Latest from AHCA on the "Doc Fix" bill and Therapy Caps

Sent to me as a member of the Virginia Health Care Association from Steve Ford,  VP Policy and Reimbursement VHCA:

As you know, the United States Senate recessed for two weeks without taking up the "Doc fix" (Sustainable Growth Rate) legislation passed by the House of Representatives late last week.  The "Doc fix" is a recurring policy issue where the annual formula for updating physician payment under Medicare results in a significant reduction relative to current physician payment.  In order to avoid the formula driven reduction, Congress typically passes legislation "fixing" the payment to maintain current payment levels.  In order to do so, Congress must come up with the required funding, which has often lead to reduction in other provider payment updates, including nursing facility payments under Medicare.

The current effort, as approved by the House, is to permanently fix the payment system for physicians.  Some of the funding for the permanent fix is coming from reductions to the 2018 market basket update for nursing facilities, but the known one-time reduction is in lieu of the annual rate reduction "surprises" that have historically funded the temporary fixes.  

While AHCA does not believe the delayed action of the Senate places the bill in jeopardy, they are advising that the extra time gives members the opportunity to reach out to their Senators, and we certainly would suggest you do so with Senators Warner and Kaine.

However, the delay does have some logistical issues of which you should be aware.  As reported by AHCA:

1.    A -21.2 percent adjustment would apply to the Part B fee schedule effective April 1.  However, if the SGR bill is enacted when the Senate returns from recess, this will not apply and there will be a 0.0 percent adjustment from April 1 - June 30. CMS will most likely hold processing of Part B claims for up to 14 days to avoid changing its billing systems while Congress acts.

    To mitigate this risk, AHCA recommends that SNF operators hold any Part B claims with dates of services on or after April 1 until it is clearer what will happen in the Senate.

    Most SNF operators typically bill on a monthly basis so that April dates of service would not be billed until May. We believe this will be sufficient time to let the legislative process proceed so that care centers will not have to change charge masters or resubmit claims, assuming the SGR bill is enacted after the Senate returns from recess in two weeks.

2.    Technically, the therapy caps exceptions process expires on March 31 and there will be a hard $1,940 therapy cap with no exceptions. However, if the SGR bill is enacted when the Senate returns from recess, this will not apply. The problem is that until Congress acts, any therapy services furnished over the $1,940 threshold during this period of uncertainty could pose payment liability risks.

     To mitigate this risk, AHCA recommends that SNF operators issue Advance Beneficiary Notices (ABNs) to beneficiaries needing Part B therapy services beyond the $1,940 threshold as of April 1, 2015. This notice will provide necessary beneficiary and provider payment liability protections depending on the resolution of the current SGR vote delay in the Senate.

For a more detailed explanation of these risks, please review the SGR Delay Impact on SNF Operations FAQ and share within your billing, therapy and other affected operational personnel.

2014 Final Report & 2015 Expansion Project - Centers for Medicare & Medicaid Services (CMS) Focused Dementia Care Survey Pilot

Memo # 15-31-NH

Posting Date 2015-03-27

Fiscal Year 2015

Summary

Final Report: Attached is a final report that outlines the basis for the Focused Dementia Care Survey Pilot, the process utilized, conclusions gathered based upon post-pilot data analysis, as well as next steps for the future. 

Expansion of Focused Dementia Care Survey Efforts: The CMS plans to expand upon the work of the focused survey pilot and has invited States to conduct such surveys in FY2015 on a voluntary basis. The expansion project will involve a more intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications, and broaden the opportunities for quality improvement among providers. 

Deficiency Implications: Deficient practices noted during the surveys will result in relevant citations. In the event that additional care concerns are identified during on-site reviews, those concerns will be investigated during the survey or will be referred to the SA as a complaint for further review.

 http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-31.pdf

HHS OIG Posts Medicaid Fraud Statistics Interactive Map

Today, OIG posts an interactive map about Medicaid Fraud Control Units (MFCU) and enforcement actions. As always, you can use the links provided to go directly to the new material. ------------------ Medicaid Fraud Control Units Medicaid Fraud Control Units Statistical Data for Fiscal Year 2014  Data Chart http://go.usa.gov/3cHe9 Interactive Map http://go.usa.gov/3cHeT