MSHA members in action.

StAMP March 2017 Report

STAMP3-2017

StAMP

StAMP/StARS: Carol Morse

StAMP:

Lisa Satterfield has moved on to be working in the field of Audiology rather than as Director of Health Care Regulatory Advocacy and the StAMP in ASHA. Our new person is Sarah Warren. I will introduce her by listing her accomplishments in ASHA. Sarah Warren, MA Director, Health Care Regulatory Advocacy,

  • Joined ASHA March 14, 2016
  • Has worked on regulatory and legislative issues for 10 years in the therapy/rehabilitation space including at the American Medical Rehabilitation Providers Association and American Physical Therapy Association.
  • Focused on Medicare Part A and B issues including implementation of MACRA and the IMPACT Act, responding to proposed rules, monitoring MMR implementation, audits and appeals, and quality measurement development and reporting.
  • Submitting a proposal for the Convention with Renee Kinder on the Medicare appeals process.

1. Manual Medicare Review   Update February 09, 2016The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the  thresholds and instead allows a targeted review process. MACRA also prohibits the use of Recovery Auditors to conduct the reviews.  CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this  medical review on a post-payment basis. The SMRC will be selecting claims for review based on: Providers with a high percentage of patients receiving therapy beyond the threshold as compared to their peers during the first year of MACRA. Therapy provided in skilled nursing facilities (SNFs), therapists in private practice, and outpatient  physical therapy or speech-language pathology providers (OPTs) or other rehabilitation providers. Of particular interest in this medical review process will be the evaluation of the number of units/hours of therapy provided in a day. For CY 2015, the limit on incurred expenses (therapy cap) is $1,940 for physical therapy (PT) and speech-language pathology services (SLP) combined and $1,940 for occupational therapy (OT) services.

2. ALJ Delay

The Office of Medicare Hearings and Appeals (OMHA) which manages the third level of the Medicare Appeals process, the Administrative Law Judges (ALJs), held an appellant forum on February 25, 2016.During the forum, Chief ALJ Nancy Griswold released the most recent numbers associated with thebacklog. In FY 2015 OMHA received over 240,000 requests for a hearing and each ALJ team is able toprocess approximately 1,200 appeals a year. The backlog is estimated to be approximately one millionrequests for hearings and providers can expect to wait at least two years to have a hearing.OMHA also announced the expansion of the Settlement Conference Facilitation (SCF) pilot to Part Aclaims. This process brings together the appellant (e.g. the provider) and CMS through a mediator toachieve a settlement on claims pending a hearing. The SCF was developed in 2014 and was limited toPart B claims until this year. In the two years SCF has been available only 2,000 Part B claims pending ahearing have been resolved. Full details on the SCF can be found on the OMHA website at http://www.hhs.gov/omha/OMHA%20Settlement%20Conference%20Facilitation/SCF%20Part%20A%2 0Docs/medicare_part_a_administrative_law_judge_appeals.html.

2. Recovery Audit Program Changes Effective January 1, 2016

In November 2015 CMS announced a series of changes to the Recovery Audit program, including revised Additional Documentation Request (ADR) limits. Many of these changes were effective January 1, 2016. A full list of these changes can be found on the CMS website at

https://www.cms.gov/Research-Statistics- Data-and- Systems/Monitoring-Programs/Medicare- FFS-

Compliance-Programs/Recovery- Audit-Program/Downloads/Recovery- Audit-Program-Enhancements11-6- 15-Update- .pdf.

3. CGS  CGS, a Medicare Administrative Contractor (MAC) recently issued guidance on their website implementing an erroneous interpretation of Medicare guidelines for the provision of services in a SNF.

I participated in a presentation to state presidents with 2 of my StAMP colleagues in February.

News from CGS

Skilled Nursing Facility: Documentation Required to Bill Speech Therapy Services — When billing for speech therapy in the Skilled Nursing Facility (SNF) setting, the patient’s medical record mustcontain documentation proving medical necessity for the service. Patients who have been transferred to a SNF from a covered hospital stay must be treated in the SNF for conditions that were treated or arose during their qualifying hospital stay. If there is no indication that the patient received speech therapy during their hospitalization, speech therapy should not be billed by the SNF. If however, the patient’s condition changes while they are in the SNF, and the need for speech therapy can be documented as medically necessary, then and only then should the SNF bill for speech therapy.

Reference: CMS Medicare Benefit Policy Manual (Pub. 100-02) chapter 8, sections 10 & 30.2.2.

http://cgsmedicare.com/parta/pubs/news/2016/02/cope32099.html

 

Carol Morse

Committee Chair

September 2015 – StaMP

STATE ADVOCATES FOR MEDICARE POLICY
STATE ADVOCATES FOR REIMBURSEMENT

SEPTEMBER 2015

StAMP:

Noridian MAC

Mentors: Carol Morse, Anne VerHoef, Joan Jaeger
 
California Kathleen Catterall catteral@pacbell.net
Hawaii Kathleen Campbell katcam@hawaii.rr.com
Nevada Megan Swank mswank@medicine.nevada.edu
Nevada Rachael Walden rwalden@medicine.nevada.edu
 
Alaska Anne VerHoef annev@gci.net
Arizona Lisa Naylor lisaannnaylor@gmail.com
Idaho Maren Hollister mhollister@elksrehab.org
Montana Carol Morse mumsey05@bresnan.net
North Dakota No rep
Oregon Kathryn de Domingo Kathy@progrehab.com
South Dakota Laura Barbera speechgirl@rushmore.com
Utah No rep
Washington Joan Jaeger Joan.jaeger@nwhsea.org
Wyoming No rep

 

Region States MAC Current LCDs Future LCD
E California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands Noridian Healthcare Solutions, LLC No speech

L33501

No speechL34210
F Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming Noridian Healthcare Solutions, LLC No speech No speech
HH&H Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, US Virgin Islands, Wisconsin and Washington National Government Services, Inc. L27404

L26884

No Aud

L33580

L33631

No Aud

HH&H Delaware, District of Columbia, Colorado, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia, and Wyoming CGS Administrators, LLC L31905

L31899

L34083

L34046

DME D Alaska, Arizona, California, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, American Samoa, Guam, Northern Mariana Islands Noridian Healthcare Solutions, LLC L11524 L33739

L33832

I am planning training at the MSHA Fall meeting in October to expand on Medicare .

ICD-10 will start October 1. Changes are that all ICD-10 begin with a letter and are 4 and 5 digits. Treating ICD is NOT the first item listed. Instead the ICD diagnosis is the initial item listed. Right or left side needs to be documented in identifying the accurate ICD-10 code.

Please go to ASHA site and log on and click practice and reimbursement for further information in transfer of ICD-9 to ICD-10. The ASHA site is most helpful.

Carol Morse
Committee Chair

StAMP

State Medicare Administrative Contractor Network

The State Medicare Administrative Contractor Network (SMAC) has changed its name to the State Advocates for Medicare Policy (StAMP). The new name more accurately reflects the mission of the Network: to influence local public policy decisions that affect Medicare coverage and reimbursement of speech-language pathology and audiology services. While much of the work is accomplished with the Medicare Administrative Contractors, the group also discusses issues related to audits, medical review, quality and outcomes, Medicare payment, and related legislation. Network members serve as conduits of information for their state associations and ASHA and receive vital information on Medicare policies and laws, participate in monthly ASHA teleconferences, and assist in making changes at the federal and regional level. Ensure your members are playing by the Medicare rules—put your StAMP on it!

–Rachel Stansberry, M.A. CCC-SLP
Speech-language Pathologist

SMAC

Medicare administrative Contractors (MACs) are recruiting for ICD-10 end-to-end users.

To volunteer as a testing submitter:

  • Volunteer forms are available on your MAC website
  • Completed volunteer forms are due April 17
  • CMS will review applications and select the group of testing submitters
  • By May 8, the MACs and CEDI will notify the volunteers selected to test and provide them with the information needed for the testing

If selected, testers must be able to:

  • Submit future-dated claims
  • Provide valid National Provider Identifiers (NPIs), Provider Transaction Access Numbers (PTANs), and beneficiary Health Insurance Claim Numbers (HICNs) that will be used for test claims. This information will be needed by your MAC by May 29 for set-up purposes; testers will be dropped if information is not provided by the deadline

Contact your MACs if you are interested – and feel free to share!
——————————
Lisa Satterfield, M.S., CCC/A
Director, Health Care Regulatory Advocacy
American Speech-Language-Hearing Association (ASHA)
2200 Research Blvd. #220
Rockville, MD 20850

Don’t forget to contact your representative for the speech-generating device legislation. All of the information is here:

Action Alert: Help Remove Mandatory Medicare Rental Requirements for Speech-Generating Devices

Representative Cathy McMorris Rodgers (R-WA-05) has introduced the Steve Gleason Act of 2015, H.R. 628. This legislation would allow Medicare beneficiaries to immediately purchase and transfer ownership of speech-generating devices (SGDs) to the patient, thereby removing them from the Medicare capped-rental requirement. In addition, access to eye-tracking devices is included. The Senate is expected to introduce companion legislation in the near future.

Ask your members of Congress to support H.R. 628 today!

Background

SGDs have been subject to additional requirements due to reinterpretation of the Social Security Act and the issuance of a coverage reminder that prohibited SGDs from having any non-speech capabilities (e.g., e-mail, internet, environmental control) or the ability to upgrade in the future at the patient’s own expense. In addition, Medicare contractors are routinely denying coverage for eye-gaze, a technology that is needed by patients with limited or absent mobility in the arms and hands. Contractors indicate the denials are due to the ability of the eye-tracking to be used for other purposes or plugged into devices that are not SGDs.

In 2013, the Centers for Medicare & Medicaid Services (CMS) reclassified several devices, including SGDs, indicating that previous interpretation of the Social Security Act was inaccurate. ASHA has been working with the Amyotrophic Lateral Sclerosis Association (ALS), the SGD manufactures, and other key stakeholders to reverse this decision.

In April 2014, CMS applied the capped-rental rule, requiring patients to rent SGDs over a 13-month period before owning the device. Capped-rental adversely affects patients in an extended hospital stay or in a skilled nursing facility because Medicare will not cover the rental fees while the patient is in the rental period. It also prohibits any ability to unlock the devices to include non-speech capabilities.

Due to pressure from ASHA, ALSA, the SGD manufactures, and members of ASHA, CMS is revising their definition of an SGD and requested comments in November. The CMS National Coverage Determination is anticipated to resolve the non-speech capabilities issue, and is expected in July. Capped-rental, however, is defined by CMS as a legislative issue. The proposed legislation, if passed, will require CMS to reclassify the SGDs.

ASHA Resources

For more information on SGD issues, please contact Lisa Satterfield, ASHA’s director of health care regulatory advocacy, at lsatterfield@asha.org, or Ingrida Lusis, ASHA’s director of federal and political advocacy, at ilusis@asha.org.

Also, check out the ASHA SMAC webpage! Please double check your email that is on that page – remember it is the email that members will use to contact. If you want it changed, email me! http://www.asha.org/Practice/reimbursement/medicare/SMAC/

A couple of announcement from CMS from Lisa Satterfield:

  • The Centers for Medicare and Medicaid Services (CMS) has awarded the Region 5 Recovery Audit contract to Connolly, LLC. The purpose of this contract is to identify and correct improper payments made for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), and Home Health and Hospice (RFQ-CMS-2014-Region 5) claims. The current Recovery Auditors (RAs) is on track to continue active auditing through Dec. 31, 2015 as the legal challenges to contracts in RAC regions 1, 2, and 4 continue.
  • For pre-payment reviews from MACs and Zone
    Program Integrity Contractors (ZPICs) Additional
    Documentation Requests (ADRs), providers and suppliers have 45 days to respond. Failure to respond within 45 days of a prepayment review ADR will result in denial of the claim(s) related to the ADR. Medical manual reviews are post-payment and managed by the RAC auditors, so this does not affect MMR. However, the MACs can request pre-payment reviews essentially when they want.
  • 2015 claims will be delayed while MACs upload new rates.

The therapy cap legislation expired 3/31/2015! New legislation is in place. Follow ASHA headlines. PLEASE read the headlines and respond immediately to your congress folks to support this legislative action. ASHA has put in many hours in Washington to support increasing therapy monies from $1940 to $3700 or no cap at all. Expect quality and outcome based reimbursement rather than fee for service.

Carol Morse, Chair

.

 

 

SMAC

IRF Proposed Rules: Medicare’s proposed rules for Inpatient Rehab Facilities and Skilled Nursing Facilities has been published, and ASHA will be commenting.
United HealthCare – Medicare Advantage: Notification has gone out nationally that UHC-MA is requiring G-codes on the claims for PT, OT, and SLP services for evaluation only. It is unclear what the purpose of collected outcomes data on evaluation-only services is,
Value-Based payment: There is more discussion in the community regarding value-based payment. Physicians currently have a value-based modifier system that requires them to add quality codes (similar to PQRS) to their claim in order to avoid additional 5% decreases in payment. PT has been discussing value-based payment – or payment related to quality and outcomes – and are starting to develop a clinical data registry for outcomes a little like NOMS, but more specific to the PQRS rules at this time.
Speech Generating Devices: There is a real possibility that SGDs will be significantly limited or unavailable to Medicare patients due to a policy that requires the devices to only function as SGDs and have no computer, wireless, or Bluetooth technology. The devices have to be
approved in order to be rented for Medicare patients (also a new policy), and the approval process is underway now. Some devices have already applied and been denied. If the manufacturers are able to make the application deadline (which is this week, because there is a 90 day review process), their devices will be stripped down to meet requirements. Some are not issuing devices to Medicare beneficiaries at all. The eye-gaze is also under scrutiny and being denied if it is purchased for a device that is no longer approved, or being denied because it has the capability to plug into other devices. Lew Golinker is a lawyer and expert in this area, and a good referral for patients. Lisa is working with him, the ALS Association, the manufacturers, the SIG, and has had meetings with Jonathan Blum and other CMS staff, the DME MAC medical directors, the DME PDAC medical director, and senators to find a solution. Please contact Lisa Satterfield, ASHA if you have patients without the ability to communicate because of Medicare policies regarding SGDs. You may contact Lisa: lsatterfield@asha.org,
Carol Morse
Committee Chair