AMRPA Magazine October 2017

October 2017 • Vol. 20, No. 10

AMRPA THE CENTER OF “COOPETITION”

Volume 20, Number 10

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 Lisa Werner, MBA, MS, SLP Director of Consulting Services for FlemingAdvanced Outcomes Design Carolyn Zollar, MA, JD Executive Vice President for Government Relations and Policy Development, AMRPA Jonathan M. Gold, JD Regulatory and Government Relations Counsel*, AMRPA Mimi Zhang Policy and Research Associate, AMRPA Lovelyn Robinson Editorial and Research Assistant, AMRPA *Admitted Only in Illinois. Supervision by Carolyn C. Zollar, J.D., a member of the D.C. Bar

Letter from the Chair........................................................................................... 3 AMRPA Legislative Update................................................................................. 4 CMS Completes Jimmo Corrective Action Plan............................................... 6 CMS Shifts Strategy on Medicare Audits ......................................................... 8 More Lessons Learned from Documentation Audits ..................................... 10 CMS Issues Anticipated Proposal to Cancel Mandatory EPM Bundling Program and Cardiac Rehab Incentive Initiative and Modify the CJR Bundling Program .......................................................... 12 MedPAC Supports Modifying Hospital Discharge Rules to Encourage Use of Higher-Quality Post-Acute Care Providers ...................... 19 CMS Warns That Outpatient Therapy Code Modifier Requirements Will Be Enforced ....................................................... 22 AMRPA Submits Comments to CMS on the CY 2018 Physician Fee Schedule .................................................................... 23 AMRPA Submits Comments to CMS on the Quality Payment Program ...... 27 Researchers Discover Treatment Option for Patients Suffering From Aggression After Traumatic Brain Injury ............................................. 30 OIG Early Alert: Nursing Home Abuse Continues to Go Unreported ......... 32

AMRPA Magazine, Volume 20, Number 10.

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.

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Robotic Exoskeleton Helps Alleviate Crouch Gait in Children with Cerebral Palsy ............................................................................ 36 Disaster Exceptions/Exemptions for Medicare Certified Providers Affected by Severe Storms and Flooding....................................................... 38 Study Findings: Intensivists Benefit Heart Patients with Breathing Difficulties and Lower Costs ........................................................... 40 CDC Report Examines Outpatient Cardiac Rehabilitation, 2013-2015......... 42 AMRPA Submits Comments on CMS’s CY 2018 OPPS Proposed Rule......... 46 CMS Transmittals of Interest for Medical Rehabilitation Providers ............. 50

Statements of fact and opinion are the responsibility of the authors alone and do not imply an opinion on the part of the officers or the members of AMRPA. All content Š2017

by American Medical Rehabilitation Providers Association.

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AMRPA Magazine October 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

AMRPA – The Center of “Coopetition”

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MRPA is a national trade association. By definition that means that all members are in the same business. And therefore, our members are in many instances, competing with each other. So we are cooperating and competing at the same time.

Some would describe this as “coopetition.”

This dynamic is not unique to health care, of course, and occurs in all industries. We come together when there are issues that can benefit all, and agree to disagree where more parochial interests prevail.

So AMRPA is a “safe place” for the common good. Advocacy for our patients and our field is the sweet spot for us, but not our only value. Providing information about current events in the rehab world (Off the Record, the magazine, member calls, etc.), sharing knowledge about best practices (annual educational meetings, webinars), being a networking environment (committee meetings, conferences) are examples of the ways AMRPA provides members with this service.

Sponsorship of eRehabData® is also a big example of coopetition.

We share our performance and results data to help measure ourselves against peers. This is a powerful way of improving performance of all who participate (rising waters lift all ships).

AMRPA also serves as an innovator. Developing the Continuing Care Hospital (CCH) concept, and the work on a new model of post-acute care, the Continuing Care Network (CCNet). These two projects could change the world of post-acute care for all our members and others in the post-acute sector, but not necessarily in the same manner.

So AMRPA is an incubator for coopetition. Membership in AMRPA should be a high priority for all rehab providers; we need the strength of your voice and active involvement in our national organization.

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AMRPA LEGISLATIVE UPDATE

By Martha M. Kendrick, Esquire, Partner, Akin Gump Strauss Hauer & Feld LLP Congress Passes Continuing Resolution with Debt Limit Extension

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n September 8, President Trump signed into law H.R. 601, legislation that combines $15.25 billion in hurricane relief aid with a measure to extend the debt ceiling and a continuing resolution (CR) to fund the government at current levels through December 8, 2017. The House voted earlier that day to pass the bill by a vote

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instructions. Faced with an already crowded September agenda, it is unclear how Senate Republicans will address the Parliamentarian’s decision.

The White House and several prominent Republican Senators have backed a new bill from Senators Lindsey Graham (R-SC) and Bill Cassidy (R-LA) that would convert Medicaid expansion and Affordable Care

Congress passed a legislative package this month that provides $15.25 billion in hurricane relief funds, extends the debt limit and funds the federal government under a Continuing Resolution through December 8, 2017.

Deliberations continue in the House on a FY 2018 Budget Resolution, which Republicans seek to use as a vehicle for tax reform.

The Senate parliamentarian ruled that the ACA repeal reconciliation instructions in the FY 2017 Resolution expire on September 30, 2017, adding difficulty to the GOP’s health care efforts.

The Senate HELP Committee is holding hearings with the hope of developing market stabilization legislation.

Congress is teeing up end-of-the year legislative packages that would include Medicare extenders and reauthorization of the Children’s Health Insurance Program (CHIP), a “must-pass” priority.

of 316-90, following the Senate’s vote of 80-17 on September 7. The President struck the deal with Democratic leaders, surprising Republican leadership and Treasury Secretary Steven Mnuchin, who had pushed for a longer-term extension of the debt limit. The short-term extension means that the debt limit debate could start up again in a few months, possibly complicating Republicans’ tax reform effort. The move also frustrated Conservatives who have opposed measures to raise the debt ceiling without corresponding spending cuts and reforms.

Work continues, meanwhile, on a FY 2018 Budget Resolution that Republicans could 4

use for tax reform through reconciliation.

The House Budget Committee approved a budget in July, but controversy over $200 billion in cuts to mandatory spending has delayed consideration of the measure.

Administration officials and House tax writers are currently meeting to discuss details of a tax overhaul and how to advance a budget resolution.

Senate Parliamentarian Rules on Reconciliation Instructions To the surprise of some observers, the Senate Parliamentarian has determined that the Budget Reconciliation instructions on the Affordable Care Act (ACA) repeal expire at the end of FY 2017 – September 30. This is a significant setback for Congressional Republicans, setting a hard and fast-approaching deadline for lawmakers who have sought to revive a repeal-and-replace effort.

While Republicans could potentially pursue repeal in the next fiscal year, they had planned to move forward with tax reform by passing an FY 2018 Budget Resolution with tax reform Reconciliation

Act (ACA) exchange funding into block grants. Additionally, states would be allowed to opt out of many of the ACA’s regulations. As we go to print, Senate leadership has been quiet on the bill so far, and it appears unlikely that the legislation will see a floor vote before the end of the month, but this could, of course, change.

HELP Committee Moving On Market Stabilization The Senate Health, Education, Labor and Pensions (HELP) Committee has wrapped up its hearings on insurance market stabilization, and Chairman Lamar Alexander (R-TN) hopes to craft legislation soon. The Committee heard from State AMRPA Magazine October 2017

Insurance Commissioners and Governors the first week of September. Two hearings the following week focused on State flexibility and testimony from health care stakeholders. Chairman Alexander and Ranking Member Patty Murray (D-WA) had the optimistic goal of drafting legislation

by September 27, the date when insurers must finalize their plans to be offered on the exchanges. Any package agreed to in the Committee is likely to be very narrow in scope; Chairman Alexander has stated it may include a continuation of the ACA’s cost-sharing reduction (CSR) payments and added flexibility for states seeking Section 1332 State Innovation Waivers. He also suggested the package likely will not address ACA taxes or a federal reinsurance pool, despite Democratic support for a reinsurance program. Even if the committee is able to advance a bipartisan legislative package, prospects for action on any market stabilization measure in the House remain uncertain.

Committee Chairman Orrin Hatch (RUT) and Ranking Member Ron Wyden (D-OR) on September 12 announced an agreement to extend CHIP funding for five years. The proposal reportedly would also maintain the ACA’s 23 percent increase in the federal matching rate through 2019 and then phase it out by 2021. It is unclear how the Committee will pay for the bill, either partially or in full. Chairman Hatch expects to release legislative text soon.

Congress also must pass a number of Medicare “extenders,” which may be packaged with CHIP reauthorization.

Several extender provisions expire on September 30, while others are set to expire on December 31, including therapy caps; the House Ways and Means Committee is expected to begin marking up the extenders legislation, one by one, over the next several weeks.

CMS Cancels Episode Payment Models and Modifies CJR On August 15, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule to cancel the Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) incentive payment model, which were scheduled to begin on January 1, 2018. The proposed rule would also reduce the number of mandatory geographic areas participating in the Comprehensive Care for Joint Replacement (CJR) model from 67 to 34.

CJR participants in the 33 remaining areas would be allowed to continue to participate on a voluntary basis. Additionally, CMS proposes to make participation in the model voluntary for all low-volume and rural hospitals. Comments on the proposal are due by October 16.

Congress jumped in head first upon its return from the August recess in early September and we expect the legislative activity to continue to increase as several “must On August 15, the pass” bills need to reach the Congressional Budget Office Congress jumped in head first upon President’s desk by the end of (CBO) released a report its return from the August recess in the year. We remain on high on the estimated effects alert that the House Ways and of ending the ACA’s costearly September and we expect the Means Committee will push to sharing reduction (CSR) legislative activity to continue to add its post-acute care valuepayments. CBO expects based purchasing proposal on that gross premiums for increase as several “must pass” bills one of these moving vehicles. silver plans would be 20 need to reach the President’s desk by Therefore, we urge you to reach percent higher in 2018 and the end of the year. out to your representatives and 25 percent higher by 2020, let them know your concerns though most people would and the impact such policies will pay net premiums similar to have on patients that need and depend The committee is encouraging industry what they would pay otherwise because on rehabilitative care. AMRPA also remains stakeholders affected by the extenders the amount of premium tax credits would diligent in advocating for full repeal of to put forth “pay-fors” so the extensions increase. As a result, federal deficits would the arbitrary therapy caps. Your support of policy are fully off-set. Senate Finance increase by $194 billion from 2017 through in sending similar messages to your is taking a different approach in that a 2026. Shortly after the report’s release, the lawmakers will make a difference as we number of the extenders likely will be White House announced it would make move into a risky legislative period! considered together. AMRPA is lobbying CSR payments to insurers for August, actively on therapy caps. but has not yet confirmed whether it will continue payments through September Martha M. Kendrick Ways and Means Committee Marks Up and the remainder of the year.

Medicare Legislation The House Ways and Means Committee Lawmakers Under Pressure to Pass held a markup on September 13 to CHIP, Medicare Extenders consider legislation “to improve Medicare “Must-pass” legislation for Congress programs and policies.” The committee includes an extension of funding for the reported a number of bills, including: H.R. Children’s Health Insurance Program 3727, which would allow telehealth services (CHIP). Funding was set to expire on to be included as a basic benefit for September 30, but states may continue Medicare Advantage enrollees; and H.R. to spend previously allocated dollars, and 3726, which would create an alternative the Centers for Medicare and Medicaid pathway to resolve technical violations of Services (CMS) may reallocate unspent the Stark rule. funds among the states. Senate Finance 5

CMS COMPLETES JIMMO CORRECTIVE ACTION PLAN

CLARIFIES RELIEF FOR MEDICARE BENEFICIARIES IN NEED OF SKILLED CARE

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he Centers for Medicare and Medicaid Services (CMS) has revised its webpage on CMS.gov detailing information about the Jimmo settlement, effective August 25, 2017. This webpage revision was ordered by a federal judge as part of a Corrective Action Plan in February 2017. The case, originally filed in January 2011, challenged Medicare’s use of an “improvement standard” in determining medical necessity for skilled nursing services, home health, and outpatient therapy (“Skilled Care”) on the grounds that it violated Medicare law and deprived Medicare beneficiaries of needed care, even if they were not improving.

Background Glenda Jimmo, the named plaintiff, and the Center for Medicare Advocacy (CMA) settled that case three years ago, but the court held jurisdiction over the case for a five-year period in case CMS did not fully implement the settlement agreement. CMA brought the case on behalf of a class of Medicare beneficiaries. Other plaintiffs in the case included the National Multiple Sclerosis Society, the Paralyzed Veterans of America and the Parkinson’s Action Network (now The Michael J. Fox Foundation for Parkinson’s Research).

The parties filed a Settlement Agreement in October 2012, which was then approved by the court in January 2013. CMS hosted a national provider call, as stipulated in the educational campaign of the Settlement Agreement, in December 2013. Despite these events, CMA asserted in court proceedings that Medicare continued to base coverage decisions on an “improvement standard,” even though there is generally no such requirement in Medicare law.

In August 2016, the court found that CMS was in part non-compliant with the Settlement Agreement, and ordered CMS to provide better education on

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Impact on Inpatient Rehabilitation Hospitals and Units With respect to Inpatient Rehabilitation Hospitals and Units (IRH/U), under the Jimmo settlement, CMS revised the Medicare Benefits Policy Manual (MBPM) to clarify that an IRH/U claim could never be denied:

New Webpage The newly published Jimmo webpage, in coordination with the Corrective Action Plan, contains two recent improvements: 1) the addition of an “Important Message About the Jimmo Settlement,” (the Important Message), and 2) a list of 15 Frequently Asked Questions (FAQs), many of which counter erroneous beliefs on the application of Jimmo in various settings. Recent clarification in these two sections of the webpage include:

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Because a patient could not be expected to achieve complete independence in the domain of self-care; or

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Because a patient could not be expected to return to his or her prior level of functioning (prior to the illness or injury that caused the hospital stay).

the coverage required under Jimmo. In February 2017, the court ordered CMS to enter into a Corrective Action Plan.

In addition to amending the MBPM for IRH/Us, CMS revised several Medicare policy manuals under the Jimmo settlement, including those for skilled nursing facilities (SNFs), home health care (HH), and outpatient therapy (OT) services. The settlement’s more expansive policy change for SNFs, home health care, and outpatient therapy services does not apply to IRH/Us. This is because IRH/Us are required by regulation to demonstrate that a patient, upon admission, has an expectation of improvement. The regulations do not require that the patient actually improve their functional status during the course of the IRH/U stay in order for the care to be covered, but the need for an intensive inpatient rehabilitation hospital program must be present throughout the course of the stay. Still, the terms of the settlement that relate to IRH/U care should help prevent at least some denials of access in the future and the settlement may engender additional challenges to the current regulatory standard in the inpatient rehabilitation hospital setting.

Rejection of improvement standard. The Important Message states that the Settlement “may reflect a change in practice” for providers and Medicare decision-

ABOUT THE AUTHORS

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

Steve Postal Director, Health Policy, Powers Pyles Sutter & Verville, PC AMRPA Magazine October 2017

makers who mistakenly believed that the Medicare program covers nursing and therapy services based on the “improvement standard.” Many health care providers, specifically physical and occupational therapy providers, still provide services based on the “improvement standard,” which denies beneficiaries medically necessary care.

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Reiteration of maintenance coverage standard. The Important Message and FAQ Answers #1 and #12 state that Medicare covers skilled care needed to maintain a patient’s function or to prevent or slow decline (i.e., the “maintenance coverage standard”).

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Maintenance standard applies as long as skilled care is required.

FAQ Answer #7 states that skilled care is covered when it is necessary to maintain or prevent decline of a patient’s current condition “so long as the beneficiary requires skilled care for the services to be safely and effectively provided.”

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Defines “maintenance services.”

FAQ Answer #3 clarifies that the “maintenance services” addressed by the Jimmo Settlement Agreement are nursing and therapy services to maintain the patient’s condition or to prevent or slow further deterioration.

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Skilled care coverage is not limited to those in decline. Answer #11 debunks the perception that providers will deny skilled care unless they see a patient’s medical condition in decline, emphasizing that, “The Medicare program does not require a patient to decline before covering medically necessary skilled nursing or skilled therapy.”

Additionally, FAQ Answer #8 addresses the role of “documentation” in facilitating accurate coverage determinations for claims involving skilled maintenance care.” FAQ Answers #14 and #15 state that Jimmo applies to Medicare beneficiaries enrolled in Accountable Care Organizations (ACOs) and Medicare Advantage (MA) plans.

Key Elements of the February Ruling and Corrective Action Plan On February 1, 2017, a federal judge issued a decision for additional relief in the Jimmo v. Burwell case. The February 2017 decision followed an August 2016 decision in the case, where the judge held that the Secretary of Health and Human Services had failed to explain that Medicare coverage for skilled care was based on a “maintenance standard” rather than an “improvement standard.”

The February decision ordered the Secretary to enforce a Corrective Action Plan that would make Medicare coverage determinations in skilled care based on a “maintenance standard.”

The plan included: •

A new Jimmo website to be housed on www.cms.gov. The Plan stipulated that the website would: 1) provide access to public documents related to Jimmo; 2) provide a message about the February decision at the top of the webpage; and 3) direct providers and suppliers with questions about claims to the appropriate Medicare Administrative Contractor (MAC);

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A statement for inclusion on the Jimmo webpage of CMS disavowing the “improvement standard,” as well as a statement that CMS has consistently denied the existence of such a standard, (the “Disavowal Statement”);

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One set of Frequently Asked Questions (FAQs), to be housed on the new Jimmo webpage, that would clarify the Jimmo settlement and its policy implications; and,

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A requirement that CMS direct its MACs and Medicare Advantage Organizations (MAOs) to conduct additional training on Jimmo.

Implications CMS’ revised Jimmo webpage is a victory for those needing rehabilitation.

Judith A. Stein, executive director of the Center for Medicare Advocacy, said, “We hope that the new CMS education and information…will help convince providers that Medicare really is available for people who need this critical maintenance care.” Michael Benvenuto, of Vermont Legal Aid, one of the Jimmo plaintiffs’ attorneys, stated, “After years of fighting over this standard in court, we are hopeful that Medicare has finally acknowledged that beneficiaries with long-standing and chronic problems are entitled to maintenance skilled care to prevent or slow decline in their overall condition.”

Despite years of controversy surrounding the Medicare’s improvement standard, it is now clear that Medicare coverage of skilled care is, in fact, available for beneficiaries in SNFs, home health, and outpatient settings who will not necessarily improve their condition, if it can be shown that such services are necessary to maintain or slow decline of function. This represents the accomplishment of a years-long goal of AMPRA and the larger rehabilitation and disability community. Although the Jimmo Settlement does not have the same implications for IRH/U patients, it still improves the coverage standard for IRH/U care. It is now up to all Medicare providers to educate themselves and their patients on the Medicare standard for coverage of skill care in these settings and implement this standard in everyday patient care decisions.

Additionally, the judge ruled that the Secretary must organize a new National Call (to correct the one from December 2013) in which it will explain the Disavowal Statement. The judge ordered the Secretary of Health and Human Services to certify compliance with its ruling by September 4, 2017.

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CMS SHIFTS STRATEGY ON MEDICARE AUDITS

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n an attempt to “improve” the Medicare claim auditing process, the Centers for Medicare and Medicaid Services (CMS) has implemented a new process they refer to as “Targeted Probe and Educate” or “TPE.” This is an evolution of the Probe and Educate audit process originally rolled out in 2014, with limited success.

Currently still in the pilot stage in four Medicare Administrative Contractor (MAC) jurisdictions, TPE is expected to be implemented nationwide this fall, which could be any day. This article provides background information and rationale behind the new auditing process and details what providers can expect under TPE. Background Since 2005, inpatient rehabilitation hospitals and units (IRH/Us) have been under heavy scrutiny from CMS and its auditors. As a result, Medicare auditing across all provider and supplier types has drastically increased as CMS has pursued “improper” payments. Currently, CMS estimates that approximately 11 percent of all Medicare fee-for-service claim payments are improper. This translates to roughly $41 billion annually, but it should be noted that these statistics are based on audit and appeal numbers that do not take into account the extreme backlog of appeals at the administrative law judge (ALJ) level and any possible reversals of denials that may come once those appeals are heard. Of the improper payments, $26.4 billion are estimated to relate to Part A payments, with $4.7 billion attributed to inpatient rehabilitation hospitals and facilities.

Past auditing approaches used by CMS have usually involved “pay and chase” models that include post-payment audits and recoupment once Medicare claims have already been paid. To accomplish these tasks, CMS has employed a host of contractors to fulfill “program integrity” functions. Currently, the stable of CMS contractors includes 8

five primary entities: the Comprehensive Error Rate Testing (CERT) contractors, the Supplemental Medical Review Contractor (SMRC), the MACs, the Recovery Auditors (RACs), and the Zone Program Integrity Contractors (ZPICs, which are in the process of transitioning over to the Unified Program Integrity Contractors [UPICs]).

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CERT contractors conduct random post-payment audits of a small volume of claims in an effort to determine the annual improper payment rate. This is a shift in the focus of the CERT contractor, which used to be focused primarily on identifying the accuracy of the MACs. This shift may offer MACs a bit more latitude to determine whether certain claims are sufficiently documented or meet medical necessity requirements without having the CERT secondguess the MACs’ decisions.

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The SMRC conducts post-payment reviews in support of CMS-identified special topics. Topics are usually selected on the basis of Office of Inspector General (OIG) reports.

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The MACs used to primarily conduct post-payment review, often on a random or probe basis, but have shifted away from post-payment review and have had a heavy focus on pre-payment review over the past 18 to 24 months. The MACs will carry out the TPE program, which is described in detail below.

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The RACs have the responsibility for post-payment audits going forward.

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The ZPICs/UPICs are responsible for investigating potential fraud.

The ZPICs are Medicare-only contractors and are being phased out and replaced by the UPICs, which are jointly responsible for both Medicare and Medicaid fraud investigations within their respective regions.

There is an interactive map available at https://www.cms.gov/Research-StatisticsData-and-Systems/Monitoring-Programs/ Medicare-FFS-Compliance-Programs/ Review-Contractor-Directory-InteractiveMap/ that identifies the specific contractor in each category (except the CERT contractors) for a given state.

The TPE Initiative As noted above, this new initiative is already under way in four MAC jurisdictions and will soon be implemented nationwide. It replaces past medical review efforts by the MACs, including the original Probe and Educate program. Previously, both postpayment and pre-payment reviews by the MACs involved potentially unlimited review—both with respect to number

ABOUT THE AUTHORS

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

Christina Hughes, JD, MPH Powers Pyles Sutter & Verville, PC AMRPA Magazine October 2017

of records and the time period for review—and often resulted in vague review results. While CMS believes the Probe and Educate program was generally successful in reducing the number of improper payments, it has acknowledged that the lack of specificity and precision in both the selection of claims to audit and providing clear results and education was subpar.

Hence, CMS has developed the TPE program.

Under TPE, providers will be selected for targeted review based on data analysis conducted by the MACs. (CMS asserts this information will not be pulled directly from any Program for Evaluating Payment Patterns Electronic Report [PEPPER] reports, but nevertheless the data should mirror those reports in that a provider who stands out on a PEPPER report is likely to stand out in the MACs’ standalone data analysis as well.) After selecting a provider for targeted review, a MAC will select 20 to 40 claims for prepayment review. A specific and detailed breakdown of the review results will be issued to the provider at the conclusion of the review. After results of the review are sent, the provider will be offered educational intervention, if appropriate.

The intervention will consist of a phone call with MAC staff, which will include, at minimum, a clinician and the review specialist or specialists involved in review of the selected claims. The call is supposed to be unlimited in length of time allotted and the provider should be allowed to direct the format of the call. Depending on the nature of the review results, a provider may choose to ask specific questions raised by the review results, get a broad overview of the reviewed claims, or even go through a claim-by-claim analysis.

Following the conclusion of the review and education (if requested), a provider will be given a pause in auditing, known as the “Period of Improvement,” in order to implement changes and corrections to its processes or procedures in response to the audit results. The Period of Improvement will last for at least 45 days, and up to eight weeks. After the Period of Improvement, the provider will undergo another round of auditing, with the MAC selecting another 20 to 40 claims for pre-payment review.

If the provider is still found deficient during the review, another educational intervention will be offered and another Period of Improvement will follow. A third round of auditing will then follow after the second Period of Improvement.

The MAC is limited to three rounds of auditing. If the provider fails its third round audit, it will be referred to CMS for additional action, which may include use of additional pre-payment review by the MAC (possibly including the use of extrapolation), referral to the RAC, or referral to the ZPIC/UPIC. Even for providers who disagree with the audit results issued by the MAC, there is no alternative (such as an ombudsman or other mediation) to the three rounds of TPE followed by referral to CMS. The provider’s only recourse is through the existing administrative appeals process and, by all accounts, the administrative appeals process is hopelessly backlogged and not a timely mechanism for providers to resolve genuine disputes with Medicare contractors.

Potential Impact of TPE Program It is too early to tell whether the new limits included in the TPE program will be a welcome respite for many providers over current auditing practices or may constitute a system that sets up providers to either comply with the contractors’ views or encounter serious consequences. IRH/Us nationwide have experienced unlimited auditing over the past 18 to 24 months, ever since CMS rescinded regulations setting guideposts for pre-payment review. With no rules on pre-payment review, the MACs experimented with unfettered access to pre-payment review as an auditing tool.

When statutory and regulatory limits on the use of pre-payment auditing were lifted, some IRH/Us discovered that the MACs are all too willing to keep providers on some level of pre-payment review indefinitely. With the extensive appeals backlog and lengthy delay in ALJ hearings, the prospect of relief was generally out of reach.

occur (from the MACs, at any rate). This could be a major positive factor for IRH/ Us—allowing for some downtime for staff involved in audits and appeals to regroup, train staff, and get a handle on the process. The education to be offered could also be of some value, both in understanding areas of potential improvement and as opportunities to provide feedback to the MACs’ staff.

Unfortunately, the TPE program is a double-edged sword for IRH/Us. The limit on audits does not come without a price—and that price could involve extreme remedies such as extrapolated overpayment demands and even fraud investigations. For those IRH/Us that get hit by such extreme measures, the prospect of continuous, low-level prepayment auditing may not seem quite so onerous. Further, because IRH/Us can often have fundamental disagreements with the MACs’ interpretations and applications of the coverage criteria for care, the educational sessions may be less helpful than intended. In the event that an IRH/U and a MAC reach an impasse regarding a particular interpretation, only the appeals process is likely to resolve the issue unless the IRH/U capitulates. With the appeals process backed up for years (the current estimate provided by the government for the backlog is 972,000 appeals pending by 2021), it is simply not an effective or timely process to resolve disagreements involving medical necessity or compliance with documentation requirements.

Considering these factors, the new TPE initiative may provide some shortterm reliability in the auditing process, particularly with respect to pre-payment review, but this may be at the expense of significantly larger potential liability in the longer term.

There are some silver linings of the new TPE initiative. For instance, the number of claims to be reviewed will be limited and there are defined time periods in which no auditing should 9

MORE LESSONS LEARNED FROM DOCUMENTATION AUDITS

By Lisa Werner, MBA, MS, CCC-SLP

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s providers continue to be plagued by chart requests from various CMS auditors, denials are being returned with increasingly creative and non-standard justifications.

Among other things, the items on CMS’s documentation guidelines from 2010 are emerging as important factors for current auditing methodology. Even with all other required items present, auditors will look beyond signature timeframes to make sure all elements stipulated in the Federal Register are included. This approach is unusual because, previously, the most common justifications for denial involved medical necessity, with auditors denying reimbursement by claiming patients could have been treated at less intense levels of care.

that physician documentation includes all of the elements required by the CMS documentation guidelines in the Federal Register.

Pre-Admission According to CMS guidelines, the preadmission screening should include: •

Patient’s prior levels of function (prior to the event or condition that necessitated intensive rehabilitation therapy)

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Expected levels of improvement

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Expected time needed to reach that level of improvement

While the PAS does not have to be completed by the rehabilitation physician, the physician does have to approve patient admissions. Pre-admission screenings should be reviewed by the rehabilitation physician and signed within 48 hours prior to the patient’s arrival. A physician’s signature should be the last on record, so, if any updates are made to the PAS after the initial approval and signature, the document should be resigned.

Admission Orders CMS requires rehabilitation physicians to generate orders for patient admissions.

Make sure you retain signed orders indicating a physician’s intention to admit patients to your hospital or unit.

Post-Admission Rehabilitation physicians are required to complete post-admission assessments within 24 hours of a patient’s admission.

CMS clarified that this document must be completed by the rehab physician rather than by a physician extender, so make sure that your rehab physician is available and conducting post-admission assessments according to these guidelines.

Unfortunately, keeping charts that include all the required forms signed in a timely manner no longer means you can rest easy.

First, auditors focus on adherence to pre-admission screening (PAS) timeframes and signature requirements, post-admission physician evaluation, overall plans of care, team conferences, number of progress notes, attendance at conference and compliance with the three hour rule.

Audits still place heavy emphasis on these items, but, once the initial bases are covered, auditors are increasingly going above and beyond in search of reasons to deny claims.

In recent denials, I’ve noticed frequent use of missing elements in the PAS, postadmission physician evaluation and the overall plan of care as justifications for denial. I’m sure you’ve all been focusing your internal audits on timeframes and signatures, but, in light of these recent trends, I urge you to add these new items to your self-auditing process. Make sure 10

•

Evaluation of complications

risks

•

Conditions rehabilitation

•

Combination of treatments needed, one of which must be physical therapy (PT) or occupational therapy (OT)

•

Expected frequency and duration of treatment in the inpatient rehabilitation facility (IRF)

•

Anticipated discharge destination

•

Any anticipated treatments

•

Other information relevant to the needs of the patient

that

for

clinical

necessitated

post-discharge

Post-admission assessments should include reviews of patient medical conditions and functional deficits that require specific attention during rehab stays. A list of risks and possible complications present at the time of admission should also be included.

While most facilities document active conditions, list preventative measures, and note functional deficits when necessary, clear plans for managing the conditions that justify rehabilitation stays are often AMRPA Magazine October 2017

omitted. The following items are part of a post-admission checklist provided by CMS: •

Document patient admission to the IRF;

status

on

•

Compare current status to the status noted on the pre-admission screening;

•

Begin developing an expected course of treatment that will then be finalized after input from all interdisciplinary team members is collected and synthesized in the overall plan of care;

•

Identify any relevant changes that may have occurred since the preadmission screening;

•

Provide guidance as to whether or not it is safe to initiate a patient’s therapy program;

•

Support the IRF admission’s medical necessity;

•

Include a documented history and physical exam, as well as a review of the patient’s prior and current medical conditions, functional conditions, and comorbidities.

Overall Plan of Care Rehabilitation physicians should synthesize patients’ plans of care by the end of the fourth rehab day. This document should be specific to each patient and include all of the following elements:

•

Estimated length of stay

•

Patient medical prognosis

•

Anticipated functional outcomes

•

Anticipated discharge from the IRF

•

Anticipated interventions that support the admission’s medical necessity

destination

• Based on patient impairments, functional status, complicating conditions and any other contributing factors. Should include the following details about the PT, OT, speech-language pathology or prosthetics and orthotics therapies: –– Intensity (number of hours/day) –– Frequency (number of days/ week) –– Duration (total number of days during IRF stay) Team Conference According to CMS, interdisciplinary teams exist to foster frequent, structured and documented communication between disciplines to help establish, prioritize and achieve comprehensive treatment goals. Elaborating further, CMS holds that providers should address all of the following in team conferences: individual progress towards rehabilitation goals, possible solutions for problems that threaten to impede progress,

reassessments of previously established rehabilitation goals, and plans for monitoring the treatment plan with revisions as needed. Make sure that your team conference documentation reflects these discussions.

It is imperative that you track attendance at team conferences. List members from each treating discipline and make sure they are present and accounted for at each meeting. Make sure that each patient has a team conference scheduled weekly, including within the first seven days of admission. Lastly, discuss any informal team meetings and document how they are used to revisit ongoing patient needs, patient progress, and adjustments to plans of care.

Summary In addition to conducting internal audits for consistent documentation and adherence to timeframe guidelines, I strongly recommend adding reviews for the required elements covered in this memo. Unfortunately, keeping charts that include all the required forms signed in a timely manner no longer means you can rest easy. Make sure the contents of your documentation meet CMS standards and that all required elements are clearly recognizable to anyone who reviews your charts.

11

CMS ISSUES ANTICIPATED PROPOSAL TO CANCEL MANDATORY EPM BUNDLING PROGRAM AND CARDIAC REHAB INCENTIVE INITIATIVE AND MODIFY THE CJR BUNDLING PROGRAM

By Carolyn C. Zollar, MA, JD, Executive Vice President of Government Relations and Policy Development, AMRPA

O

n August 17, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to eliminate one of the Obama administration’s mandatory bundling programs issued in final form in the last few days of his administration and vastly modify the other mandatory bundling program. In addition, the proposal would rescind the cardiac rehabilitation incentive program. These proposals are totally consonant with the philosophy of the Trump administration and specifically mirror the positons taken by new Secretary of the Department of Human Services Thomas E. Price, MD, when he was a congressman. This article summarizes the proposed changes.

AMRPA worked with its various committees in fashioning a comment letter. Comments were due on October 16, 2017.

Simply put, the rule proposed to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) Incentive payment model and to rescind the regulations issued pursuant thereto.

It also proposed to revise extensively the Comprehensive Care for Joint Replacement (CJR) program, which is discussed further below. The EPM program and CR incentive program were the second of two mandatory bundling programs and originally published in final form on January 3, 2017. The effective date for many provisions was February 18, 12

2017. There was also a start day of July 1, 2017, for certain CJR model changes for surgical hip and femur fracture episodes (SHFFT) so as to align with the July 1, 2017, start date for the EPMs and CR model. The EPMs included three bundled payment models for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), and surgical hip/femur fracture treatment (SHFFT) episodes.

After an Executive Order in January 2017 and then an Interim Final Rule (IFC) with a request for comment in March 2017, a final rule issued on May 19 delayed the program until January 1, 2018. CMS noted that it had 47 responses to the IFC. The comments contained therein highlighted concerns with the EPM model’s design, pricing, quality measures, episode length, inappropriateness of including surgical hip and knee fracture patients in the CJR, CR and SNF waivers and its mandatory nature.

The comments also expressed concerns about the CR incentive payment design, with a focus on the direct supervision requirements. Other comments expressed concerns about the precedence rules for model overlap with Models 2-4 for the Bundled Payments for Care Improvement (BPCI) initiative.

As a result, CMS concluded that certain aspects of the programs’ design should be improved and more fully developed prior to their initiation. Therefore it would not be in the best interests of

beneficiaries and providers to move forward. CMS stated that canceling the EPM and CR incentive payment model as well as altering the scope of the CJR model offers “CMS greater flexibility to design other episode-based payment models, while still allowing us to test and evaluate the impact of the ongoing CJR model on enhancing the quality of care while reducing costs.” CMS notes that if the rescission is finalized interested providers will have an opportunity to participate in bundling in calendar year 2018 via new voluntary bundled payment models. Apparently, CMS’ Innovation Center expects to develop new voluntary bundled payment models during CY 2018 that would be designed to meet the criteria for an Advanced APM pursuant to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). It also recognized strong evidence-based and other positive stakeholder feedback they received regarding the CR incentive payment model and, given that, may revisit the model for a new voluntary initiative.

AMRPA filed extensive comments on the proposed rule for the EPM, SHFFT, CR program, and original CJR program, which can be found on the AMRPA website, www.amrpa.org.

Summary of Episode Payment Models (EPM) Under the EPMs, the acute care hospital AMRPA Magazine October 2017

in which a Medicare fee-for-service (FFS) beneficiary is admitted for care for a heart attack, bypass surgery or surgical hip/ femur fracture treatment is accountable for the cost and quality of care provided during the inpatient stay and for 90 days after discharge. Specifically, participant hospitals would be paid a fixed target price for each care episode, with hospitals that deliver higher-quality care receiving a higher target price. Beneficiaries in the AMI and CABG models generally have chronic cardiovascular disease, which likely contributed to the acute events or procedures that initiate the episodes.

Acute care hospitals in BPCI Models 2 and 4 for the hip and femur procedures (except major joint) or for all three of the BPCI cardiac episodes (AMI, PCI and CABG) are exempt from participating in the EPMs. A. Episode Pricing and Timeline CMS would set target prices every year for the models based on historical data on total costs related to the episode of care for FFS beneficiaries admitted for heart attacks, bypass surgery or SHFFT, beginning with the hospitalization and extending 90 days following discharge.

Target prices would be adjusted based on the complexity of treating a heart attack or providing bypass surgery. As in the CJR model, hospitals’ risk would phasedin over the five years of the model, with no downside losses (repayment to CMS) required in the first year.

•

Use a patient satisfaction and experience measure that covers all potential post-acute care settings to which the patient may be discharged. Short of that, CMS should include patients discharged to nursing homes and SNFs in the HCAHPS Survey.

•

Work with organizations such as the American Association of Cardiovascular and Pulmonary Rehabilitation, the American College of Cardiology and the American Heart Association to identify appropriate measures that address domains such as function and functional capacity, health care-related quality of life, use of preventative medication, and depressive symptoms.

The EPM final rule also expanded the CJR program to include surgical hip and femur fracture treatment (SHFFT) episodes, except major joint (MS-DRGs 480-482).

CJR, as currently implemented, begins with • Provide information to stakeholders admission to acute care hospitals for lower ensuring that the AMI Excess extremity joint replacements Days measure is valid and (LEJR) procedures assigned tested measure for the AMI to MS-DRG 469 (Major joint patient population. replacement or reattachment Simply put, the rule proposed to • Regarding the SHFFT of lower extremity with major model, develop measures complications or comorbidities) cancel the Episode Payment Models that are more clinically or MS-DRG 470 (Major joint (EPMs) and Cardiac Rehabilitation appropriate for hip and femur replacement or reattachment (CR) Incentive payment model and fraction patients.

We did not of lower extremity without recommend applying only to rescind the regulations issued major complications or the CJR measures set to the comorbidities), including total pursuant thereto.

SHFFT patient population. and partial hip replacement in the setting of hip fracture.

C. Participants in the Models Based on analysis of historical The AMI and CABG models would have episodes beginning in CY 2012-2014, B. Quality Measurement and Pay-forbeen implemented in 98 geographic CMS found that there would have Performance areas, defined by metropolitan statistical been approximately 109,000 qualifying Under the EPMs, only hospitals that meet areas (MSAs). Eligible MSAs must have SHFFT historical episodes. Medicare quality standards would be paid the had at least 75 AMI Model eligible cases expenditures associated with these savings from providing care for less than among other criteria. Because the SHFFT episodes total $4.7 billion. However, in the quality-adjusted target price. Similar to model builds upon the existing CJR contrast to LEJR episodes in the current CJR, CMS adopts a pay-for-performance program, the SHFFT model would be CJR model, which are mostly elective and methodology for EPMs that relies upon tested in the 67 CJR MSAs in which the during which hospital readmissions are a composite quality score to assign CJR model is underway. Approximately rare, the EPM SHFFT episodes have very respective EPM participants to four quality 1,120 hospitals would participate in the different patterns of care. Beneficiaries categories. These quality categories will AMI and CABG models and 860 hospitals undergoing these procedures commonly determine an EPM hospital’s eligibility in the SHFFT Model. Rural counties are have chronic conditions that contribute for a reconciliation payment as well as excluded from the models. to the initiation of the episodes and the effective discount percentage at need both planned and unplanned care reconciliation. As set forth in the CJR D. Waivers throughout the EPM episode following program below, AMRPA was concerned CMS adopted its proposal to waive the discharge from the initial hospitalization. with the quality measures in the programs. home health “incident-to” requirement The focus of all three programs is an acute With respect to the EPM and CR program, for the AMI, CABG and SHFFT EPMs. care hospital only as the bundle holders we recommended that CMS: This waiver, also active in CJR, allows a or CR participants. AMRPA advocated • Include a minimum of one functional beneficiary who does not qualify for home for recognition of inpatient rehabilitation outcome measure for reach of the health services under standard Medicare hospitals as well.

AMI, CABG, and SHFFT models. requirements to receive post-discharge 13

visits in his/her home any time during their EPM episode. For the AMI program only, CMS adopted its proposal to waive the skilled nursing facility (SNF) 3-Day rule requirement only on the condition that the SNF has been rated three stars or higher on the Five Star Rating Program for seven of the last 12 months. This requirement would also parallel CJR. CMS also waived certain geographic site requirements for telehealth services.

E. Alternative Payment Models under MACRA The EPM final rule also established new pathways for physicians who participate in certain bundled payment models to qualify in Quality Payment Program (QPP), implemented under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. MACRA introduced financial incentives for physicians participating in Advanced Alternative Payment Models (Advanced APMs). For the new EPMs, clinicians may potentially earn the QPP incentive payment beginning in performance year 2019 or potentially as early as performance year 2018 if they collaborate with participant hospitals that choose the Advanced APM path. For the CJR model, clinicians may potentially earn the incentive payment beginning in performance year 2017. The EPM rule also creates opportunities in the new Medicare ACO Track 1+ so that, under that model, clinicians may potentially earn the incentive payment beginning in performance year 2018.

Summary of Cardiac Rehabilitation Incentive Program In promoting incentives for CR, and in the original rule proposing it, CMS noted that CR programs are very successful but enormously underutilized and pointed to medical literature showing that CR and intensive cardiac rehabilitation (ICR) services are capable of achieving significant improvements in long-term patient outcomes. Research estimates that only about 35 percent of AMI patients receive CR or ICR. In the EPM final rule CMS stated, “This pattern is virtually unchanged over the past two decades, despite clinical practice guidelines for CR that were published in 1995 and subsequently endorsed by a number of professional associations and CMS.”

14

The CR program is limited to a maximum of two one-hour sessions per day for up to 36 sessions over up to 36 weeks, with an option to extend. ICR programs would be limited to 72 one-hour sessions, up to six sessions per day, over a period of up to 18 weeks. CR participants would receive an incentive payment of $25 for the first 11 services provided and $175 for subsequent services. The CR/ICR services qualifying for incentive payments are identified by the HCPCS codes for CR/ICR services in the CR performance year, when those CR/ICR services are paid under the OPPS or to any supplier reporting place of service code 11 on a PFS claim.

Under the AMI/CABG EPM, the hospital where the initial hospitalization for AMI or CABG treatment occurs would be financially accountable for the entire AMI or CABG episode. Under the CR incentive payment model, CMS would provide a CR/ICR incentive payment to selected hospitals with financial responsibility for AMI or CABG model episodes (hereinafter EPM-CR participants) because they are already engaged in managing the AMI or CABG model beneficiary’s overall care for a period of time following hospital discharge. Similarly, CMS would provide CR incentive payments to hospitals under the traditional Medicare FFS program.

That is, CMS will provide a CR incentive payment specifically to selected non-EPM hospitals (hereinafter FFS-CR participants).

Approximately 1,320 hospitals total would participate in the CR Incentive Payment Model.

Focusing on the two types of hospitals (FFS and non-EPM) would allow CMS to test the effects of the CR incentive payments, as well as identify potential interactions between the proposed CR incentive payment and the underlying EPM and FFS payment methods. There may be providers and suppliers other than hospitals caring for beneficiaries with AMI or CABG whose care is paid under the Medicare FFS program and that could assume responsibility for encouraging greater utilization of CR/ICR services under the CR incentive payment model.

However, for purposes of comparability with the EPM and non-EPM participating hospitals, CMS believed that hospitals are the appropriate entity to take on care coordination responsibility for increasing

the utilization of medically necessary CR/ICR services for those beneficiaries following AMI or CABG who are in the CR incentive payment model but that are not in an EPM. However, the focus is on acute care hospitals and did not reach out to inpatient rehabilitation hospitals with cardiac rehabilitation programs, which AMRPA noted in its comments on the original rule proposing the CR Incentive program.

Both the EPM-CR and FFS-CR participants are allowed to offer beneficiary engagement incentives, with certain limitations. Finally, the CR Incentive Payment Program also would provide a waiver of the definition of a physician to include a physician or non-physician practitioner in performing specific physician functions. Specifically, these functions include prescribing exercise, and establishing, reviewing and signing an individualized treatment plan every 30 days. For the purposes of the waiver non-physician practitioner is defined as a physician assistant, nurse practitioner or clinical nurse specialist.

Proposed Changes to the CJR Program The CJR model originally became effective on April 1, 2016, and mandated that hospitals in 67 specified metropolitan statistical areas (MSAs) must participate in an episode-based payment program for hip and knee joint replacements. The CJR payment is similar to that for the EPM with a target price, a timeline and various quality measures. The proposed rule, which would be effective February 1, 2018, reduces the mandatory participation in the CJR essentially by one half to 34 MSAs. Hospitals in the other 33 MSAs would no longer be required to participate in the CJR model, but may elect voluntarily to participate in that program by notifying CMS by January 31, 2018. In addition, within the 34 MSAs for which participation is mandatory, identified low volume or rural hospitals also would no longer be required to participate but they may elect to do so voluntarily.

A. Proposed Voluntary Participation Election (Opt-In) for Certain MSAs And Low-Volume And Rural Hospitals CMS is proposing to revise the CJR model to allow it to continue to evaluate AMRPA Magazine October 2017

the effects of the model while limiting the geographic reach of the current mandatory models. Specifically, CMS proposes that the CJR model would be: 1. Mandatory in approximately half of the selected geographic areas) that have the highest historic LEJR episode payments (34 of the 67 selected MSAs); and 2. Voluntary participation for hospitals in the remaining 33 MSAs, and for hospitals that are rural and lowvolume in any of the 67 MSAs. o These hospitals have a one-time opportunity to actively opt-in to continued CJR participation for performance years 3-5 by January 31, 2018, and this election would apply prospectively beginning February 1, 2018. Otherwise, CMS will be automatically withdrawn the hospitals from CJR effective February 1, 2018. o Low-volume hospitals are identified

by CMS as having fewer than 20 LEJR episodes in total across the three historical years of data used to calculate the performance year 1 CJR episode target prices.

Lists of the mandatory and voluntary MSAs are included at the end the article.

CMS states that maintaining mandatory participation for half of the CJR model across a wide range of providers will continue to allow evaluate program savings. If it allowed voluntary participation in all of the 67 selected MSAs, the overall estimated model impact would no longer show savings, and would likely result in additional costs to the Medicare program. CMS estimates that the CJR model changes it proposes will reduce the previously projected CJR model savings by approximately $90 million. Therefore, the total CJR model impact after the changes in this proposed rule will save the Medicare program $204 million, instead of $294 million, over the remaining threeyear performance period (2018 through 2020) of the CJR model.

The CJR model began on April 1, 2016, and is currently in the second performance year (with episodes ending on or after January 1, 2017, and on or before December 31,

2017). The third performance year, which includes all CJR episodes ending in calendar year 2018. The fifth performance year is CY 2020 and the CJR program would end on December 31, 2020.

In our 2015 comments on the CJR model proposed rule, AMRPA outlined concerns about CMS having the legal authority to implement the CJR program and recommended that the program be made voluntary, and also allow IRFs to opt-in.

This letter is also on the AMRPA website, www.amrpa.org.

CMS also proposes that non-rural or non-low-volume hospitals in the 34 mandatory participation MSAs would be required to participate in the CJR model for performance years 3, 4 and 5 even if they subsequently become a rural hospital. Similarly, CMS proposes that any rural hospital that opts-in during the one-time elective period would be required to continue participating in the CJR model even if that hospital no longer meets the definition of rural hospital. CMS states that these policies would allow it to accurately identify the hospitals that would participate in the model for the remainder of performance year 3 and performance years 4 and 5 and minimize confusion about which hospitals are CJR model participants moving forward.

In addition, CMS proposes that any hospital with a new CMS Certification Number (CCN) that comes into existence after the proposed voluntary participation election period would not be required and/ or eligible to join the CJR model. These new hospitals would not be applicable in the case of a reorganization event where the remaining entity is a hospital with a CCN that was participating in the CJR model prior to the reorganization event.

Consistent with its current policy, such hospital would continue participation in the CJR model regardless of whether all predecessor hospitals were participant hospitals prior to the reorganization event.

B. Proposed Adjustment to the Pricing Calculation for the CJR Telehealth HCPCS Codes To Include the Facility PE Values In the CJR final rule, CMS established nine HCPCS G-codes for providers to report home telehealth evaluate and management (E/M) visits furnished under

the CJR telehealth waiver. In finalizing this pricing method for these codes, CMS did not include the practice expense (PE) RVUs of the comparable office and other outpatient E/M visit codes in the payment rate for these unique CJR model services, believing that practice expenses incurred to furnish these services are marginal or are paid for through other MPFS services.

However, since the publication of the CJR model final rule, stakeholders have expressed concern that the zero value assigned to the PE RVUs for these codes have underpriced these services, as there additional costs related to the delivery of telehealth services such as maintaining the telecommunications equipment, software and security, etc.

To address these concerns, CMS believes an alternative to assigning zero PE RVUs would be to use the facility PE RVUs for the analogous in-person services. Thus, CMS proposes to use the facility PE RVUs for the analogous services in pricing the nine CJR HCPCS G codes.

C. Proposed Clinician Engagement List for Eligibility in the Quality Payment Program CMS is proposing an approach that would broaden the scope of eligible clinicians for whom it would make a Qualifying Practitioner (QP) determination based on services furnished through the Advanced APM tracks of the CJR model. Pursuant to MACRA, clinicians that are QPs under qualified Advanced APMs do not need to report MIPS measures in order to participate in the Quality Payment Program.

Specifically, CMS proposes to create a “clinician engagement list” that would include those physicians, non-physician practitioners, and therapists without a financial arrangement under the CJR model, but who are either directly employed by or contractually engaged with a participant hospital to perform clinical work for the participant hospital when that clinical work, at least in part, supports the cost and quality goals of the CJR model. The new clinician engagement list would function similarly to the existing “clinician financial arrangement list” (which includes only those clinicians with a contractual arrangement with CJR participant hospitals) in that it would be 15

Table 1—Proposed CJR Mandatory Participation MSAs MSA

MSA name

Wage-adjusted episode payments (in $)

10420

Akron, OH

$28,081

11700

Asheville, NC

27,617

12420

Austin-Round Rock, TX

28,960

13140

Beaumont-Port Arthur, TX

MSA

MSA name

Wage-adjusted episode payments (in $)

14500

Boulder, CO

24,115

15380

Buffalo-Cheektowaga-Niagara Falls, NY

26,037

32,544

16020

Cape Girardeau, MO-IL

24,564

Carson City, NV

26,128

17140

Cincinnati, OH-KY-IN

28,074

16180

18580

Corpus Christi, TX

30,700

16740

26,736

20020

Dothan, AL

30,710

Charlotte-Concord-Gastonia, NC-SC

22500

Florence, SC

27,901

17860

Columbia, MO

25,558

23540

Gainesville, FL

29,370

19500

Decatur, IL

24,846

24780

Greenville, NC

27,446

19740

Denver-Aurora-Lakewood, CO

26,119

25420

Harrisburg-Carlisle, PA

28,360

20500

Durham-Chapel Hill, NC

25,151

26300

Hot Springs, AR

29,621

28660

Killeen-Temple, TX

27,355

31080

Los Angeles-Long BeachAnaheim, CA

28,219

31180

Lubbock, TX

29,524

32820

Memphis, TN-MS-AR

28,916

33100

Miami-Fort Lauderdale-West Palm Beach, FL

33,072

33740

Monroe, LA

30,431

33860

Montgomery, AL

30,817

35300

New Haven-Milford, CT

27,529

35380

New Orleans-Metairie, LA

29,562

35620

New York-Newark-Jersey City, NY-NJ-PA

31,076

36420

Oklahoma City, OK

27,267

36740

Orlando-Kissimmee-Sanford, FL

29,259

37860

Pensacola-Ferry Pass-Brent, FL

38300

22420

Flint, MI

24,807

23580

Gainesville, GA

23,009

26900

Indianapolis-Carmel-Anderson, IN

25,841

28140

Kansas City, MO-KS

27,261

30700

Lincoln, NE

27,173

31540

Madison, WI

24,442

33340

Milwaukee-Waukesha-West Allis, WI

25,698

33700

Modesto, CA

24,819

34940

Naples-Immokalee-Marco Island, FL

27,120

34980

Nashville-DavidsonMurfreesboro-Franklin, TN

26,880

35980

Norwich-New London, CT

25,780

36260

Ogden-Clearfield, UT

25,472

29,485

38900

Portland-Vancouver-Hillsboro, OR-WA

22,604

Pittsburgh, PA

30,886

40980

Saginaw, MI

25,488

38940

Port St. Lucie, FL

30,423

41180

St. Louis, MO-IL

26,425

39340

Provo-Orem, UT

28,852

39740

Reading, PA

28,679

41860

San Francisco-OaklandHayward, CA

23,716

42680

Sebastian-Vero Beach, FL

28,015

42660

Seattle-Tacoma-Bellevue, WA

23,669

45300

Tampa-St. PetersburgClearwater, FL

32,424

45780

Toledo, OH

46220

43780

South Bend-Mishawaka, IN-MI

23,143

44420

Staunton-Waynesboro, VA

25,539

28,658

45820

Topeka, KS

24,273

Tuscaloosa, AL

31,789

48620

Wichita, KS

25,945

46340

Tyler, TX

30,955

10740

Albuquerque, NM

$25,892

12020

Athens-Clarke County, GA

25,394

13900

Bismarck, ND

22,479

16

For a list of low-volume hospitals located in the mandatory MSAs eligible to opt-in during voluntary election period, please see Table 3 in the proposed rule (page 39315 of the Federal Register).

AMRPA Magazine October 2017

recognized as an Affiliated Practitioner List. CMS uses the Affiliated Practitioner List to identify those clinicians who could qualify for Advanced APM participation.

The physicians, non-physician practitioners, or therapists included on the CJR model Affiliated Practitioner List as of March 31, June 30, or August 31 of a QP performance period would be assessed to determine their QP status for the year. CMS uses this list to determine whether clinicians meet the payment amount or patient count thresholds to be considered QPs (or Partial QPs) for a year by evaluating whether individual clinicians on an Affiliated Practitioner List have sufficient payments or patients flowing through the Advanced APM. To identify clinicians for inclusion on the proposed clinician engagement list, CMS proposes that each participant hospital in the Advanced APM track of the CJR model submit a clinician engagement list to CMS on a no more than quarterly basis.

Further, if there are no individuals that meet the requirements to be reported on a clinician engagement list, the participant hospital must actively attest in a form and manner required by CMS that there are no individuals to report.

D. Incentivizing Participation In The CJR Model In order to keep hospitals in all MSAs selected for participation in the CJR model actively participating in the model, CMS is soliciting comment on ways to further incentivize eligible hospitals to elect to continue participating in the CJR model for the remaining years of the model and to further incentivize all participant hospitals to advance care improvements, innovation, and quality for beneficiaries throughout LEJR episodes. CMS is soliciting comment on this requirement and any alternative gainsharing caps that may be appropriate to apply to physicians, non-physician practitioners, physician group practice (PGPs), and non-physician PGPs.

E. Other Proposals and Clarifications 1. Proposed Codification of CJR ModelRelated Evaluation Participation Requirements CMS proposes to add provisions in § 510.410(b)(1)(i)(G) to specify that CMS may take remedial action if a participant hospital, or one of its collaborator, collaboration agent, or downstream collaboration agent fails to participate in model-related evaluation activities conducted

by CMS and/or its contractors for any performance year in which the hospital participates. CMS believes the addition of this provision would make participation and collaboration for the CJR model evaluation clear to all participant hospitals and in particular to hospitals that are eligible to elect voluntary participation.

2. Clarification of CJR Reconciliation Following Hospital Reorganization Event CMS proposed clarification that reorganization events, or mergers, that involve a CJR model participant hospital and a hospital that is not participating in the CJR model resulting in the new organization operating under the CJR participant hospital’s CCN would not affect the reconciliation for the CJR participant hospital for episodes that start before the effective date of the reorganization event. Episodes that start after such reorganization event would be subject to an updated quality-adjusted episode target price that is based on historical episodes for the CJR participant hospital which would include historical episode expenditures for all hospitals that are integrated under the surviving CCN (these policies have already been in effect). To further clarify the policy, CMS proposed adding a provision specifying that separate reconciliation calculations are performed for episodes that occur before and after

a reorganization that results in a hospital with a new CCN. F. Quality-Related Issues in the CJR Program In the rule, CMS does not propose changes to any quality elements of the CJR program, such as measures required for reporting or the evaluation time frame. AMRPA commented extensively on these issues in its letter to the original CJR proposed rule. Specifically AMRPA recommended that CMS supplement its three proposed mandatory CJR model quality measures (the complication, readmission, HCAHPS Survey measures) and adopt two additional mandatory quality measures. These additional measures would include the following, in order of their importance and the percentage weight to be attributed to each, as part of a CJR participant hospital’s quality score: •

A functional measure that assess the CJR patient’s capacity to walk in a meaningful and measurable way; and

•

A pain experience and management measure.

AMRPA has urged CMS to include patients discharged to nursing homes and SNFs in the HCAHPS survey. AMRPA also recommended that CMS use a patient satisfaction and experience measure that is better suited for LEJR patients and covers the entire episode of care. Note that a recent Narratives column in Health Affairs presented a patient caregiver’s perspective of the challenges they experienced when his mother received a hip replacement under the CJR program, particularly in post-acute care, provider and patient communications, and coordination among providers.

17

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For questions about the AMRPA PAC Market Analysis Reports or to submit a completed subscription agreement, please contact Mimi Zhang, AMRPA Policy and Research Associate, at mzhang@amrpa.org.

For more information, visit www.amrpa.org/Resources-Communication/AMRPA-PAC-Market-Analysis-Reports

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AMRPA Magazine October 2017

MEDPAC SUPPORTS MODIFYING HOSPITAL DISCHARGE RULES TO ENCOURAGE USE OF HIGHERQUALITY POST-ACUTE CARE PROVIDERS

By Mimi Zhang, Policy and Research Associate, AMRPA

O

n September 7 and 8, 2017, the Medicare Payment Advisory Commission (MedPAC) kicked off its 2018 public meeting cycle in Washington, DC. MedPAC is an independent legislative branch agency that provides Congress with analysis and policy advice on the Medicare program.

MedPAC’s public meetings throughout fall and winter culminate in its annual March Report to Congress on Medicare payment recommendations for the upcoming federal fiscal year.

Of interest to inpatient rehabilitation providers, MedPAC held a meeting session on September 7 titled, Encouraging Medicare Beneficiaries to Use Higher-quality Post-acute Care Providers, in which it examined the role that acute-care hospitals play in discharge planning and the quality of skilled nursing facilities (SNFs) and home health agencies (HHAs) used by Medicare beneficiaries. At the session’s end, MedPAC staff presented policy options to the Commissioners intended to encourage Medicare beneficiaries to use higher-quality post-acute care (PAC) providers.

The September meetings also saw the introduction of two new MedPAC Commissioners: •

David Grabowski, PhD, professor of health care policy in the Department of Health Care Policy at Harvard Medical School. His research examines the economics of aging with a particular interest in the areas of long-term care and post-acute care.

•

Dana Gelb Safran, ScD, chief performance measurement and improvement officer and senior vice president of enterprise analytics at Blue Cross Blue Shield of Massachusetts.

Highlights: •

MedPAC Staff Presentation In 2015, about 40 percent of Medicare hospital discharges resulted in use of at least one of the four PAC settings. Local markets often have multiple providers, and while many markets have multiple SNFs and HHAs, inpatient rehabilitation hospitals and units (IRFs) and long-term care hospitals (LTCHs) are concentrated in urban areas.

MedPAC also found that provider quality varies widely within a silo. For example, average SNF readmission rates differed two-fold between SNFs in the highestperforming (i.e., lowest readmission rate) quartile compared to the lowestperforming quartile. MedPAC staff reported that this variation was observed across all PAC silos.

Furthermore, beneficiary choice of PAC provider has not been influenced by quality data. Although provider-level data is publicly available on Nursing Home Compare and Home Health Compare, research on referral patterns indicate that these efforts did not shift utilization to “high performing” providers. IRF Compare and LTCH Compare were not mentioned.

The staff member summarized the shortcomings MedPAC has observed with regard to current discharge care planning processes in the Medicare

•

Fewer hospital readmissions from post-acute care would benefit the patient and the Medicare program, but Medicare beneficiaries do not always select the highest-quality SNF or HHA available to them.

MedPAC will evaluate how changes to Medicare’s discharge planning requirement rules can support acute care hospitals in guiding beneficiaries to higherquality PAC providers.

program, including: •

Acute care hospitals and health systems are limited in the means they can use to encourage the use of better PAC providers;

•

Medicare does not require the use of quality measures in discharge planning; and

•

Beneficiaries often have a better provider nearby.

Discharge Planning MedPAC interviewed hospital discharge planners to gain a better sense of the dynamics involved in discharge planning and PAC referrals. Due to Medicare’s discharge planning requirements, discharge planners have concerns about patient steering and are hesitant to recommend specific PAC providers. There is however variation in how hospitals cover PAC quality during discharge planning, as some choose to 19

be more transparent in communicating to beneficiaries those PAC providers they consider to be high-performing.

Although the Improving Medicare PostAcute Care Transformation Act (IMPACT) requires the use of quality as a factor in discharge planning, the regulation implementing that requirement has yet to be finalized. MedPAC also noted that beneficiaries often have limited or no knowledge of PAC capabilities or may not be aware of the need for PAC, and PAC availability and capacity may also affect beneficiaries’ options.

most of these reforms with the exception of CJR. In CJR, CMS has revised discharge planning requirements to permit hospitals to recommend specific PAC providers, though this is limited in scope to lower extremity joint replacements and beneficiaries still retain freedom of choice.

Analysis of SNF and HHA Quality MedPAC analyzed how often beneficiaries who used SNF or HHA in 2015 had another provider nearby (<15 miles) with “higher quality.” Quality was assessed using a composite measure that included rehospitalization rates and changes in mobility. However, MedPAC staff did not provide details on how they measured changes in mobility or from where the functional data was sourced. While other factors — provider

capacity, patient clinical needs (e.g., ventilator-dependency), and beneficiary preferences such as proximity to family — affect PAC provider selection, these were not accounted for in this analysis.

MedPAC staff concluded that most SNF and HHA users did not choose the highest quality provider available, and presented the data below.

Options Considered The staff concluded their portion of the meeting by presenting the following options to encourage higher-quality PAC use for the Commissioner’s discussion:

In recent years, hospitals have assumed greater financial risk for post-discharge A. Near-term options that modify outcomes through mandatory programs Medicare’s discharge planning such as Hospital Readmission Reduction guidance: (HRRP) and the Comprehensive Care for Joint Replacement (CJR) programs, or more voluntary initiative such as the Bundled MedPAC Table: Most SNF and HHA users had a nearby provider of higher quality Payment for Care Number of higher quality providers available within a 15-mile radius Improvement (BPCI) 0/No better 1 2 3 4 5 or Total Percent of beneficiaries Initiative or accountable with better options nearby: options more care organizations (ACOs).

Nonetheless, Medicare’s discharge planning rules remained unchanged in 20

SNF patients

14.7%

12.2%

9.8%

8.3%

8.2%

46.8%

100%

HHA patients

5.5%

5.7%

6.0%

5.9%

7.4%

69.5%

100%

• Beneficiaries in urban areas generally had more higher-quality options nearby.

• Average quality differences between selected and nearby providers were non-trivial (e.g., better SNFs had a hospital readmission rate that was about 3 percentage points lower than selected provider).

AMRPA Magazine October 2017

1. Modify discharge planning rules to allow hospitals to recommend PAC providers. This would be consistent with other efforts to hold hospitals accountable for post-discharge care.

2.

Require discharge planners to consider PAC facility quality in the development of discharge plans.

3.

Require that hospitals provide quality data to beneficiaries seeking PAC. B. Longer-term options that create financial incentives for hospitals and PAC providers: 1. Expand the Hospital Readmissions Reduction Program to apply to more conditions, which MedPAC

has previous recommended.

2. Implement PAC VBP programs.

In addition to the current SNF VBP, CMS could establish IRF and LTCH VBP programs and expand the HHA VBP. Next Steps The Commissioners were supportive of modifying Medicare’s discharge planning rules so that they are more aligned with the forces that acute care hospitals face in today’s value-based healthcare environment.

However, Commissioners were more hesitant to support expanding Medicare’s valuebased programs by developing PAC value-based purchasing (VBP) programs for inpatient rehabilitation facilities (IRFs) and long-term care hospitals

(LTCHs), or by expanding the Hospitals Readmissions Reduction Program (HRRP).

Several Commissioners highlighted underlying issues in the HRRP and the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program which they felt compromised how capably these programs represent provider quality.

MedPAC plans to include a chapter on this topic in its March 2018 Report to Congress, so AMRPA anticipates that MedPAC will meet again on this issue in the coming months.

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732.321.7790 21

CMS WARNS THAT OUTPATIENT THERAPY CODE MODIFIER REQUIREMENTS WILL BE ENFORCED

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

I

n a July MLN Matters article, the Centers for Medicare and Medicaid Services (CMS) says that in a recently conducted review it found that certain code modifiers required for claims being submitted under the Outpatient Therapy Services Benefit (OPT) were being used inconsistently and incorrectly. The errors CMS identified in the review included providers failing to include modifiers for “always therapy” codes, as well as multiple modifiers being included for the same line of service when only one modifier is permitted.

As a result, CMS has issued instructions to its Medicare Administrative Contractors (MACs) that will result in claims being returned when the modifiers are incorrectly used or improperly omitted, beginning in January 2018. CMS stated that its new instructions to MACs will result in numerous actions by the contractors, including: • MACs will return/reject claims that contain an “always therapy” procedure code, but do not also contain the appropriate discipline-specific therapy modifier of GN, GO or GP. • MACs will return/reject claims if any service line on the claim contains more than one occurrence of a GN, GO or GP therapy modifier.

• MACs who are returning/ rejecting such claims will use Group Code CO and Claim Adjustment Reason Code (CARC) 4 on the related remittance advice.

22

These new instructions pertain to the CMS requirement that certain Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes that CMS has designated as “alwaystherapy” or “sometimes therapy” must include a clinician-specific modifier when billed to Medicare under OPT. A provider submitting a claim for one of these codes must include either GN (Speech-Language Pathologist), GO (Occupational Therapist) or GP (Physical Therapist) modifier, depending on which type of clinician is providing the services. Providers may only include one clinician modifier per service.

The “always-therapy” codes must be provided by either physical therapists (PTs), occupational therapists (OTs) or speech-language pathologists (SPs), and thus a modifier is always required for these codes. When the “sometimes therapy” codes are provided by an OT, PT or SP, the modifier still must be used.

However, the “sometimes therapy” codes may be provided by clinicians other than PTs, OTs and SPs, and in those instances the modifier is not required.

The list of codes considered “always therapy” and “sometimes therapy” is updated annually and posted to CMS’ website at https://www.cms.gov/ Medicare/Billing/TherapyServices/ AnnualTherapyUpdate.html.

In addition to codes that must include one of the three code modifiers, there are some codes that are considered discipline-specific and can only be submitted using one of the modifiers.

Highlight: •

Contractors are being instructed to return claims that do not include discipline-specific code modifiers.

They are: • GN (Speech-Language Pathologist): 92521, 92522¸ 92523, 92524, 92597, 92607 • GO (Occupational Therapist): 97165, 97166, 97167, 97168 • GP (Physical Therapist): 97161, 97162, 97163, 97164 A primary purpose of these code modifiers is to track and enforce the financial limitations on outpatient therapy services under Part B of Medicare, commonly known as the “Therapy Caps.” There are currently two caps, one for physical therapy and speech-language pathology services combined, and one for occupational therapy services. Through an exceptions process, the threshold is $3,700 for each cap, after which a manual medical review of therapy claims may be triggered.

Currently, an effort is underway by AMPRA and affiliated coalition members to find a way to repeal these caps or extend the exceptions process before it expires at the end of 2017. AMRPA will provide updates to members on these efforts as they develop. *Admitted Only in Illinois. Supervision by Carolyn C. Zollar, JD, a member of the DC Bar

AMRPA Magazine October 2017

AMRPA SUBMITS COMMENTS TO CMS ON THE CY 2018 PHYSICIAN FEE SCHEDULE Editor’s Note: On September 8, 2017, AMRPA submitted formal comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed updated to the Physician Fee Schedule (PFS) for Calendar Year 2018. As part of this proposed rule, CMS also issued a Request for Information (RFI) seeking opportunities and suggestions for creating regulatory flexibilities and improvements. This article reproduces AMRPA’s comments in response to this proposed rule and RFI, in an abbreviated form.

The full comments are available for members at www.AMRPA. org.

A

Request for Information

MRPA shares the Administration’s goal of transforming the health care delivery system to streamline administrative processes to put patients back at the center of their own care.

AMRPA’s recommendations include several points that AMRPA has raised previously, including in response to other RFIs for payment systems under the Medicare Program for CY 2018. The recommendations included herein focus on two areas of particular relevance to the PFS, namely Medicare denials and appeals and the Medicare Part B outpatient therapy cap.

Appeals and Denials As CMS, the Department of Health and Human Services (HHS), and this Administration are well aware, the challenges stemming from Medicare’s broken claim review and audit system, and the resulting years-long appellate backlog, are daunting.

AMRPA applauds the Administration for taking a hard look at the shortcomings of the current audit programs and proposing additional resources to addressing the magnitude of backlogged appeals. Simply put, the aggregate burdens of the Medicare’s various audit programs have become intolerable for health care providers. According to CMS’ own data, appeals filed in 2017 will take well in excess of 1,000 days to process. Many of AMRPA’s members have been waiting three to four years for a hearing before an administrative law judge (ALJ), without access to the funds in controversy. All the while, AMRPA members report that a single appeal can cost a provider more than $7,000 in administrative and other costs. Notably, however, at the ALJ stage, many of our members are successful in getting the substantial majority of denials overturned.

While AMRPA shares CMS’ goal of combatting fraud, waste and abuse in the Medicare program, AMRPA believes reining in arbitrary documentation requirements would, over time, substantially reduce the strain that Medicare claims appeals are placing on our administrative law system, judicial system and taxpayers. In addition to reducing layers of rigid policies designed

to second-guess clinical judgment, many improvements could be made to the audit processes themselves to ease burdens on providers and patients. AMRPA recommends CMS take the following actions, at a minimum, and would welcome the opportunity to work with the agency to developing even biggerpicture solutions to a worsening problem.

1. Eliminate Technical Denials To lessen the draconian penalties imposed on IRFs for highly technical paperwork errors, and to reduce the overall burden on the administrative appeals system, CMS should eliminate technical errors as a basis for Medicare contractors to deny claims. This change would prevent claims from being denied for many of the more perfunctory reasons, such as failing to check a box on a form or documenting an action an hour late, unless they are systematic or can otherwise be shown to impact patient care.

A prohibition on technical denials would reduce the total number of claims that are appealed, as well as the rate at which such denials are overturned. It would also alleviate one of the most frustrating aspects of providing services to Medicare beneficiaries – delivering high-quality care that restores a patient’s physical and cognitive function only to be denied payment for an insignificant mistake in the paperwork.

2. Streamline the Appeals Process In order to shorten the lengthy Medicare appeals process, reduce the costs associated with pursuing appeals, and hasten the time to final resolution, CMS should consolidate the redetermination and reconsideration stages of the appeals process. At a minimum, providers should be allowed to opt out of the reconsideration before proceeding to ALJ review. Notably, Qualified Independent Contractor (QIC) reconsiderations rarely result in a different outcome than the original redetermination and are rightfully perceived as a “rubber stamp” of the initial denial. This posture is likely based on the information and circumstances that QICs are empowered to take into consideration, as well as their general orientation to the bases for denials, including technical denials and contractor errors.

3. Halt Recoupment of Claims Denied Post-Payment through the Issuance of an ALJ Decision In order to lessen the financial strain imparted by the current appeals process, and to spare CMS compounding interests costs, CMS should expand the current limitation on recoupment related to post-payment denials through the date an ALJ decision is issued. Under current law, claims that are denied and reaffirmed on redetermination must be paid back pending appeal. As noted above, however, it is not until the ALJ phase that there is a meaningful opportunity to review the medical necessity of care.

Therefore, this proposal would alleviate some of the financial 23

burden borne by providers stuck in the years-long appeals backlog by allowing them continued access to reimbursement for care already furnished. This proposal would also benefit CMS by taking some of the pressure off the ALJ backlog and reducing the amount of interest that must be paid back to providers at the conclusion of the appeals process in the case of overturned denials.

4. Create an Audit “Circuit Breaker” Medicare contractors should be barred from conducting payment reviews based solely on statistical analyses when a provider demonstrates why its caseload is at variance with the applicable regional or national analyses. In recent years, Medicare contractors have increasingly audited cases citing statistical analysis as their rationale. For example, the contractor’s letter may state that documents are requested because the provider exceeds the regional average for the particular types of cases audited. In reality, the multitude of factors that influence individualized post-acute care placement decisions are not conducive to an oversimplified audit-by-number approach.

Providers may exceed the averages stated in the letters for any number of valid reasons, which may not be apparent in simple statistical analyses. For instance, a status as a teaching hospital or certain subspecialties may result in patterns outside of the norm for otherwise comparable providers. In the end, such statistical analyses simply demonstrate variation from a mean, not improper practices. Audits on this basis alone are therefore harassing, unwarranted and add to the overall burden of a flawed recovery audit program.

5. Require Recalculation of Error Rates for Providers Under PrePayment Review Medicare Administrative Contractors (MACs) that institute ongoing pre-payment reviews against a provider should be required to recalculate providers’ error rates on a quarterly basis (and include the results of any favorable appeals in the calculation) for purposes of determining whether it is appropriate to continue pre-payment review or revise the percentage of claims to be reviewed. Since prior regulations limiting the use of recalculation were rescinded, there has been a noticeable increase in its use by the MACs with virtually no rules restricting these contractors. While pre-payment review furthers can help identify improper payments before they are made, it also creates significant administrative inefficiencies if it fails to account for appeal outcomes, continuously shuttling new denials into the appeals system.

6. Deem Appealed Claims as Payable if they Remain Pending for Five Years or More After the Initial Determination For any appeal still pending five years after the date of the initial determination on the claim, the claim should be deemed payable. By presuming that after a certain period of time a claim should be considered finally decided, this proposal is consistent with reopening regulations treatment for claims not involving allegations of fraud or similar fault. A five-year period accounts for the typical year it should ordinarily take an appeal to work through the ALJ level of appeal (at most), plus the four years permitted for reopening. But for the extensive appeal backlog, this five-year period would typically account for the maximum amount of time reimbursement for a claim could be at issue.

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Medicare Outpatient Therapy Caps While the annual financial limitations on outpatient therapy services, commonly referred to as the therapy caps, are not discussed in this proposed rule, AMRPA is concerned about the disproportionate impact this arbitrary financial limitation has on some of the most vulnerable Medicare beneficiaries, such as those with neurological conditions. The impact of the cap on these patients is compounded by the fact that unlike occupational therapy services, which has its own cap, physical therapy and speech-language pathology services are subject to the same cap. This situation is particularly problematic if a hard cap with no exceptions process is in place or if the manual medical review (MMR) process for therapy services that exceed a $3,700 threshold is not structured properly.

While we appreciate that the Medicare and Chip Reauthorization Act of 2015 (MACRA) extended the therapy cap exceptions process through December 31, 2017, AMRPA is committed to seeking full repeal of the therapy caps. Or, if full repeal cannot be achieved, we support the permanent extension of an exceptions process that balances the desire to protect the Medicare Trust Fund with preserving access to rehabilitation services for Medicare beneficiaries. Additionally, we strongly support separating physical therapy and speech language pathology services by providing each service type with its own cap.

Physician Fee Schedule Recommendations Proposed Code Value Changes for Rehabilitation Services

Physical Medicine and Rehabilitation (PM&R) Codes: 97112, 97113, 97116, 97533, 97537, 97754.

AMRPA supports the proposed update to these code values and appreciates CMS’ thorough evaluation of the Health Care Professionals Advisory Committee (HCPAC) recommendations for these codes. AMRPA also agrees with CMS’ conclusion that it should not adopt the HCPAC recommendations for practice expense (PE) value for these codes due to the Multiple Procedure Payment Reduction (MPPR) that is already applied to these codes.

Orthotics and Prosthetics Management and/or Training: 97760, 97761, 97762, 977X1.

AMRPA supports CMS’ proposal to revise the code value of 97760 and 97761, and the proposed value of newly created code 977X1. More specifically, and similar to the above codes, we agree with CMS’ proposal to adopt HCPAC’s recommended work relative value units (RVUs) for these codes, and appreciates CMS taking a thoughtful approach and not adopting the PE values recommended by HCPAC due to the MPPR. In responding to CMS’ lower, alternative proposed work RVU of .33 for 977X1, AMRPA believes this lower value is not appropriate. Many orthotics and prosthetics require increasingly complex and critical subsequent encounter adjustments based on changes in the status of a patient.

These services often require a great deal of time and expertise on the part of the therapist. In addition, some orthotic devices are dynamic in nature and need regular adjustments to ensure that the fit is correct. Orthotics and prosthetics management and training technology has evolved since the last valuation of these codes, meaning more specialized expertise is needed by a therapist.

Therefore, AMRPA encourages CMS to adopt the higher value.

AMRPA Magazine October 2017

Cognitive Function Intervention: 97X11, 97532, GXXX1 AMRPA appreciates CMS recognizing that different specialties bill 97532 at different intervals, and that replacing 97532 with once per encounter code 97X11 could lead to payment discrepancies between specialties. However, we also have concerns about CMS’ proposal to remedy this with a new G-code that would be specific to Medicare. AMRPA believes that creating this new, Medicare only code, in combination with rendering new CPT code 97X11 invalid for Medicare (while it will presumably be valid for other payors) will lead to considerable confusion. At the very least, providers would bear some burden of educating providers about this newly created G-code should CMS proceed with this proposal. Therefore, we encourage CMS to either commit to extensive outreach to the provider community should it choose to implement these codes, or explore an alternative to this approach, such as allowing for a modifier to the newly proposed code to account for billing pattern differences across specialties.

MACRA Patient Relationship Codes As AMRPA has commented in the past, we have serious concerns that the current MACRA patient relationship categories fail to account for the relationship dynamics in multidisciplinary settings commonly utilized for rehabilitation. By regulation, both IRFs and CORFs are defined by their interdisciplinary, team-based approach to the delivery of patient care. These interdisciplinary team members can include: a rehabilitation physician (physiatrist); a therapist from each discipline (Physical, Occupational, SpeechLanguage) involved in treating the patient; a registered nurse with specialized training or experience in rehabilitation; a social worker or case manager (or both); and prosthetic and orthotic practitioners.

Operationalizing these codes in settings where patient care is delivered in an interdisciplinary, multidimensional manner such as in IRFs and CORFs will be uniquely challenging. AMRPA urges CMS to address these setting-specific considerations in its ongoing work to implement patient relationship categories and codes.

Further, a hallmark of medical rehabilitation is the intensity of care delivered by clinicians who spend many hours working with their patients providing therapy in a one-on-one or a small group environment. However, these classifications fail to capture and document the intensity of clinicians’ interactions with their patients. So while the use of patient relationship codes will enable CMS to evaluate the Medicare dollars attributable to clinicians, this reporting process fails to capture the true intensity of the patient care that clinicians, especially in medical rehabilitation settings, provide.

Due to these concerns, AMRPA recommends that CMS clarify which classification category most befits therapists (physical therapists, occupational therapists, speech-language pathologists) and their respective roles in a patient’s episode of care.

Telehealth Services Expanding the use of telehealth services under Medicare may help to boost access and create efficiencies, especially when it comes to the management of chronic disease and for providing

services in urban, rural and underserved areas. Some states permit physical therapist, occupational therapist and speechlanguage pathologists, in addition to physicians, to furnish telehealth services, and they do so safely and effectively.

Therefore, AMRPA recommends that CMS establish a demonstration program to evaluate the clinical benefit of delivering limited types of therapy, such as those provided by physical therapists, occupational therapists, and speechlanguage pathologists, through the use of telehealth to Medicare beneficiaries.

Remote Patient Monitoring CMS seeks comment on whether it should make separate payments for CPT codes that describe remote patient monitoring (RPM), such as codes 99091 (Collection and interpretation of physiologic data…digitally stored and/or transmitted by the patient…) and 99090 (Analysis of clinical data stored in computers…). AMRPA thinks that utilization of remote technology is paramount in ensuring the continued progress of a patient being treated by rehabilitation clinicians. RPM technology enables clinicians to track prescribed activity levels of a patient, and these activities are some of the most powerful treatments for improving functionality and health-related quality of life, especially for those patients with chronic conditions.

The use of RPM technology allows for functional assessments by a clinician, which are an objective measurement of observable and easily-monitored patient characteristics. These functional assessments correlate to a patient’s current health status as well as help determine their future health care needs. RPM technology allows a clinician to not only monitor a patient’s current progress, but also use RPM to adjust or enhance a current course of treatment based on patient status from a distant location. Because of the significant cost accumulated by individuals with lower levels of functional status, tracking activity metrics remotely is an efficient and cost-effective method to assess rehabilitation and overall progress. Further, patient engagement and understanding of his or her functional status plays a significant role in the individual’s ability to effectively manage chronic conditions. Such monitoring also helps to prevent complications associated with bed rest or adopting a sedentary lifestyle.

To develop appropriate RVUs for the use of RPM, CMS should work with the RUC, HCPAC or other stakeholder organizations to thoroughly evaluate the value of the services provided. This evaluation should include examination of how all specialties, including rehabilitation specialists, utilize RPMs, and adjust the values accordingly.

Allowing for separate billing under these codes would be a “win-win,” because it would encourage the use of more efficient remote monitoring of patient status, while also empowering some of the most resource intensive patients to take an active role in their health and recovery. Therefore, AMRPA encourages CMS to allow for separate billing for RPM codes such as 99090 and 99091, and to undertake a thorough consultation with stakeholders to determine the value of these codes.

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Skilled Nursing Facility “Three-Day” Waiver While CMS’ proposal regarding the use of waivers by Accountable Care Organizations (ACOs) for the three-day qualifying acute care stay requirement mostly involves minor changes in administrative requirements, AMRPA has overarching concern that the use of these waivers may be an ill-informed policy. Specifically, AMRPA thinks this waiver may inappropriately increase skilled nursing facility (SNF) admissions without providing beneficiaries appropriate levels of care. AMRPA bases this opinion on research showing a disparity in various outcome measures when comparing SNF patients with those admitted to IRFs. Specifically, a large-scale two-year retrospective analysis of highly matched pairs across a spectrum of conditions of patients admitted to IRFs and SNFs for their post-acute care found significant differences in outcomes, including re-hospitalizations, days in the community, mortality and days alive.

While CMS does have mechanisms in place to track patient outcomes and resource use, many of the previously discussed outcome variations are only pronounced in periods extending beyond the first year, and CMS’ measures often capture a much shorter timeframe. Further, CMS has no way to differentiate outcomes between those admitted to a SNF following the normally required three-day acute admission, and those admitted through a waiver. This dynamic leads to a situation

where an acute care hospital, looking to drive its length of stay or resource use performance metrics to a certain level, could prematurely send a patient to a SNF using this waiver despite a more intensive setting being more appropriate, and face little in the way of negative repercussion for its outcome measures.

AMRPA favors providing regulatory flexibilities to ACOs to allow for innovative approaches to patient care. However, these flexibilities should be evidenced based, and not carry risks to patients. The use of these waivers offers little in the way of determining outcomes for those patients who received the waiver, and carries the risk of patients being pushed to SNFs to improve metrics, when the SNF level of care may not, in fact, be the most appropriate setting. Therefore, while we recognize CMS is proposing only small changes in the waiver application requirements, AMRPA nonetheless urges CMS to conduct a serious evaluation of this waiver before it considers expanding it any further. At the very least, CMS should develop means by which short and long-term patient outcomes differences can be tracked under this waiver so that its impact can be carefully evaluated.

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AMRPA Magazine October 2017

AMRPA SUBMITS COMMENTS TO CMS ON THE QUALITY PAYMENT PROGRAM Editor’s Note: On August 18, 2017, AMRPA submitted formal comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed updated to the Quality Payment Program for Calendar Year 2018. This article reproduces AMRPA’s comments in response to this proposed rule in an abbreviated form. The full comments are available for members at www.AMRPA.org.

The Quality Payment Program was created by Congress in 2015, and includes the Merit-Based Incentive Payment Program (MIPS) and Advanced Alternative Payment Models (Advanced APMs).

These replace the Sustainable Growth Formula that was previously used to adjust the Physician Fee Schedule (PFS).

A

MIPS-Eligible Providers

s AMRPA stated in response to the CY 2017 proposed rule, the MIPS program should be as inclusive as possible, and therefore available to all willing clinicians who provide services covered under Medicare Part B. Currently, the regulations define MIPS-eligible clinician as including physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. (See 42 C.F.R. § 414.1305.) This list notably does not include many specialists who provide rehabilitation services under Part B, including physical therapists, occupational therapists, speech-language pathologists and psychologists.

As CMS appreciates, these types of clinicians provide essential care to patients, often working with them more intensely than physicians.

In medical rehabilitation, for example, physical, occupational, speech and other therapists are essential to the rehabilitation process, and have an enormous impact on patient outcomes. In the final rule for CY 2017, CMS stated it would consider expanding the definition of MIPS eligible clinician for year three of the MIPS program, and also noted several commenters requesting as much flexibility and advance notice of the operational aspects of this inclusion as possible. However, in this proposed rule, CMS is mostly silent on its plans for incorporating these rehabilitation clinicians in future years, including how the current MIPS structure might be applied to non-physician therapists. We urge CMS to continue the process of expanding the list of MIPS eligible clinicians and to work with stakeholders to ensure the program is structured to best accommodate these clinicians’ specialties.

Further, while AMRPA supports expanding the definition to include additional groupings of clinicians as soon as possible, we are concerned CMS may proceed without providing adequate notice, education and training to allow for a constructive transition for these clinicians. AMRPA believes that inclusion of these clinicians through only one rulemaking cycle – where a rule would be finalized less than two months before the start of the performance period – would not provide a sufficient runway for a smooth transition. This

fact is especially true because many of the clinicians who may be added, such as rehabilitation professionals, occupy a unique space in the medical field that has nuanced but important differences from the space currently eligible clinicians occupy. Due to the aforementioned concerns, AMRPA urges CMS to begin planning now for incorporating non-physician rehabilitation clinicians in year three by providing notice and soliciting comment on its implementation plans no later than the publication of the CY 2018 final rule.

Therefore, AMRPA fully supports the inclusion of non-physician rehabilitation clinicians and other statutorily eligible clinicians in MIPS and encourages CMS to work with stakeholders to ensure the program is structured to best accommodate these clinicians’ specialties. We urge CMS to provide at least one year of notice and education before incorporating these clinicians in to the program.

Low-Volume Exclusions It is important that CMS permit exemptions for very lowvolume providers from MIPS since MIPS reporting burdens may disproportionately impact low-volume practices in ways that higher-volume providers can more easily accommodate. However, equally important is not denying a clinician the chance to be incentivized to provide more efficient, higher-quality care through MIPS performance incentives. Therefore, AMRPA supports CMS’ proposal to provide clinicians the ability to opt-in to MIPS if they meet or exceed one of the low-volume threshold determinations.

We urge the Agency to adopt the proposal.

This opt-in proposal is especially important in light of the significantly increased low-volume thresholds that CMS proposes to adopt, and AMRPA believes CMS should adopt this proposal in 2018, rather than waiting until 2019. Without the opportunity to opt-in, a high percentage of clinicians would not have the option to strive to be rewarded for higher-quality care, and without the potential for higher reimbursement, these clinicians may face financial difficulties investing in training, staff and other resources that would improve their quality of care. This would essentially serve to accelerate improvements in larger practices while leaving lower-volume clinicians behind.

Therefore, AMRPA urges CMS to adopt its proposal to allow for certain low-volume clinicians to opt-in to MIPS as soon as possible, especially in light of its newly proposed exclusion thresholds.

Facility-Based Providers AMRPA agrees with CMS that MIPS should accommodate the participation of the broadest range of clinicians, including facilitybased providers. However, AMRPA is alarmed that CMS’ proposal excludes large numbers of facility-based clinicians from exercising this option due to its narrow definition of facility-based clinician 27

and because it only allows for the use of the Hospital Value-Based Purchasing (VBP) Program for facility-based measurement.

First, CMS’ proposal to define facility-based providers as those delivering 75 percent or more of services in only general acute-care inpatient hospitals (POS 21) and emergency rooms (POS 24) does not allow for those who practice at inpatient rehabilitation facilities (IRFs), often billed as POS code 61, to participate. In its explanation for this proposal, CMS states that “a larger and more diverse group of clinicians contributes to quality in the inpatient hospital setting than in other settings in which we might begin to implement this measurement option.” (See 82 Fed. Reg. 30124.) AMRPA disagrees that there is a significant distinction between how clinicians in a general, acute care hospital contribute to their facilities when compared to a clinician in an IRF, which is also an inpatient hospital.

Second, CMS proposes a crosswalk using the Hospital VBP Program as a stand in for the MIPS facility-based measures as the only surrogate for facility-based scoring. This proposal again excludes many clinicians, including those practicing in freestanding rehabilitation hospitals, since these IRFs do not participate in the VBP. This proposal will create an unintended disparity between similar providers since clinicians practicing in one type of IRF (units within an acute hospital) will be able to use facility-based scoring, while those practicing in another type (freestanding IRFs) will not, despite providing the same services to the same types of patients.

Further, CMS stated it chose the Hospital VBP because it is a payfor-performance (rather than a pay-for-reporting) program, and because the Hospital VBP focuses on capturing “the breadth of care provided in a facility,” rather than those quality programs more narrowly tailored to certain areas. AMRPA disagrees that a program like the IRF QRP would not be as effective at capturing facility performance for purposes of MIPS facility-based scoring. While the IRF QRP is a pay-for-reporting program, CMS does not explain why a pay-for-reporting program would be less effective for these purposes. The IRF QRP captures a very wide range of measures that assess a facilities’ resource use and also, importantly, provides a clinically rich picture of the patients treated by IRF clinicians.

These quality measures, which CMS has deemed sufficiently valid to institute a public reporting of the measures via the IRF Compare website, more than meet the standard of capturing a “breadth of care” provided in an IRF. Additionally, several of the IRF QRP measures above are comparable with measures available under the Physical Medicine specialty set included in MIPS. Therefore, AMRPA urges CMS to also include POS code 61 in its definition of a facility-based provider and allow for clinicians practicing in IRFs to use the IRF QRP as their facility-based measure.

Complex Patient Bonus As previously discussed, IRFs treat patients who require both intensive rehabilitation services and close physician supervision. By regulation, not only do IRF patients require intensive rehabilitation programs and close physician supervision, 60 percent of an IRFs patients must have one of 13 specific conditions, which include stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, brain injury and neurological disorders. (See 42 28

C.F.R. § 412.29(b)(2).) These are complex patients whose treatment and resource needs far exceed those of patients with less complex conditions. Therefore, AMRPA is encouraged to see CMS is proposing ways to account for the treatment of complex patients in MIPS scoring.

In addition to recommending CMS adopt the proposal to award a complex patient bonus this year, AMRPA encourages CMS to make accounting for the complexity of patients a permanent feature of the MIPS program. As CMS states in the proposed rule, and especially in light of the fact that the cost category will begin to make up a larger portion of a clinician’s MIPS score, it is important to account for the complexity of patients. Doing so would help to ensure that clinicians are not unfairly penalized for treating patients, who through no fault of the clinician, have high costs. CMS clearly recognizes that treating complex patients can put clinicians at a disadvantage vis-à-vis their performance on cost metrics. That risk will not simply disappear in CY 2019 and beyond, and therefore AMRPA urges CMS to continue to account for this factor in future years.

Finally, although AMRPA is in favor of CMS adopting the complex patient bonus, we have concerns about the use of the Hierarchical Condition Categories (HCC). The HCC risk-adjustment model was initially developed for setting payment benchmarks for the Medicare Advantage program. Its broad application across various Medicare quality reporting programs since then perhaps pushes the appropriateness of its use beyond the original design.

Therefore, AMRPA recommends CMS adopt the patient complexity bonus for CY 2018, and encourages CMS to continue to account for patient complexity through score adjustment in future years, including developing more targeted, accurate models to use for risk-adjustment purposes.

Quality Performance Category AMRPA believes that improving and maintaining quality of care are the most important goals of the MIPS program. Accordingly, AMRPA appreciates CMS’ proposal to continue to weigh quality as 60 percent of a clinician’s score. Further, AMRPA encourages CMS to continue to use quality as the most significant portion of a clinician’s MIPS score in future years. As CMS has noted, there is significant concern among clinicians about the currently developed cost measures and how they will impact a clinician’s score. Due to these concerns, and the belief that quality should be the linchpin of a value-based system, AMRPA encourages CMS to explore ways it could continue to use quality as the largest factor in a MIPS clinician’s score, including using its current regulatory authority or seeking such authority from Congress.

Within the quality category, CMS is proposing to again require practitioners to report at least six applicable measures, including one outcome measure. AMRPA supports the idea of quality over quantity, and in that regard we appreciate that CMS is not proposing to increase the number of required measures. AMRPA believes relying on meaningful measures, such as outcome measures, rather than a myriad of less significant measures, such as process measures, will incentivize true clinical quality and not superficial process changes.

AMRPA Magazine October 2017

In addition to a strong correlation to quality outcomes, it is imperative that selected measures are relevant to a provider’s area of practice. In the area of medical rehabilitation, measures of the change in an individual’s physical and cognitive function during a post-acute care stay are key indicators of the quality of care delivered. To help develop the most relevant measures, AMRPA again encourages CMS to consult specialty medical societies when developing measure sets.

Therefore, AMRPA urges CMS to pursue ways to weigh the quality category heavily in the MIPS score calculation, minimize provider burden by focusing on fewer but more significant measures, and consult medical specialty groups to develop outcome measures for use in the MIPS score.

Cost (Resource Use) Performance Category AMRPA urges CMS to finalize its proposal to weight cost performance at zero percent for CY 2018. However, AMRPA remains very concerned about the future inclusion of cost performance in MIPS scores. AMRPA recognizes CMS’ statutory mandate to include cost performance by CY 2019, but believes much more development of appropriate measures must take place so that clinicians’ scores are not negatively impacted by factors outside of their control and so clinicians are not penalized for treating medically complex patients.

Not enough has been done to develop measures that would prevent improper stinting or cherry-picking healthier patients to influence cost scores. As an example, there is evidence that the Medicare Spending Per Beneficiary (MSPB) measure disproportionately rewards low-quality providers. (See Anup Das et al., Adding a Spending Metric to Medicare’s Value-Based Purchasing Program Rewarded Low-Quality Hospitals, 35 Health Affairs 898, 904 (May 2016).) It is very concerning to AMRPA that a measure that has been shown to deliver these types of results will serve as one-half of the cost category in MIPS. Further, the risks of improper stinting are higher in MIPS and any program where providers can pick and choose which quality measures to report. This factor is why cost measures must be adequately risk adjusted using sophisticated models, granular inter-specialty comparisons, and attribution methods that are applicable to the specialty to which it is applied.

While we appreciate CMS’ proposal to weight the cost category far less than quality in the second year of MIPS (and believe it should be so in future years of the program), we call on CMS to enhance efforts to closely monitor for such improper stinting and institute mandatory effectiveness of care measures to counterbalance incentives to stint.

Similarly, clinicians should only be responsible for costs associated with care that they have some ability to influence. Without that, clinicians have an incentive to select less resource intensive patients, which puts adequate treatment for some of the most severe, at-risk patients in jeopardy. A suggestion for better balanced cost measures is to ensure clinicians in like settings be compared to one another rather than just using inter-specialty comparisons. Comparing clinicians in like settings provides a much more accurate benchmark that does not overlook important differences in the intensity of care and patient population treated in different settings.

Therefore, AMRPA urges CMS to develop more sophisticated cost performance measures that discourage improper stinting, do not penalize clinicians for costs outside of their control, account for treatment settings and not just specialties, and take a longer term view of value.

Advancing Care Information AMRPA appreciates CMS’ continued acknowledgement that hospital-based providers have little say in the use of electronic health records (EHRs) in their facilities, and that an exemption from this category is warranted for these clinicians. CMS further expands this position in the proposed rule by extending the definition of a hospital-based clinician beyond just those who practice in inpatient hospitals (POS 21), on-campus outpatient hospital (POS 22) and emergency room (POS 23), to also include those who deliver services at off-campus-outpatient hospitals (POS 19).

Despite recognizing its authority to modify the hospital-based definition, CMS has inexplicitly left out other facility-based sites of care where reasoning for an exemption is equally valid. As previously discussed, many clinicians practice at IRFs, which is an inpatient hospital under POS code 61. A clinician who uses this POS code has as little influence over the use of EHR as clinicians at POS codes 19, 21, 22, 23. It follows that a clinician with this tantamount lack of input in this category should also not have an erroneous adjustment made to their MIPS score for factors outside of their control.

Therefore, AMRPA recommends CMS expand their definition of hospital-based clinicians to include all those clinicians who provide care in hospital-based settings, including POS code 61, and should also provide exemptions from the advancing care information category when it expands MIPS eligibility to more non-physician rehabilitation professionals.

Risk Adjustment for Social Factors AMRPA supports CMS’ efforts to adjust performance based on socioeconomic status (SES) or socio-demographic status (SDS).

AMRPA has been encouraged that CMS is committed to drawing lessons from the work undertaken by the Assistant Secretary for Planning and Evaluation (ASPE) and other academic research. It is AMRPA’s position that the need for SES adjustments is immediate and should begin as soon as feasible. A recent article by two MedPAC Commissioners underscores the need for SES adjustments across Medicare’s quality reporting programs to shield providers serving the vulnerable patient populations from unwarranted penalties. (See Herb Kuhn & David Nerenz, It’s time to add socio-demographic factors when weighing quality performance, MODERN HEALTHCARE, Feb. 6, 2016.) The need is particularly acute in the rehabilitation context, where certain conditions (e.g., neurotrauma) are disproportionately observed in lower SES patient populations. It is essential that these factors are accounted for so that a clinician’s MIPS score is agnostic of patient characteristics beyond their control.

Therefore, AMRPA encourages CMS to develop adjustors that account for SES and SDS in the MIPS program and incorporate them as soon as possible.

29

RESEARCHERS DISCOVER TREATMENT OPTION FOR PATIENTS SUFFERING FROM AGGRESSION AFTER TRAUMATIC BRAIN INJURY

A

ccording to researchers from the Indiana University (IU) School of Medicine, patients with chronic traumatic brain injury (TBI) and moderate-severe aggression experienced benefits from Amantadine, a drug originally developed in the 1960s as an antiviral medication. The findings were published in the September/October issue of the Journal of Head Trauma Rehabilitation.

traumatic brain injury, she said.

IU School of Medicine Associate Professor Dawn M. Neumann, PhD, who served as topical issue editor focusing on treatment for emotional issues after TBI, wrote in the issue preface, “Of the vast array of consequences of traumatic brain injury, emotional deficits are among the most prevalent, persistent and challenging to treat. However, they remain grossly understudied compared to other impairments, especially with respect to interventions. As emotional functioning is integral to well-being and quality of

drugs, Dr. Gillespie was prescribed Amantadine. “The effects were immediate and just amazing,” Dr. Gillespie said. “It calms down part of your brain and gives you a moment to pause and reflect.”

Dr. Gillespie, who works with brain injury patients as part of her role at IU, said she has seen it work in other patients as well.

“It helps you reclaim your identity a bit,” she said. “And to get that back helps you get your quality of life back too.”

TBI patients commonly experience the Dr. Hammond said traumatic brain emotional and behavioral symptoms of injuries are very common and can happen aggression and anger that often suddenly to people of all ages and result in poorer rehabilitation demographics. It’s estimated outcomes and negatively that someone in the United affect their relationships with States suffers from a TBI once family and friends, their ability every 15 minutes. Dr. Hammond Of the vast array of consequences to live at home and maintain highlighted the importance of of traumatic brain injury, emotional steady employment. the study as it expands treatment options for brain injury patients deficits are among the most The research team, led with aggression, which can have prevalent, persistent, and devastating effects on people’s

by Flora Hammond, MD, challenging to treat. lives and ability to function. chair of the IU School of Medicine Department of Physical Medicine and Dawn M. Neumann, PhD The research was supported Rehabilitation and Covalt IU School of Medicine by the U.S. Department of Professor of Physical Education, Office of Special Medicine and Rehabilitation, Education and Rehabilitative life, it is our obligation as rehabilitation found that in multiple studies of patients Services, National Institute on Disability, researchers and clinicians to endeavor to with chronic TBI and moderate-severe Independent Living, and Rehabilitation narrow this gap.” aggression, taking 100 miligrams of the Research grant H133A080035. drug Amantadine twice daily experienced First Hand Patient Experience benefits in decreasing aggression, from For the study abstract, please see http:// One of Dr. Hammond’s patients and the patient’s perspective. Dr. Hammond journals.lww.com/headtraumarehab/ colleague, Elena Gillespie, PhD, an said scientists initially realized the potential Abstract/2017/09000/Potential_Impact_ adjunct assistant research professor at IU for Amantadine to help patients with brain of_Amantadine_on_Aggression_in.4.aspx School of Medicine, suffered from a mild injuries because people with Parkinson’s brain injury after a bicycle accident. Dr. disease, a disorder of the central nervous For the preface referenced above please Gillespie said at first she didn’t recognize system, showed cognitive improvements see Treatments for Emotional Issues After her own symptoms – feeling irritable and while taking the drug to prevent viruses Traumatic Brain Injury, Section Editor(s): exhausted all of the time – until another such as the flu. Amantadine is no longer Neumann, Dawn PhD, Journal of Head colleague suggested she might have a widely used as an antiviral medication, Trauma Rehabilitation: September/ brain injury. Upon seeing Dr. Hammond, but it is still used to help people with October 2017 - Volume 32 - Issue 5 - p she discovered that she had a concussion Parkinson’s disease, and—now—those 283–285. and mild brain injury. After trying other who experience aggression due to 30

AMRPA Magazine October 2017

31

OIG EARLY ALERT: NURSING HOME ABUSE CONTINUES TO GO UNREPORTED

By Lovelyn M. Robinson, Research and Editorial Assistant, AMRPA

A

s part of its ongoing efforts to detect and combat elder abuse, the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) issued preliminary results of its ongoing review of potential abuse or neglect of Medicare beneficiaries in skilled nursing facilities (SNFs), and recommends that the Centers for Medicare and Medicaid Services (CMS) take “immediate action” to address the underreporting of physical and sexual abuse at nursing homes.

In the report titled, “Early Alert: The Centers for Medicare & Medicaid Services Has Inadequate Procedures To Ensure That Incidents of Potential Abuse or Neglect at Skilled Nursing Facilities Are Identified and Reported in Accordance With Applicable Requirements,” the OIG identified 134 cases across 33 states in which hospital emergency department records “indicated possible sexual or physical abuse, or neglect, of nursing home residents” from 2015 through 2016.

The OIG also found that a “significant percentage” of these incidents may not have been reported by hospital medical staff to law enforcement.

The OIG released the report to alert the CMS of these findings, citing the Government Auditing Standard, which states that “early communication to those charged with governance or management may be important because of their relative significance and the urgency for corrective followup action.”

Methods The OIG sought to: 32

•

Identify incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs

•

Determine whether these incidents were reported and investigated in accordance with applicable requirements

The OIG requested and reviewed emergency room records for 134

Medicare beneficiaries who were admitted with any of the 12 primary diagnoses codes that explicitly indicate potential abuse or neglect. The OIG reviewed the hospital inpatient record if the hospital admitted the Medicare beneficiary for further treatment of their injuries. The OIG also reviewed Survey Agency reports in CMS’s ASPEN Complaint/Incident Tracking System

Responsibilities for Reporting and Investigating Incidents of Potential Abuse or Neglect There are various mechanisms that incidents of potential abuse or neglect may be reported to appropriate law enforcement and regulatory authorities: Section 1150B of the Social Security Act

Requires “covered individuals” – owners, operators, employees, managers, agents or contractors – in federally funded long-term care (LTC) facilities to immediately report any suspicion of a crime committed against a resident of that facility. Those reports must be submitted to at least one law enforcement agency (with jurisdiction where the facility is located) and the Survey Agency. Covered individuals who fail to report under section 1150B are subject to various penalties, including civil monetary penalties of up to $300,000 and possible exclusion from participating in any Federal health care program.

Skilled Nursing Facilities (SNFs)

SNFs must ensure that all alleged violations, such as mistreatment, neglect or abuse (including injuries of unknown source) and misappropriation of resident property, are reported immediately to the administrator of the facility and to other officials, including the Survey Agency, in accordance with State law through established procedures (42 CFR § 483.13). SNFs must also investigate these allegations and report results within five days to the administrator of the facility and to other officials, including the Survey Agency, and if the alleged violation is verified, appropriate corrective action must be taken.

Medicaid Fraud Control Units (MFCUs)

MFCUs operate in 49 States and the District of Columbia and investigates and prosecutes a variety of health care-related crimes, including patient abuse or neglect in health care facilities.

CMS and the Survey Agencies

CMS is responsible for maintaining oversight of compliance with Medicare health and safety standards by health care providers. Survey Agencies conduct investigations to determine how well health care providers, including SNFs, comply with their applicable CoPs, including the reporting of potential abuse or neglect. When the Survey Agency or CMS Regional Office (RO) substantiates a finding of abuse, the Survey Agency or RO must report to law enforcement and, if appropriate, the MFCUs. AMRPA Magazine October 2017

(ACTS) for each SNF covering the period when the incident of potential abuse or neglect occurred. It also reviewed the Medicare exclusion database and interviewed CMS officials to determine whether HHS had implemented any civil monetary penalties or excluded

any providers from Federal health care programs due to the incidents.

may have been the result of potential abuse or neglect that occurred from January 1, 2015, through December 31, 2016.

The OIG found that, although the circumstances surrounding each of these incidents varied, 100 of the

OIGâ&#x20AC;&#x2122;s Findings â&#x20AC;˘

The OIG identified 134 Medicare beneficiaries whose injuries

Table 1: Primary Diagnosis of Potential Abuse or Neglect Diagnosis Code Description

Total Beneficiary Count

Beneficiaries Treated in the Emergency

Beneficiaries Admitted to the Hospital

V715

Observation following alleged rape or seduction

48

48

0

Z0441

Encounter for examination and observation following alleged adult rape

32

32

0

Adult sexual abuse, suspected, initial encounter

28

26

2

99583

Adult sexual abuse

11

10

1

99581

Adult physical abuse

6

6

0

T7611XA

Adult physical abuse, suspected, initial encounter

2

2

0

T7421XA

Adult sexual abuse, confirmed, initial encounter

2

2

0

T7401XA

Adult neglect or abandonment, confirmed, initial encounter

1

1

0

T7411XA

Adult physical abuse, confirmed, initial encounter

1

1

0

99585

Other adult abuse and neglect

1

1

0

99580

Adult maltreatment, unspecified

1

0

1

29530

Sexual sadism

1

0

1

134

129

5

Diagnosis Code

T7621XA

TOTAL

33

134 cases (74 percent) contained indications (victim or witness statements and photographs) that the beneficiaries’ injuries may have been caused by potential abuse or neglect at the SNFs. For 34 of the 134 cases (26 percent), OIG was not able to determine whether potential abuse or neglect existed without further investigation, which was outside its scope of the audit.

The OIG referred all 134 incidents to appropriate law enforcement officials and sent CMS a list of these incidents separately. A breakout of the cases by diagnosis code is provided below in Table 1 and by state in Table 2.

Table 2: Incidents of Potential Abuse or Neglect in SNFs During 2015 and 2016 State

Number of Incidents

Illinois

17

Michigan

13

Texas

9

California

8

New York

7

Ohio

7

Florida

6

Kentucky

5

Pennsylvania

5

Washington

5

Indiana

4

North Carolina

4

Tennessee

4

Virginia

4

Wisconsin

4

Arkansas

3

Iowa

3

Louisiana

3

Minnesota

3

Alabama

2

Georgia

2

Massachusetts

2

Nevada

2

Oklahoma

2

West Virginia

2

Connecticut

1

Maryland

1

Mississippi

1

Montana

1

New Jersey

1

New Mexico

1

Oregon

1

Utah

1

TOTAL

•

OIG Calls for Immediate Action by CMS The OIG concluded that these preliminary results, in combination with some of its prior work on SNFs, raise significant concerns that incidents of potential abuse or neglect at SNFs have gone unreported. Detecting and combatting elder abuse requires covered entities, SNFs, Medicare Fraud Control Units (MFCUs), Survey Agencies and CMS to meet their responsibilities.

OIG’s preliminary results combined prior report results raise significant concerns that incidents of potential abuse or neglect in SNFs have gone unreported.

134 incidents (72 percent) were reported to local law enforcement.

However, the OIG found no evidence in the hospital records that the remaining 38 incidents (28 percent) were reported to local law enforcement despite state mandatory reporting laws requiring the hospitals’ medical staff to do so. Survey Agencies substantiated only seven of the 134 total incidents in their survey reports.

134 •

34

Many of the incidents of potential abuse or neglect that identified may not have been reported to law enforcement. According to the records reviewed, 96 of the

room services with claims for reimbursement of SNF services to identify instances of potential abuse or neglect. It also found that CMS had not taken any enforcement actions or used the penalties under its purview to ensure SNF employees report incidents of potential abuse or neglect.

CMS procedures are not adequate to ensure that incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs are identified and reported.

The OIG discovered that CMS does not match Medicare claims for reimbursement of emergency

The OIG suggests that CMS take the following immediate actions to ensure that incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs are identified and reported: •

Implement procedures to compare Medicare claims for emergency room treatment with claims for SNF services to identify incidents of potential abuse or neglect of Medicare beneficiaries residing in SNFs and periodically provide the details of this analysis to the Survey Agencies for further review

•

Continue to work with the HHS Office of the Secretary to receive the delegation of authority to impose the civil monetary penalties and exclusion provisions AMRPA Magazine October 2017

Report Title

Issuer

Report Number

Date Issued

Massachusetts Did Not Comply with Federal and State Requirements for Critical Incidents Involving Developmentally Disabled Medicaid Beneficiaries

OIG

A-01-14-00008

7/2016

Connecticut Did Not Comply with Federal and State Requirements for Critical Incidents Involving Developmentally Disabled Medicaid Beneficiaries

OIG

A-01-14-00002

5/2016

Nursing Facilities’ Compliance with Federal Regulations for Reporting Allegations of Abuse or Neglect

OIG

OEI-07-13-00010

8/2014

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries

OIG

OEI-06-11-00370

2/2014

Criminal Convictions for Nurse Aides With Substantiated Findings of Abuse, Neglect and Misappropriation

OIG

OEI-07-10-00422

10/2012

Unidentified and Unreported Federal Deficiencies in California’s Complaint Surveys of Nursing Homes Participating in the Medicare and Medicaid Programs

OIG

A-09-09-00114

9/2011

Nursing Facilities’ Employment of Individuals With Criminal Convictions

OIG

OEI-07-09-00110

3/2011

Nursing Homes: Some Improvement Seen in Understatement of Serious Deficiencies, but Implications for the Longer-Term Trend Are Unclear

GAO

GAO-10-434R

4/2010

Nursing Homes: Federal Monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weaknesses

GAO

GAO-08-517

5/2008

Nursing Homes: More Can Be Done to Protect Residents from Abuse

GAO

GAO-02-312

3/2002

of section 1150B of the Social Security Act •

After receiving the delegation of authority, CMS should: –– Promulgate appropriate regulations, if CMS determines it is necessary, to impose penalties under section 1150B –– Enforce section 1150B, including imposing penalties for violations –– Ensure that the State Operations Manual (SOM) is updated as planned with an effective date of November 28, 2017, to include references to section 1150B, including its penalty provisions –– Notify Survey Agencies when the SOM is updated to include references to section 1150B and direct them to refer suspected violations of section 1150B to CMS for appropriate action

OIG plans to make formal recommendations to CMS when the audit is complete as its findings are preliminary at this time. It will issue a draft report at the conclusion of the audit and include CMS’s comments and

actions taken in response to the Early Alert. The OIG has a 60-day comment period for accepting comments or questions about this Early Alert (A-0117-00504).

Related Reports The OIG has issued numerous reports detailing problems with the quality of care and the reporting and investigation of potential abuse or neglect at group homes, nursing homes and SNFs. For example, OIG’s recent audit reports on critical incident reporting at group homes showed that group home providers did not report up to 15 percent of critical incidents to the appropriate state agencies.

Furthermore, OIG’s study of adverse events in SNFs found that an estimated 22 percent of Medicare beneficiaries experienced adverse events (infections, pressure ulcers, and medicationinduced bleeding) during their SNF stays. Medical record review determined that 69 percent of these patient-harm events could have been prevented had the SNF provided better care. Over half of the residents harmed during their SNF stays required hospital care to treat the adverse event. OIG also has numerous ongoing or planned projects related to beneficiary health and safety and looks forward to sharing our results

with CMS and the public as soon as they are available. The Government Accountability Office (GAO) also issued several reports on these issues.

For OIG’s Early Alert: The Centers for Medicare and Medicaid Services Has Inadequate Procedures to Ensure That Incidents of Potential Abuse or Neglect at SkilledNursing Facilities Are Identified and Reported in Accordance with Applicable Requirements (A-01-1700504), please see https://oig.hhs.gov/ oas/reports/region1/11700504.pdf

35

ROBOTIC EXOSKELETON HELPS ALLEVIATE CROUCH GAIT IN CHILDREN WITH CEREBRAL PALSY

R

esearchers from the National Institute of Health’s (NIH) Clinical Center Rehabilitation Medicine Department have created the first robotic exoskeleton specifically designed to treat crouch (or flexed-knee) gait in children with cerebral palsy by providing powered knee extension assistance at key points during the walking cycle.

Cerebral palsy is the most prevalent childhood movement disorder in the U.S. with approximately 10,000 new cases diagnosed each year. It is caused by a brain injury or abnormality in infancy or early childhood that disrupts the control of movement, posture and balance.

during walking with motorized assistance; and • Quantify short-term alterations in lower limb gait biomechanics in response to robotic knee extension assistance.

The study followed seven individuals between the ages of 5 and 19 who were diagnosed with crouch gait from cerebral palsy and had Gross Motor Function Classification System levels I-II - each could walk at least 30 feet without use of a walking aid.

Walking with the exoskeleton was welltolerated with all participants able to walk independently without mobility

of children with crouch gait while they walked,” said Thomas Bulea, PhD, the principal investigator of the study and staff scientist in the NIH Clinical Center Department of Rehabilitation Medicine. “The improvements in their walking, along with their preserved muscle activity, make us optimistic that our approach could train a new walking pattern in these children if deployed over an extended time. This study paves the way for the exoskeleton’s use outside the clinic setting, greatly increasing the amount and intensity of gait training, which we believe is key to successful long-term outcomes in this population.”

The researchers state that this study is the first step toward the long-term goal of implementing a novel devicebased approach to treating crouch gait, and suggests that Crouch gait, the excessive powered knee exoskeletons bending of the knees while The study is the first step toward should be investigated as an walking, is a common and alternative to or in conjunction debilitating condition the long-term goal of implementing with conventional treatments. in children with cerebral a novel device-based approach to The results of this study provide palsy. Despite conventional treating crouch gait. evidence to support further treatments (including device development and larger muscle injections, surgery, controlled intervention studies physical therapy and of pediatric exoskeleton orthotics), crouch gait can aids or therapist assistance with six efficacy for gait rehabilitation in cerebral lead to a progressive degeneration of doing so in the first practice session. palsy and other disorders. the walking function, ultimately resulting Improvements in knee extension were in the loss of walking ability in roughly observed in six participants with gains half of adults with the disorder.

Citation (8-37°) similar to or greater than average The NIH Clinical Center researchers tested their prototype powered knee exoskeleton in a cohort study to: • Determine if motorized knee extension assistance safely and effectively reduced crouch gait during walking in ambulatory children with cerebral palsy; • Evaluate its effect on voluntary muscle activity to determine whether children continued to use their own muscles

36

improvements reported from invasive surgical interventions. Importantly, the gains in knee extension occurred without a reduction in knee extensor muscle activity, indicating that these participants worked with the exoskeleton rather than offloading the task of straightening the leg during walking to the robot.

Zachary F. Lerner, PhD, Diane L. Damiano, PhD, Thomas C. Bulea. PhD Lower extremity exoskeleton improves knee extension in children with crouch gait from cerebral palsy, Science Translational Medicine 2017.

“Most wearable exoskeletons have been designed for adults with paralysis, with the exoskeleton replacing the lost function of the user’s. We sought to create a device that could safely and effectively improve the posture AMRPA Magazine October 2017

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37

DISASTER EXCEPTIONS/EXEMPTIONS FOR MEDICARE CERTIFIED PROVIDERS AFFECTED

BY SEVERE STORMS AND FLOODING

T

he Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to acute care hospitals, PPS-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities (SNFs), home health agencies (HHAs), hospices, inpatient rehabilitation facilities (IRFs), outpatient dialysis facilities, long-term care hospitals (LTCHs) and ambulatory surgical centers (ASCs) located in areas affected by Hurricane Harvey due to the devastating impact of the storm. These providers will be granted exceptions without having to submit an extraordinary circumstances exception request if they are located in one of the Texas counties or Louisiana parishes, all of which have been designated by the Federal Emergency

Management Agency (FEMA) as a major disaster county.

The scope and duration of the exception under each Medicare quality reporting program is described in the updated memo posted on September 7, 2017, however, all of the exceptions are being granted to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.

If FEMA expands the current disaster declaration for Hurricane Harvey to include additional counties or parishes, CMS will update this memo to expand the list of providers eligible to receive an exception without submitting a request to include the hospitals, PPS-exempt cancer hospitals, inpatient psychiatric facilities, skilled nursing facilities, home

health agencies, hospices, inpatient rehabilitation facilities, long-term care hospitals, and ambulatory surgical centers located in the additional counties and parishes.

In addition, CMS will continue to monitor the situation and adjust exempted reporting periods and submission deadlines accordingly.

Additional details and materials are available on the CMS Hurricane web page (https://www.cms.gov/AboutCMS/Agency-Information/Emergency/ Hurricanes.html). Please check back frequently for updates.

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AMRPA Magazine October 2017

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39

STUDY FINDINGS: INTENSIVISTS BENEFIT HEART PATIENTS WITH BREATHING DIFFICULTIES AND LOWER COSTS

B

reathing difficulties are a common aspect of certain types of heart disease and researchers at the University of Maryland-School of Medicine (UM SOM) have found that a new, collaborative treatment model for seriously ill heart patients with breathing difficulties results in better care and lower costs.

and after the intensivist consultations were started. A total of 363 patients receiving mechanical ventilation in the CICU were included: 162 in the pre-implementation group and 201 in the post-implementation group.

The researchers analyzed how long patients were in the hospital, assessed whether patients met a benchmark of 28 days of unassisted breathing, calculated costs associated with both length of stay (LOS) and total hospitalization, and recorded in-

than previously,” says study senior author Michael T. McCurdy, MD, FCCM, FCCP, FAAEM, associate professor of pulmonary and critical care medicine and emergency medicine at UM SOM. “Plus, we saved well over $4 million a year in hospital costs. It was striking.”

“This is a developing paradigm — critical care medicine-trained physicians working collaboratively with cardiologists in a CICU,” says study co-author Gautam V. Ramani, MD, assistant professor of medicine at UM SOM and medical director of clinical advanced heart failure at UMMC. “The takehome message: there is a role for a collaborative model between critical care and cardiac care.”

The first-ever study, published in the Journal of the American College of Cardiology, examined the use of medical specialists in intensive care (known as intensivists) for patients receiving mechanical breathing assistance in the cardiac intensive care unit (CICU) at the University of The number of patients discharged to Maryland Medical Center home from the CICU rose significantly, A key finding underscores direct (UMMC). UMMC’s adult CICU has 15 beds serving about 2,000 benefits to patients, says Dr. from 27 percent to 42 percent. patients annually, with a variety McCurdy, “The number of patients of cardiac abnormalities and Michael T. McCurdy, MD discharged to home from the CICU conditions: heart attack, preFCCM, FCCP, FAAEM rose significantly, from 27 percent and post-heart transplantation University of Maryland Medical Center to 42 percent.” management, drug and mechanical circulatory support, Dr. Ramani says the next stage and treatment of pulmonary could be to use physicians trained hospital death rates. The researchers found hypertension. At UMMC, the intensivists have in both cardiology and critical care medicine: that using intensivists to help treat these additional expertise in pulmonary medicine “It’s difficult to find these people. It’s a new patients improved their care, decreased the and the use of mechanical ventilators. Prior area, a new field. Not many people have amount of time the patients stayed in the to the intensivist consultations, cardiologists dual certification, but there is increasing hospital, and lowered costs. were responsible for monitoring and weaning recognition that this collaborative approach patients from mechanical ventilators in the can reduce the length of stay and improve “When we looked at the clinical results of CICU. patient outcomes.” our intervention, we were removing the breathing tube faster, and getting patients Study Findings out of the Cardiac ICU about two days earlier The study examined data from a year before 40

AMRPA Magazine October 2017

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We need all IRFs to lend a hand in challenging aggressive Medicare auditors in order to level the playing field, and preserve and enhance patient access to IRF care.

For more information, or to speak with a FAIR Fund leader or staff member, contact Rebecca Schnorf at 41 rschnorf@firminc.com or at (217) 321-2477.

CDC REPORT EXAMINES OUTPATIENT CARDIAC REHABILITATION, 2013-2015

T

he Centers for Disease Control and Prevention’s (CDC) released its Morbidity and Mortality Weekly Report (MMWR).

The report, “Use of Outpatient Cardiac Rehabilitation Among Heart Attack Survivors — 20 States and the District of Columbia, 2013 and Four States, 2015,” examines the use of cardiac rehabilitation among adults following a heart attack in 20 states and the District of Columbia (DC) in 2013 and four states in 2015.

awareness, with special focus among populations who are most underserved A systematic review has shown that after a heart attack, patients using cardiac rehab were: •

•

53 percent (95 percent confidence interval [CI] = 41 percent – 62 percent) less likely to die from any cause 57 percent (95 percent CI = 21 percent – 77 percent) less likely to experience cardiac-related mortality than were those who did not use cardiac rehab

and in 2015, four states (Georgia, Iowa, Maine, and Oregon) were included in the cardiovascular health module, which contained questions about using cardiac rehab after a heart attack. The median response rates for the BRFSS were 46.4 percent and 47.2 percent for 2013 and 2015.

Demographic characteristics included: •

age

•

sex

•

race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, or Hispanic),

The report states that each year, approximately 210,000 heart attacks are • recurrent events and outpatient cardiac However, it notes that even with longrehabilitation among heart attack standing national recommendations survivors helps reduce these recurrences encouraging use of cardiac rehab and improve health outcomes. Heart intervention has been underutilized and • disease is the leading cause of death in the United States and each year approximately 790,000 adults have a myocardial infarction (heart attack), Outpatient cardiac rehab has including 210,000 that are recurrent heart attacks.

highest level of education achieved (less than high school, high school graduate, some college, or college graduate) having any kind of health insurance

historically been underutilized, and this continues to be the case in all demographic groups.

Cardiac rehabilitation (rehab) includes exercise counseling and training, education for heart-healthy living, counseling to reduce stress, and provides patients with education regarding the causes of heart attacks and tools to initiate positive behavior change, and extends patients’ medical management after a heart attack to prevent future events.

It lists several strategies that could increase the use of cardiac rehabilitation among all heart attack survivors and have the potential to substantially improve health outcomes of heart attack survivors. These included: •

lowering out-of-pocket payment

•

improving access

•

standardizing referrals

•

providing education to enhance

42

Selected self-reported cardiovascular disease (CVD) risk factors included: •

hypertension

•

high blood cholesterol

•

diabetes

•

obesity

•

current smoking

the differences were evident by sex, age, race/ethnicity, level of education, cardiovascular risk status, and by state.

Each respondent was categorized based on their number of CVD risk factors (0, 1, 2, 3, 4, or 5).

Study Participants The researchers conducted an annual telephone survey using the 2005 Behavioral Risk Factor Surveillance System (BRFSS) data (https://www. cdc.gov/brfss), which includes core component and optional modules.

Among heart attack survivors, the crude and adjusted percentage of cardiac rehab use was assessed overall and by state of residence in 2013 and 2015, as well as by demographic characteristics and CVD risk in 2013. P-values were obtained by Wald F test and p<0.05 were used to identify statistically significant differences among subgroups. The BRFSS’s complex sample design was accounted for using statistical software with BRFSS respondent sampling weights and design variables.

In 2013, 20 states (Arizona, Arkansas, Florida, Georgia, Hawaii, Iowa, Maine, Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, Tennessee, Washington, and Wisconsin) and DC,

Participants with history of a heart attack AMRPA Magazine October 2017

are identified by an affirmative response to the question, “Has a doctor, nurse, or other health professional ever told you that you had a heart attack, also called a myocardial infarction?”

Participants identified as heart attack survivors were asked: “After you left the hospital following your heart attack, did you go to any kind of outpatient rehabilitation?”

The study findings were subject to four limitations: 1. BRFSS data are self-reported and are limited by recall bias, which could lead to underestimation of either heart attacks or use of cardiac rehab.

2. The survey does not provide information about why survey respondents did not participate in cardiac rehab, or whether

those who did had attended the recommended number of cardiac rehab sessions.

3. Since state participation in using the rehab module of the BRFSS was low (40 percent in 2013 and 8 percent in 2015) and inconsistent over time, these findings do not provide nationally representative estimates.

4. With relatively few respondents reporting a history of heart attack

Findings • In 2013, a total of 166,913 participants who completed the cardiovascular health module, 4.8 percent (95 percent CI = 4.6–5.0) were heart attack survivors.

• In 2015, a total of 20,776 participants from four states completed the module, 4.3 percent (3.9–4.7) were heart attack survivors.

• Overall, 33.7 percent (95 percent CI = 31.8–35.6) of heart attack survivors in 2013 and 35.5 percent (95 percent CI = 31.0–40.3) in 2015 reported use of cardiac rehab after leaving the hospital following their heart attack.

• Among 9,490 heart attack survivors, older adults, men, non-Hispanic whites, persons with college or higher education and those with two, three, or four (of five) CVD risk factors were more likely to receive cardiac rehab than were younger persons, women, non-Hispanic blacks, Hispanics, persons with less than a college education and persons with fewer than two or with five out of five CVD risk factors (relative to those with two, three of four; p<0.05).

• The adjusted percentage of cardiac rehab use ranged from 20.7 percent in Hawaii to 58.6 percent in Minnesota.

• Among the four states that used the cardiac rehab module in 2015, both the crude and adjusted percentages of cardiac rehab use were lowest in Georgia and highest in Iowa.

• Among the four states that used the module in both 2013 and 2015, the overall adjusted percentage of cardiac rehab use was 35.6 percent (95 percent CI = 32.1–39.3) in 2013 and 35.5 percent (95 percent CI = 31.0–40.3) in 2015 (p = 0.8075).

43

(183 [DC] to 2,288 [Florida]), state-level confidence intervals were wide and might account for nonsignificant differences in cardiac rehab use for some characteristics.

Conclusion In the analysis, approximately one in three heart attack survivors reported receiving cardiac rehab after suffering a heart attack and a series of systematic reviews referenced in the report emphasized missed opportunities to access cardiac rehabilitation which has been documented to improve patient survival, quality of life, functional status, and cardiovascular risk profile following a significant health event, as well as reduce risk for a recurrent heart attack and psychological disorders.

Again, the authors state that outpatient

44

cardiac rehab has historically been underutilized and this continues to be the case in all groups. No subgroup examined had utilization rates exceeding 50 percent and no state had utilization rates above 61 percent. Even with low percentages of rehab use, disparities in its use were apparent and therefore, improvement in referral is needed; however, populations with lower use of cardiac rehab, such as women, those with lower levels of education, and minority populations should be further assessed to determine barriers to the use of cardiac rehab. Some strategies that offers improvement included higher payment for rehabilitation by insurers, eliminating or reducing copays for patients, extending cardiac rehab clinic hours to improve access, as well as providing standardized referrals that are to cardiac rehab staff member liaisons

at hospital discharge or by primary care providers and cardiologists. In addition, patients who have experienced a heart attack should be made aware of alternative models of cardiac rehab, such as telehealth and home-based rehab, to reduce the barriers related to transportation and responsibilities at home or work.

Citation Fang J, Ayala C, Luncheon C, Ritchey M, Loustalot F. Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC. Use of Outpatient Cardiac Rehabilitation Among Heart Attack Survivors â&#x20AC;&#x201D; 20 States and the District of Columbia, 2013 and Four States, 2015.

MMWR Morb Mortal Wkly Rep 2017;66:869â&#x20AC;&#x201C; 873. DOI: http://dx.doi.org/10.15585/mmwr. mm6633a1.

AMRPA Magazine October 2017

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45

AMRPA SUBMITS COMMENTS ON CMS’S CY 2018 OPPS PROPOSED RULE Editor’s Note: On September 11, 2017, the American Medical Rehabilitation Providers Association submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the calendar year (CY) 2018 Medicare Hospital Outpatient Prospective Payment System (OPPS) proposed rule regarding proposals to pay for Total Knee Arthroplasty (TKA), Total Hip Arthroplasty (THA) and Partial Hip Arthroplasty (PHA) procedures in outpatient surgical settings. The complete letter is provided below and is also available on the www.amrpa.org website.

achieve long-term positive outcomes. In AMRPA members’ experiences, the best way to deal with THA and TKA when they are elective procedures is through a comprehensive pre-planned package of care, including pre-rehabilitation that commences prior to a patient’s TKA or THA entailing weight reduction and other interventions. This is followed by surgery in a hospital or Ambulatory Surgical Center (ASC), and post-operative care in a post-acute care setting or in the home depending upon the patient’s clinical circumstances and supports.

September 11, 2017

In concept, AMRPA supports allowing Medicare to reimburse hospital outpatient departments and ambulatory surgery centers (ASCs) for TKA procedures (CPT code 27447) and THA procedures (CPT codes 27130) under certain circumstances.

CMS’ conditions for removing these procedures from the IPO list appear to be satisfied, as advances in arthroplastic technique and perioperative anesthesia have led to shorter stays and quicker recovery times for certain patients, and many outpatient settings are capably equipped to perform the surgeries. Such advances have also significantly reduced the traditional risks associated with these procedures, making patients with less medical complexity appropriate candidates for outpatient settings with or without an overnight stay. That said, we note that there is limited literature or data on safety or outcomes about these outpatient procedures for the Medicare beneficiary population, likely because CMS does not currently reimburse for them in an outpatient setting. We encourage CMS to monitor carefully patient outcomes through robust quality reporting programs for the hospital outpatient quality reporting (HOQR) and ambulatory surgical center (ASC) quality reporting (ASCQR) programs, as discussed further below.

Seema Verma Administrator Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, MD 21244-1850 Re: Medicare Program; Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; CMS-1678-P Dear Administrator Verma, On behalf of the American Medical Rehabilitation Providers Association (AMRPA), we write in response to the proposed rule for the calendar year (CY) 2018 Medicare Hospital Outpatient Prospective Payment System (OPPS) published in the Federal Register on July 20, 2017. Our comments seek to respond to the Agency’s questions about the removal of Total Knee Arthroplasty (TKA) procedures from the inpatient only (IPO) list, and the possible removal of Total Hip Arthroplasty (THA) and Partial Hip Arthroplasty (PHA) from the IPO list.

AMRPA is the national trade association whose members provide medical rehabilitation services across the spectrum of health care settings including inpatient rehabilitation facilities (IRFs), hospital outpatient departments (HOPDs), and other settings such as comprehensive outpatient rehabilitation facilities (CORFs), rehabilitation agencies, and skilled nursing facilities (SNFs).

AMRPA members help patients maximize their health, functional skills, independence, and participation in society so they can return to home, work, or an active retirement. We appreciate the opportunity to provide comments to the Centers for Medicare and Medicaid Services (CMS) on these proposals relating to TKA, THA, and PHA procedures.

AMRPA concludes that some TKA and THA procedures could be safely performed in an outpatient setting for a subset of Medicare beneficiaries where there is less medical complexity (i.e., few or no comorbidities, a clinically-acceptable BMI for the procedure, etc.). We recommend that CMS avoid prescriptive eligibility rules that supplant physician-patient decision-making about the type of care that is most responsive to individual patient needs.

Nevertheless, adequate and appropriate patient selection criteria and screening processes are critical to successful episodes of care. Ensuring that only the appropriate Medicare beneficiaries undergo this trajectory of care not only protects patients’ wellbeing by reducing the risk of post-operative complications and unplanned hospital readmissions, but would also minimize unanticipated costs to the Medicare program.

I. Removal of Total Knee Arthroplasty and Total Hip Arthroplasty Procedures from the IPO List AMRPA supports patient-centric policy changes which create tailored treatments that are responsive to a beneficiary’s individual needs, place them in the most appropriate setting of care, and

Quality of Care AMRPA thinks it is imperative that CMS be proactive in evaluating the impact of these placement determinations on the quality of care that Medicare beneficiaries receive. Any shift in procedures from an inpatient to an outpatient setting must be accompanied

46

AMRPA Magazine October 2017

by robust quality measurement analysis to assess the immediate and longer-term implications of the changes in practice.

Although the incidence rate of adverse events may be low given the emphasis on careful patient selection, we recommend that CMS add measures to the HOQR and ASCQR programs to incorporate THA and TKA procedures. Significant risks in the perioperative period (such wound infection, cardiac events, and DVT, among others) should be the subject of prospective and contemporaneous data collection and analysis to monitor for potential adverse clinical consequences. The Inpatient Hospital Quality Reporting (IQR) Program monitors readmissions and surgical complications due to THA and TKA procedures. The HOQR and ASCQRP do not but should follow suit if such procedures will now be conducted in those settings.

Furthermore, quality measures must assess not only immediate patient safety metrics, but longer-term indicators of recovery such as mobility and functional status. AMRPA recommends that the quality measure set additionally include pain experience and management measures, and ambulation functional measures.

While this approach may require changes to the ASCQR and HOQR programs, these concurrent changes are necessary to ensure accountability to beneficiaries and the Medicare program.

Access to Post-Acute Care We appreciate CMS’ proposal to prohibit Recovery Auditor Contractors (RACs) for two years from denying a hospital claim for patient status for TKA procedures performed in the inpatient setting. The decision regarding the most appropriate care setting for surgery is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and preferences. The same can be said for the post-surgery/postacute setting of care. While the vast majority of beneficiaries who fit the criteria for an outpatient TKA or THA procedure would not need institutional post-acute care services, CMS should ensure that those beneficiaries who do require more intensive rehabilitation, such as that provided in IRFs, would not unfairly encounter access issues. Early initiation of comprehensive rehabilitation is critical to successful functional outcomes for joint replacement patients, such as mobility and range of motion.

Such therapy and working with prosthetists in post-acute care settings can also help optimize placement of the prosthesis and improve the prosthesis’ survival rate, thereby benefiting the return on investment of Medicare’s dollars. However, some Medicare Administrative Contractors (MACs) in certain jurisdictions continue to conduct targeted prepayment medical audits of lower extremity fracture cases treated in IRFs. AMRPA encourages CMS not to limit beneficiaries’ access to post-acute care providers as this decision should also be driven by clinical judgment, as well as be agnostic to which setting a beneficiary received their surgery be it inpatient or outpatient.

II. Removal of Partial Hip Arthroplasty (PHA) Procedures from the IPO List AMRPA is not wholly convinced there is an evidentiary basis at this time to support that PHA procedures can performed optimally in outpatient settings as envisioned by CMS in the proposed rule, i.e. through the application of thorough patient selection criteria and engaged physician-patient dialogue. In our members’ experience, PHA patients are often admitted from

the emergency department and have sustained a hip fracture from accidents such as a fall, (i.e. non-elective). Furthermore, these beneficiaries are typically older, more frail, and present with more comorbid conditions. CMS has previously recognized this. In the Comprehensive Care for Joint Replacement (CJR) Program, PHA episodes are stratified apart from TKA episodes and have a different benchmark price in order to account for the heterogeneity of PHA patients and their less predictable care trajectories. We recommend that CMS reconsider removing PHA procedures from the IPO list.

As the Agency is well aware, there is compelling evidence that site of service decisions can have profound long-term consequences when patients are not treated in the most medically appropriate setting. A robust two-year retrospective analysis found significant quality differences between highly matched pairs of Medicare beneficiaries receiving their immediate post-acute care in IRFs versus SNFs for hip fractures, with significantly higher mortality among those patients treated in SNFs. While we would not anticipate increased mortality among hip replacement patients treated in outpatient settings, it is important that CMS monitor this trend comprehensively and longitudinally.

III. Implications of Outpatient TKA, THA, and PHA Procedures on Medicare Bundled Payment Programs Beyond the context of OPPS, ongoing bundling initiatives applicable to joint replacement procedures would need to be reworked significantly to avoid disruptions caused by their removal from the IPO list. Shifting younger and healthier patients out of acute care hospitals for these procedures will invariably lead to higher average costs and longer average lengths of stay for inpatient procedures, resulting in a significant disparity between the baseline performance period and the performance period under the CJR model.

Therefore, AMRPA believes the optimal solution would be to include outpatient TKA and THA procedures within the existing models. This approach would be truly the only way to ensure that the universe of TKA and THA procedures captured in the baseline period is comparable to the universe of these procedures in the CJR performance period. In the CJR model, this change would likely require redesign to permit other providers, including outpatient surgery and post-acute care providers, to serve as the bundle-holder. Without this change, it is unlikely that performance in the CJR model would be reflective of variables that are within an acute care hospital’s control.

Given that DRG payments for TKAs are essentially flat (other than risk adjustments and outlier payments), most of the cost constraints would need to be realized in the post-operative period. Savings may come from reduced hospital readmissions, emergency visits, and other complications, but it would mostly be derived from shifting patients away from to post-acute rehabilitative care to home-based or outpatient therapy, if any at all. Because the CJR financial accountability period extends only 60 days following discharge, the effects of skimping on recovery and rehabilitation are unlikely to be fully reflected in two months of quality data. Restricting access to rehabilitation is particularly disconcerting if the CJR patient case mix becomes more medically complex as a result of this proposal to cover TKA 47

and THA procedures under the OPPS. To address design flaws in the CJR model that could be exacerbated by CMS’ current proposals, the CJR quality assessment period should extend well beyond the 60-day window for financial accountability. Specific quality measures should capture a period of at least six months post-discharge to assess longer-term gains in function and mobility as well as other outcomes associated with adequate post-acute rehabilitative care, such as days in the community. This would provide the program with a more comprehensive picture about the impact of any reduction in resource use in the post-operative period.

IV. Conclusion AMRPA appreciates CMS’ efforts to modernize Medicare rules

Bruce M. Gans, MD Chair, AMRPA Board of Directors Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation National Medical Director for Rehabilitation, Select Medical

Suzanne Kauserud, FACHE, MBA, PT Chair, AMRPA Quality Committee Administrator, Carolinas Rehabilitation – Charlotte Vice President, Continuing Care Division of Carolinas HealthCare System

48

to keep abreast of best practices in medicine and innovative technologies. While we support removing the proposed THA and TKA procedures from the IPO list, this does not necessarily mean that outpatient settings are the appropriate setting for most of these procedures but these placement decisions are best left to clinicians and patients. We also recommend that CMS reevaluate whether PHA procedures should be removed from the IPO list. If you have any questions regarding our comments, please contact Mimi Zhang, Policy and Research Associate (mzhang@amrpa.org / 202-223-1920) or Carolyn Zollar, J.D., Executive Vice President for Government Relations and Policy Development (czollar@ amrpa.org / 202-223-1920).

Sincerely,

Robert Krug, MD Co-Chair, AMRPA Clinical and Consumer Affairs Committee President and Executive Medical Director, Mount Sinai Rehabilitation Hospital Regional Vice President and Chief Medical Officer for Rehabilitation Services, Trinity Health of New England

Karl Sandin, MD Co-Chair, AMRPA Clinical and Consumer Affairs Committee Interim Medical Director, Immanuel Rehabilitation Institute

AMRPA Magazine October 2017

15TH ANNUAL AMRPA EDUCATIONAL CONFERENCE & EXPO

OCTOBER 23-25, 2017 • SWISSÔTEL

REGISTER NOW! www.amrpa.org

We're bringing together the most influential voices in rehab for a deep dive into industry trends and issues. View the speaker line-up on our website!

This is your chance to: • • • •

Get a firsthand look at new technologies and innovative strategies Advance the interests of your practice Network with key individuals and influencers Positively influence patient care

Learn from other rehab professionals' experiences with issues impacting the post-acute care industry.

Questions? Please contact Rachel Koresky, AMRPA Member Services Coordinator, at rkoresky@amrpa.org.

To discuss exhibit and sponsorship opportunities, contact Samantha Schwarz at sschwarz@amrpa.org or 202-207-1132.

49

CMS TRANSMITTALS OF INTEREST FOR MEDICAL REHABILITATION PROVIDERS

October 2017

Note: The Centers for Medicare and Medicaid Services (CMS) daily publishes 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 #

50

Issue Date

Subject

Implementation Date

R1917OTN

2017-09-13

Correcting Payment of Inpatient Prospective Payment System (IPPS) Transfer Claims Assigned to Medicare Severity-Diagnosis Related Group (MS DRG) 385 and Allowing Part A Deductible on Medicare Secondary Payer (MSP) Same Day Transfer Inpatient Claims

N/A

R3858CP

2017-09-08

Fiscal Year (FY) 2018 Inpatient Prospective Payment System (IPPS) and LongTerm Care Hospital (LTCH) PPS Changes

2017-10-02

R3857CP

2017-09-08

2018 Annual Update of Healthcare Common Procedure Coding System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update

2018-01-02

R3859CP

2017-09-08

October Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

2017-10-02

R170SOMA

2017-09-08

Revisions to the State Operations Manual (SOM) Appendix A â&#x20AC;&#x201C;Survey Protocol, Regulations and Interpretive Guidelines for Hospitals

2017-09-08

R292FM

2017-09-01

Revision to Publication 100-06, Chapter 3, Medicare Overpayment Manual, Section 200, Limitation on Recoupment

2018-04-02

R1912OTN

2017-09-01

HIGLAS Enhancement Required for Implementation of Overpayment-Based Denials

2018-04-02

R3854CP

2017-09-01

October 2017 Update of the Ambulatory Surgical Center (ASC) Payment System

2017-10-02

R202NCD

2017-08-25

Updates to Pub. 100-04, Chapter 18 Preventive and Screening Services and Chapter 32 Billing Requirements for Special Services and Publication 100-03, Chapter 1 Coverage Determinations Part 4

2017-09-26

R3849CP

2017-08-25

Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System (PPS) Pricer Changes for FY 2018

2017-10-02

R3848CP

2017-08-25

Updates to Pub. 100-04, Chapter 18 Preventive and Screening Services and Chapter 32 Billing Requirements for Special Services and Publication 100-03, Chapter 1 Coverage Determinations Part 4

2017-09-26

R3850CP

2017-08-25

Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/ Biological Code Changes - October 2017 Update

2017-10-02

R3852CP

2017-08-25

October 2017 Integrated Outpatient Code Editor (I/OCE) Specifications Version 18.3

2017-10-02

R3853CP

2017-08-25

October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)

2017-10-02

R3840CP

2017-08-18

Common Edits and Enhancements Modules (CEM) Code Set Update

2018-01-02

R3841CP

2017-08-18

Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE)

2018-01-02

R3842CP

2017-08-18

Healthcare Provider Taxonomy Codes (HPTCs) October 2017 Code Set Update

2018-01-02

AMRPA Magazine October 2017

R3843CP

2017-08-18

2018 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder

2018-01-02

R107GI

2017-08-18

Affordable Care Act Bundled Payments for Care Improvement Initiative Recurring File Updates Models 2 and 4 January 2018 Updates

2018-01-09

R738PI

2017-08-18

Provider Error Rate Formula

2017-09-19

R1904OTN

2017-08-18

Multi-Carrier System (MCS), Fiscal Intermediary Shared System (FISS) and VIPS Medicare Shared System (VMS) Automation of Prior Authorization (PA) Requests/Pre-Claim Reviews (PCR) and Their Responses with Multiple Services (for programs like Home Health (HH)) via the Electronic Submission of Medical Documentation (esMD) System

N/A

R1906OTN

2017-08-18

Out-of-Jurisdiction Providers (OJP) and Qualified Chain Providers (QCP) Move to Correct A/B MAC Jurisdiction - Analysis CR Only

2018-01-02

R3836CP

2017-08-18

Home Health Value-Based Purchasing Implementation

2017-11-21

R1910OTN

2017-08-18

Guidance on Implementing System Edits for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

N/A

R3833CP

2017-08-11

Quarterly Update to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS)

2017-10-02

R1900OTN

2017-08-11

CICS Region Merge(s) for A/B MACs - Analysis Only

2018-01-02

Updated as of September 14, 2017

About CARF: ■ Accredits programs interna�onally ■ Reviews business and clinical prac�ces ■ Guides person-centred, evidence-based prac�ces ■ Establishes quality performance improvement systems ■ Hosts training and educa�on on standards Benefits of CARF accredita�on: ■ Service excellence ■ Business improvement ■ Funding access ■ Compe��ve differen�a�on ■ Risk management ■ Posi�ve visibility ■ Accountability ■ Peer networking

Since 1966, the CARF seal has been the hallmark of quality in person-centered services.

Snap the QR code or visit www.carf.org/ Programs/Medical for full program descriptions.

CARF is a leading independent, nonprofit accreditor of health and human services.

CARF is internationally recognized for its consultative external peer-review process and evolving field-driven standards.

To learn more about CARF and how accreditation can help your organization.

Call (888) 281-6531 or email med@carf.org today!

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AMRPA Magazine October 2017