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REIMBURSEMENT COMMITTEE

REIMBURSEMENT COMMITTEE. KPTA 2013 Spring Conference Committee Members: Les Durst Mark Dwyer Pat Erickson Zach Frank Kim Galbreath Mark Kohls Debby O’Neill Aaron Proctor Diana Sherrard Joy Wenger. Sequestration.

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REIMBURSEMENT COMMITTEE

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  1. REIMBURSEMENT COMMITTEE KPTA 2013 Spring Conference Committee Members: Les Durst Mark Dwyer Pat Erickson Zach Frank Kim Galbreath Mark Kohls Debby O’Neill Aaron Proctor Diana Sherrard Joy Wenger

  2. Sequestration In general, Medicare FFS claims with dates-of-service or dates-of discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payments. Beginning April 1, 2013 the 2 percent reduction will be applied to Periodic Interim Payments (PIP), Critical Access Hospital (CAH) and Cancer Hospital interim payments, and pass-through payments for Graduate Medical Education, Organ Acquisition, and Medicare Bad Debts. Exempted- Medicaid and VA 2% cut actually approx. a 1.6% cut due to 2% cut is only Medicare portion, not beneficiary co-pay Example: $100 bill $80 - 2% = $78.40 $20 co-pay - $0 = $20

  3. MPPR (Multiple Procedure Payment Reduction) 50 percentreduction on 2nd and subsequent codes billed for a date of service for all settings. ~ 6% - 7% decrease in PT services (use MPPR calculator for input on each practice) Private insurers that have currently implemented MPPR policy: BCBS of Kansas City 3/11 Wellmark Aetna UHC Humana- Medicare Advantage – Feb. 2012

  4. THERAPY CAP Medicare Administrative Contractors (MACs) will conduct prepayment review on claims reaching the $3,700 threshold with dates of service January 1, 2013 to March 31, 2013. CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process. Effective April 1, 2013, the Recovery Auditors will conduct prepayment review for all claims processed on or after April 1, 2013. Recovery Auditors will complete two types of review.

  5. THERAPY CAP Pre-payment Review: Claims submitted in the Recovery Audit Prepayment Review Demonstration states will be reviewed on a prepayment basis. These states are Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri. In these states, the MAC will send an ADR to the provider requesting the additional documentation be sent to the Recovery Auditor (unless another process is used by the MAC and the Recovery Auditor) The Recovery Auditor will conduct prepayment review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision.

  6. THERAPY CAP Post payment Review: In the remaining states, the Recovery Auditors will conduct immediate post payment review. In these states, the MAC will flag the claims that meet the criteria, request additional documentation and pay the claim. The MAC will send ADR to the provider requesting the additional documentation be sent to the Recovery Auditor. The Recovery Auditor will conduct post payment review and will notify the MAC of the payment decision

  7. THERAPY CAP Section 603 (b) of the American Tax Relief Act counts outpatient therapy services furnished in a Critical Access Hospital (CAH) toward a beneficiary’s annual cap and threshold amount using the Medicare Physician Fee Schedule rate. CAHs are not subject to the therapy cap, the manual medical review process, or the use of the KX modifier.

  8. PQRS The Physician Quality Reporting System (PQRS) changes from an incentive-based program to a penalty program in 2013. In order to avoid penalties of 1.5 percent in 2015 physical therapists can report a variety of measures. See APTA’s PQRS webpage for more information.

  9. Functional Limitation Reporting Attend educational presentation Sunday April 7, 2013 from 8:30 am until 12:30 pm In 2013, Physical therapists must submit information regarding a patient’s functional limitation for Medicare Part B services. For more information visit APTA’s Functional Limitation Reporting webpage. Include reporting on patients who have Medicare part B as a primary insurance and those who have Medicare part B as a secondary insurance. "Any claims filed after July 1, 2013 even if the date of service is before July 1st must have the Functional Limitations G codes or will be denied."

  10. THANK YOU !!

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