as a Virtual Group. Although a group joining a Virtual Group may consist of non-eligible clinicians, the non-eligible clinician payments will not be subject to adjustment. Adjustments to Final Score There will be several options for earning bonus points for the MIPs score in CY 2018. First, CMS is finalizing a 5-point bonus option called the Complex Patient Bonus. This bonus will be based on the Hierarchical Condition Category (HCC), which is used to evaluate risk in Medicare Advantage plans and other programs, as a proxy for medical complexity. The HCC approach will average the HCC scores of patients treated by the MEC to assign the score to the final MIPS score. CMS will also factor in percentage of patients treated by the MEC who are dual-eligible for Medicare and Medicaid. The Complex Patient Bonus is only finalized for CY 2018, and currently not included for future years. CMS is also finalizing a small practice bonus of five points to the final MIPS score of MECs who participate in groups of 15 or less MECs. In order to receive the bonus, the MECs will need to submit data on at least one of the performance categories. Like the Complex Patient Bonus this proposal is just included for CY 2018, and not in future years. Advanced Alternative Payment Models (Advanced APMs) As previously discussed, clinicians can be exempt from MIPS by participating in an Advanced APM as a qualified participant (QP). A QP receives a 5 percent positive adjustment on allowable charges in the applicable payment year. CMS has laid out several criteria to determine eligibility to be considered an Advanced APM. Specifically, an Advanced APM must:

•

Require its participants to use CEHRT;

•

Provide for payment for covered professional services based on quality measures comparable to measures under the quality performance category under MIPS; and

•

Require its participating entities to bear financial risk for monetary losses that are in excess of a nominal amount, currently defined as 8 percent of revenue.

To determine if a clinician qualifies as a QP, the clinician must meet a threshold of minimum amount of its payments or patients through the Advanced APM. For 2018, CMS states the patient threshold is 25 percent of total payments that the clinician received must be tied to an Advanced APM, or 20 percent of patients treated must be paid for through an Advanced APM. Currently, only APMs that are Medicare APMs (and meet certain criteria) can be considered Advanced APMs. Beginning in CY 2019, CMS is establishing eligibility standards for becoming a QP by participating in APMs that are paid for by other entities, like Medicaid or private payers. To qualify as another-Payer Advanced APM, the entities or clinicians must submit information to CMS indicating they meet similar standards that apply to Medicare Advanced APMs. For a clinician to become a QP using the all-payer option, they must meet the threshold of 50 percent of total payments coming from approved Advanced APMs, with at least 25 percent of the payments coming from Medicare Advanced APMs. CMS will raise the all-payer the threshold to 75 percent of total payments from any Advanced APM payer by 2021. More information on the QPP can be found on CMS’ webpage at: www.qpp.cms.gov.

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AMRPA Magazine December 2017

CMS FINALIZES CY 2018 HOME HEALTH RULE WITHOUT NEW HHGM PAYMENT MODEL

n November 1, the Centers for Medicare and Medicaid Services (CMS) issued the Calendar Year (CY) 2018 final rule for the home health prospective payment system (HH PPS), which also finalizes proposals for the Home Health Value-Based Purchasing (HHVBP) Model and the Home Health Quality Reporting Program (HH QRP). Notably, CMS did not finalize a new HHA payment system it had proposed earlier this year, the Home Health Grouping Model (HHGM) that would have changed the unit of payment from 60-day to 30-day episodes of care. Rather, CMS states that it will take additional time to further engage with stakeholders and will take the comments submitted on the proposed rule into further consideration “regarding patients’ need that strikes the right balance in putting patients first.” Like many other provider and patient groups, AMRPA submitted comments to CMS expressing concerns with the impact that the HHGM model will have on downstream postacute care providers that could have adverse effects on the patients served by the postacute provider continuum.

Background To be eligible for the home health benefit under Medicare, beneficiaries must need intermittent skilled nursing or therapy services and must be homebound and under the care of a physician. Covered home health services include skilled nursing, home health aide, physical therapy, speech-language pathology, occupational therapy, medical social services, and medical supplies. Home Health Agencies (HHAs) are paid a national, standardized 60-day episode payment for most covered home health services, adjusted for case-mix and area wage differences. Payment Policy Provisions for CY 2018 Based on policies adopted in the final rule, CMS projects that Medicare payments to

HHAs in CY 2018 will be reduced by 0.4 percent, or $80 million. This decrease reflects the effects of a one percent home health payment update percentage ($190 million increase); a -0.97 percent adjustment to the national, standardized 60-day episode payment rate to account for nominal case-mix growth for an impact of -0.9 percent ($170 million decrease); and the sunset of the rural add-on provision ($100 million decrease). The Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA) requires the market basket percentage increase to be 1.0 percent for post-acute providers for CY 2018.

Highlights: •

•

CY 2018 payments to home health agencies will be reduced by 0.4 percent, or $80 million. CMS did not finalize its proposed Home Health Grouping Model (HHGM), which would have dramatically changed the home health payment system.

three measures beginning with the CY 2020 HH QRP:

CMS is implementing a 0.97 percent reduction to the national, standardized 60day episode rate in CY 2018 to account for nominal case-mix growth from 2012 to 2014. CY 2018 will be the third year and final year of the phase-in of the reduction to account for nominal case-mix growth. The -0.97 percent adjustment to the national, standardized 60-day episode payment rate to account for nominal case-mix growth results in an estimated decrease in HH PPS payments for CY 2018 of -0.9 percent.

•

Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury;

•

Application of Residents Experiencing One or More Falls with Major Injury (NQF #0674); and

•

Application of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631).

HH episodes and visits furnished before January 1, 2018, experience a 3 percent payment increase due to the rural-add on provision. MACRA extended the rural add-on provision to HH episodes and visits ending before January 1, 2018. Therefore, for episodes and visits that end on or after January 1, 2018, a rural add-on payment will not apply.

These are assessment-based measures and are calculated using data from the HH patient assessment instrument, Outcome and Assessment Information Set (OASIS). These measures will also meet the requirements of the Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT) for HHAs to report quality data in the domains of Skin Integrity, Medical Conditions and Comorbidities, and Functional Status. Pursuant to the IMPACT Act, HHAs, skilled nursing facilities (SNFs), inpatient rehabilitation hospitals and units (IRFs), and long-term care hospitals (LTCHs) must report quality and resource use measures, as well as report standardized patient assessment data.

Home Health Quality Reporting Program (HH QRP) Provisions Like other post-acute care providers, HHAs must annually report quality data to CMS under the HH Quality Reporting Program or receive a 2 percent reduction to their annual payment update. Substantive changes to the HH QRP are promulgated in the annual HH PPS payment rule and there are currently 23 quality measures in the program. In this rule, CMS finalized the adoption of the following

In the CY 2018 home health proposed rule, CMS proposed adding multiple data elements to the OASIS to collect standardized 29

patient assessment data. However, CMS did not adopt those changes, as it has done in other post-acute care final rules this year. The changes would have added assessment items on the OASIS to collected standardized patient assessment data in three IMPACT Act domains: Cognitive Function and Mental Status; Special Services, Treatments, and Interventions; and Impairments. CMS intends to evaluate further how to best identify standardized patient assessment data that satisfies each of these categories and can be reported by HHAs in the least burdensome manner. CMS is also removing 235 data elements from 33 current OASIS items, effective January 1, 2019. CMS states it determined these items are not needed to calculate quality measures already adopted in the HH QRP or for other purposes unrelated to the HH QRP, including payment, survey, the HH VBP Model or care planning. CMS also finalized a number of procedural requirements for the HH QRP, including a process for requesting reconsideration of determinations regarding compliance with the HH QRP, as well as policies for requesting exceptions and extensions of reporting timeframes. Home Health Value-Based Purchasing Model Provisions The Home Health Value-Based Purchasing (HHVBP) Model began testing on January 1, 2016, and has an overall purpose of improving the quality and delivery of home health care services to Medicare beneficiaries. 30

All Medicare certified HHAs providing services in Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee and Washington (competing HHAs) are required to participate in the Model.

related to the HHVBP Model: •

Agencies in the HHVBP Model must submit a minimum of 40 completed Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) surveys for purposes of receiving a performance score for any of the HHCAHPS measures, beginning with performance year (PY) 1 of the program; and

•

Removal of the OASIS based measure, Drug Education on All Medications Provided to Patient/ Caregiver during all Episodes of Care, from the set of applicable measures for PY 3 and subsequent years.

Under the Model, payment adjustments will be increased incrementally over the course of the program in the following manner: 1. A maximum payment adjustment of 3 percent (upward or downward) in CY 2018; 2. A maximum payment adjustment of 5 percent (upward or downward) in CY 2019; 3. A maximum payment adjustment of 6 percent (upward or downward) in CY 2020; 4. A maximum payment adjustment of 7 percent (upward or downward) in CY 2021; and 5. A maximum payment adjustment of 8 percent (upward or downward) in CY 2022. Payment adjustments will be based on each HHA’s Total Performance Score (TPS) in a given performance year (PY) on: (1) A set of measures already reported via OASIS and HHCAHPS for all patients serviced by the HHA and select claims data elements; and (2) three new measures where points are achieved for reporting data.

In addition, CMS is considering the following measures for inclusion in the Model in future years: •

Total Change in ADL/IADL Performance by HHA Patients;

•

Composite Functional Decline Measure; and

•

Behavioral health measures, such as HHA Correctly Identifies Patient’s Need for Mental or Behavioral Health Supervision, and Caregiver Can/ Does Provide for Patient’s Mental or Behavioral Health Supervision Need.

The CY 2018 HH PPS final rule was published in the November 7, 2017, issue of the Federal Register.

In the CY 2018 final rule, CMS adopted the following changes and improvements AMRPA Magazine December 2017

HIGHEST-COST PATIENTS ARE GENERATING MOST OF MEDICARE’S POTENTIALLY PREVENTABLE SPENDING STUDY FINDS

large share of Medicare spending is generated by a relatively small group of patients with expensive medical needs and accounts for the vast majority of potentially preventable Medicare spending, according to a recent study published in the Annals of Internal Medicine. The study findings highlight the need to understand and mitigate the health consequences of frailty, particularly as the U.S. population grows older. As policymakers consider ways to control federal health care spending, developing care management interventions that target the health conditions of these patients could significantly reduce avoidable expenditures in Medicare, and could be a more patientcentric policy than reducing payments to health care providers such as post-acute care. Methods While it has been known that a small number of beneficiaries account for a disproportionately high volume of Medicare spending, the study authors set out to investigate how much of that spending could be due to potentially preventable care utilization. In the article Concentration of Potentially Preventable Spending Among High-Cost Medicare Subpopulations, the authors used Medicare claims data to determine the share of spending that is potentially preventable across different groups of high-cost Medicare patients, how this spending differs by care setting, and which conditions drive most of the spending. The sample consisted of 6,112,450 Medicare beneficiaries and study measurements included a proportion of spending considered to be potentially preventable. Potentially preventable spending was identified by totaling costs for avoidable emergency room visits and costs for certain conditions incurred within 30 days after hospitalization. Beneficiaries in the highest 10 percent of

total standardized individual spending were defined as “high-cost” patients, based on a 20 percent sample of Medicare fee-forservice claims from 2012. The researchers categorized patients into the following six clinical subpopulations: 1. 2. 3. 4. 5. 6.

Nonelderly disabled; Frail elderly; Major complex chronic; Minor complex chronic; Simple chronic; and Relatively healthy.

Potentially preventable spending was calculated by summing costs for avoidable emergency department visits using the Billings algorithm plus inpatient and associated 30day post-acute costs for ambulatory caresensitive conditions (ACSCs). The amount and proportion of potentially preventable spending were then compared across the high-cost subpopulations and by individual ACSCs. Results Potentially preventable spending varied across Medicare subpopulations, with the majority of the spending concentrated among frail elderly persons. Most potentially preventable spending by this beneficiary subgroup was for health care provided in inpatient settings and skilled nursing facilities (SNFs). The authors found that much of the preventable inpatient spending by this group was related to treatment for heart failure, pneumonia, urinary tract infections, diabetes complications and dehydration. Furthermore: •

•

In 2012, 4.8 percent of Medicare spending was potentially preventable, of which 73.8 percent was incurred by high-cost patients. Despite making up only 4 percent of the Medicare population, high-cost frail elderly persons accounted for 43.9 percent of total potentially preventable spending ($6,593 per person).

Highlight: •

In 2012, 4.8% of Medicare spending was potentially preventable, of which 73.8% was incurred by high-cost patients.

•

High-cost non-elderly disabled persons accounted for 14.8 percent of potentially preventable spending ($3,421 per person) and the major complex chronic group for 11.2 percent ($3,327 per person).

•

Frail elderly persons accounted for most spending related to admissions for urinary tract infections (UTIs), dehydration, heart failure and bacterial pneumonia.

The authors conclude that clinical leaders and policymakers may be able to make significant gains in reducing potentially preventable Medicare spending by focusing on the subgroup of frail elderly patients. The highest-cost patients — predominantly the frail elderly — are generating most of Medicare’s potentially preventable spending. Targeting these individuals through simple care interventions such as outpatient management of heart failure and prevention of UTIs, may substantially reduce unnecessary spending. Other gains in reducing potentially preventable spending could be made by targeting nonelderly disabled patients with conditions related to asthma, diabetes, mental illness and substance abuse. For the complete study, see J. F. Figueroa, K. E. Joynt Maddox, N. Beaulieu et al., “Concentration of Potentially Preventable Spending Among High-Cost Medicare Subpopulations,” Annals of Internal Medicine, published online October 17, 2017.

PULMONARY REHABILITATION SHOULD BE AMONG “FIRST LINE” THERAPIES FOR PATIENTS WITH LUNG FIBROSIS, STUDY SAYS

ulmonary rehabilitation programs can significantly improve exercise ability, breathing and overall quality of life in patients with pulmonary diseases and should be considered as “a first line therapy,” according to a study published recently in the journal BMC Pulmonary Medicine. Many medical rehabilitation providers offer inpatient and outpatient pulmonary rehabilitation programs for patients with chronic obstructive pulmonary disease (COPD), sarcoidosis, idiopathic pulmonary fibrosis (IPF), cystic fibrosis and other conditions. Pulmonary rehabilitation programs provide a multi-dimensional continuum of services for patients and their families, and are guided by a multidisciplinary team of clinicians to optimize patients’ physical and social functioning. The study, “Effectiveness of Pulmonary Rehabilitation in Patients with Interstitial Lung Disease of Different Etiology: A Multicenter Prospective Study,” found that patients with interstitial lung diseases (ILDs) benefited considerably from inpatient or outpatient pulmonary rehabilitation programs regardless of their underlying disease etiology. Progressive fibrosis and chronic lung inflammation alters both structure and function of lung tissue. Patients often experience shortness of breath, tiredness and muscle fatigue, all symptoms that severely impact their daily life activities and health-related quality of live (HRQoL). Managing respiratory symptoms is critical for patients with pulmonary diseases, and pulmonary rehabilitation programs are one way of possibly achieving this goal. Pulmonary rehabilitation programs are based on tailored and supervised training in breathing techniques and educational sessions to promote self-management 32

of symptoms and physical activity. Such programs are known to ease both respiratory and non-respiratory symptoms, but evidence that they can promote meaningful clinical improvements in patients with idiopathic pulmonary fibrosis (IPF) is lacking. In addition, the current guidelines on managing ILD provide a weak recommendation for pulmonary rehabilitation. To address this, a research team at University of Modena Reggio in Emilia, Italy, conducted a prospective study to confirm the positive impact of pulmonary rehabilitation delivered both as in- and outpatient programs in a population of patients with ILDs of different severity, and to investigate whether baseline exercise capacity, disease severity or ILD etiology might differently affect clinical outcomes following a standard pulmonary rehabilitation course. The researchers evaluated the therapeutic benefit of a standard pulmonary rehabilitation program in 41 patients with pulmonary diseases, including 26 people with IPF. The program consisted of at least 24 rehabilitation training sessions and was conducted six days a week, with each session lasting at least three hours. Weekly programs consisted of aerobic and weight training (endurance exercises), two 30-minute breathing technique sessions, and three group education sessions. Study Results •

Overall, all patients were seen to benefit from a pulmonary rehabilitation program delivered by teams at specialized centers. Improvements were seen in exercise capacity and in disease symptoms that included shortness of breath and leg fatigue.

•

Quality of live and chronic breathing problems also significantly improved after the program completion,

Highlight: •

Managing respiratory symptoms is critical for patients with pulmonary diseases, and pulmonary rehabilitation programs are one way of possibly achieving this goal.

independently of disease severity or disease type (IPF or non-IPF). •

In particular, the team observed that both IPF and non-IPF patients who showed a poorer physical capacity at the study’s start (determined by the six-minute walking test) were more likely to benefit from pulmonary rehabilitation in terms of exercise performance and HRQoL.

In conclusion, the authors found that “there is a growing body of evidence to support pulmonary rehabilitation as a fundamental treatment for patients with lung fibrosis that should be early referred to tailored exercise programs.” Furthermore, they recommend that “pulmonary rehabilitation should be a first line therapy for managing symptomatic patients with ILD of different nature and mild to moderate severity.” For the abstract and complete report, see Effectiveness of pulmonary rehabilitation in patients with interstitial lung disease of different etiology: a multicenter prospective study. https://bmcpulmmed.biomedcentral.com/ articles/10.1186/s12890-017-0476-5

AMRPA Magazine December 2017

STUDY UNDERSCORES NEED FOR PROACTIVE PARTNERSHIPS BETWEEN HOSPITALS AND PROVIDERS IN REDUCING PATIENT HARM

hile hospitals may focus on regulatory harm reduction programs such as Medicare’s Hospital Value-Based Purchasing Program (HVBPP) and Hospital Acquired Conditions (HAC), the types of harm captured by these programs are often narrow and limited to a small set of events. To better address a wider spectrum of hospital harm events, one patient safety organization (PSO) developed an automated all-cause harm trigger system to more effectively identify current patients who may have experienced harm or may be at risk for harm. The organization’s experience and findings may be helpful to those inpatient rehabilitation hospitals and units (IRH/ Us) looking to advance their harm identification processes and improve patient safety. The study, “Developing and Evaluating an Automated All-Cause Harm Trigger System,” published in the Joint Commission Journal on Quality and Patient Safety 2017, reports a pilot test at two Florida Adventist Health System hospitals of an automated harm trigger identiﬁcation system. The system as able to capture a wider array of harms in a larger sample of patients accurately and more efficiently than the manual system.

Background From 2009 through 2012, the Adventist Health System Patient Safety Organization (AHS PSO) used the Global Trigger Tool as a manual method for harm identiﬁcation and reduction. Although the tool did increase harm awareness and identified opportunities for improvement across the system, the organization felt that the resources required to continue with a manual identiﬁcation tool were unsustainable. There was also a

growing concern that the retrospective identification of harm, i.e., after the patient’s discharge, did not allow for intervention during the hospital stay. Therefore, the AHS PSO decided to seek an alternative method for patient harm identification. The AHS PSO and another PSO jointly developed an automated all-cause harm trigger identification system that allowed for real-time bedside intervention, realtime trend analysis affecting patient safety, and continued learning about harm measurement. The two pilot hospitals shared the same electronic health record platform thereby enabling live information sharing across the test model. Automated positive harm triggers and work-flow models were developed and evaluated. Nurse reviewers analyzed the electronic health records of current patients with positive triggers to determine if harm had occurred. If harm was identified, it was classified as hospital-acquired or outsideacquired and was grouped into one of five harm categories and assigned a severity level. Results Combined data from the two hospitals in a period of 11 consecutive months indicated that: 1. The automated review process captured far more harms and a wider array of harms than the manual process. The PSO found a total of 2,696 harms, hospital-acquired and outside-acquired, using the automated trigger review process, as compared to 132 harms found using a manual review process for similar time periods. 2. They identified the 10 most frequently identified hospital-acquired harms and corresponding severity levels

Highlight: •

Progressing from a solely harm measurement process to a real-time bedside intervention may assist hospital care teams in preventing harms.

(see Table 2). Hypoglycemia related to medication was the most frequently identiﬁed harm. In addition, bleeding related to medication, and oversedation related to medication were consistently found in the top 10 harms. None of these events are included in a regulatory harm reduction program. 3. Third, they compared the number of harms found using the automated trigger review process to the number hospital-reported harms under the Patient Safety Indicator (PSI) 90 regulatory program. At the time of this study, the PSI 90 program included eight indicators. The automated system identified 256 harms related to the PSI 90 Composite descriptions, whereas only 77 harms were reported to the Centers for Medicare and Medicaid Services (CMS) for the same time frame (see Table 3). 4. Finally, they found that almost one third (32%) of harm events occurred outside the hospital. These outsideacquired harms mirrored the top ten hospital-acquired harms. Awareness of all-cause harm, including outsideacquired harms, emphasizes the need for proactive partnerships and alignment of incentives between hospitals and community care providers and services. Conclusion The study found that an automated harm trigger identiﬁcation system captured a 33

Source: The Joint Commission Journal on Quality and Patient Safety 2017; 43:155–165. Vol. Volume 43, No. 4, April 2017, pg 161.

wider array of harms in a larger sample of patients accurately and efficiently. The automated system revealed not only more harm but a broader scope of harm, and led to a better understanding of patient safety vulnerabilities. The real-time analysis of harm at the hospital level was shared throughout the system, and it was also able to identify harm that occurs outside of the hospital, offering opportunities for alignment of safety goals with community partners.

Citation See “Developing and Evaluating an Automated All-Cause Harm Trigger System” Christine Sammer, DrPH, RN; Susanne Miller, RN, MS; Cason Jones, MLS, MHA; Antoinette Nelson, RN, BSN, MSHSA; Paul Garrett, MD; David Classen, MD, MS; David Stockwell, MD

Based on their experience, the PSO found that automated all-cause harm trigger system is most valuable at the hospital-level close to the bedside care team. Progressing from a manual harm measurement process to a real-time bedside intervention allowed for the hospital care team to improve multiple components of their harm identification and prevention strategies.

AMRPA Magazine December 2017

CMS TRANSMITTALS OF INTEREST FOR MEDICAL REHABILITATION PROVIDERS

December 2017

Note: The Centers for Medicare and Medicaid Services (CMS) publishes daily official transmittals used for communicating reminder items, requests for action or information to fiscal intermediaries and carriers. In this section of the AMRPA magazine you will find specifically selected transmittals listed that would be of interest to medical rehabilitation providers. To view the entire lists please see: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017-Transmittals.html Transmittal #

Issue Date

Subject

Implementation Date

R755PI R3916CP

2017-11-09 2017-11-09

2017-12-11 2018-04-02

R3912CP

2017-11-09

R3909CP

2017-11-08

R3917CP

2017-11-08

R1960OTN

2017-11-03

R3903CP

2017-11-03

Tracking Medicare Contractors' Prepayment and Postpayment Reviews Claim Status Category and Claim Status Codes Update Off-Cycle Update to the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2018 Pricer Quarterly Update for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) - January 2018 Calendar Year (CY) 2018 Participation Enrollment and Medicare Participating Physicians and Suppliers Directory (MEDPARD) Procedures Implementation of the Award for the Jurisdiction Part A and Part B Medicare Administrative Contractor (JJ A/B MAC) Annual Medicare Physician Fee Schedule (MPFS) Files Delivery and Implementation and Medicare Physician Fee Schedule Database (MPFSDB) 2018 File Layout Manual

R108GI

2017-11-03

R1966OTN

2017-11-03

R1956OTN

2017-11-01

R1939OTN

2017-10-27

R753PI

2017-10-27

R1937OTN

2017-10-27

R3897CP

2017-10-27

R1950OTN

2017-10-27

R1952OTN

2017-10-27

R3898CP

2017-10-27

R3888CP

2017-10-20

R3885CP

2017-10-17

R748PI

2017-10-13

R7p233

2017-10-06

R3878CP

2017-10-06

R3877CP

2017-10-06

MAC Transition Workload Handbook Out-of-Jurisdiction Providers (OJP) and Qualified Chain Providers (QCP) Move to Correct A/B MAC Jurisdiction - Analysis CR Only Analysis and Design Working Sessions for the Development of a Pre-Payment Common Additional Documentation Request (ADR) Letter Fiscal Intermediary Shared Systems (FISS) Enhancements to the Mass Adjustment of Process Recovery Audit Contractor (RAC) Claims Certificates of Medical Necessity (CMN) and Durable Medical Equipment (DME) Information Forms (DIF) Provider Education and Referral Reporting Pulmonary Rehabilitation (PR) Services Addition to Chapter 19, Indian Health Services (IHS) Fiscal Intermediary Shared System (FISS) and VIPS Medicare Shared System (VMS) to Update Records Based on the Automation of Prior Authorization (PA) Requests/Pre-Claim Reviews (PCR) and their Responses with Multiple Services (for programs like Home Health (HH)) Calculating Interim Rates for Graduate Medical Education (GME) Payments to New Teaching Hospitals Correction to Prevent Payment on Inpatient Information Only Claims for Beneficiaries Enrolled in Medicare Advantage Plans Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2018 Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings Provider Reimbursement Manual Part 2, Provider Cost Reporting Form and Instructions, Chapter 33, Form CMS-216-94 January 2018 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files Annual Update of HCPCS Codes Used for Home Health Consolidated Billing Enforcement

2018-01-02 2018-01-02 N/A 2018-02-26 2018-01-02 2017-12-04 N/A 2017-10-02 2018-04-02 2017-11-28 2017-11-27 2018-04-02

2018-04-02

2017-10-23 2018-04-02 2018-01-02 2017-10-02 2017-11-14 2017-10-06 2018-01-02 2018-01-02

Updated as of November 10, 2017 35

AMRPA Magazine December 2017