Wednesday, November 25, 2015

CMS Updates 2016 Medicare Part B Physician Fee Schedule File – Therapy File Posted on AHCA Website

Dan Ciolek

On November 16, 2015, the Centers for Medicare and Medicaid Services (CMS) published the CY 2016 Medicare Physician Fee Schedule (PFS) Final Rule (CMS-1631-FC) in the Federal Register. This is the first PFS final rule since the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which repealed the Sustainable Growth Rate formula. The MACRA allowed the zero percent update that would have ended on March 31, 2015, to continue through June 30, 2015, allowed for a one-half percent (0.5%) update from July 1, 2015, to December 31, 2015, and allows for a one-half percent (0.5%) update for CY 2016. The MACRA also extends the physician work geographic practice cost index (GPCI) floor of 1.0, and the therapy cap exceptions process, through December 2017.

You may note that the 2016 conversion factor of $35.83 is slightly lower that the 2015 conversion factor of $35.93. This is due to the application of a required -0.02 percent Budget Neutrality Adjustment and a -0.77 percent Target Recapture Amount adjustment related to the misvalued procedure code policy.

The final rule continues the multiple procedure payment reduction (MPPR) policy for “always therapy” services. The MPPR policy required, effective April 1, 2013, a 50 percent reduction to be applied to the practice expense component of payment for the second and subsequent “always therapy” service(s) that are furnished to a single patient by a single provider on one date of service (including services furnished in different sessions or in different therapy disciplines). The MPPR worksheet lists those “always therapy” services subject to the MPPR policy and the reduced fee payment amounts.

Supporting documentation and downloads for Regulation #CMS-1631-FC may be found here. An overview of the Physician Fee Schedule Payment Policies may be found at and an overview of skilled nursing facility consolidated billing and annual updates can be found at

Thanks again to the efforts of Tony Marshall, President and CEO of the Georgia Health Care Association; AHCA is able to offer members the 2016 therapy fees for each CPT/HCPCS Code in each geographic area are provided in this Excel file. The file contains the following information:

1. The 2016 Medicare Part B Fee Schedule (Part B Fees) for Outpatient Rehabilitation for each Carrier and Locality

2. The 2016 Medicare Part B MPPR Fee Schedule for "Always Therapy Services (50% MPPR Factor) for each Carrier and Locality

3. The 2016 Relative Value Units (RVUs) for each Outpatient Rehabilitation Therapy Code

4. The 2016 Geographic Practice Cost Indices (GPCI) by Medicare Carrier and Locality

The Part B Fee Schedule amounts are calculated as follows:

((A1 x B1) + (A2 x B2) + (A3 x B3)) x Conversion Factor (Part B Fees), and

((A1 x B1) + ((A2 x B2) x (1-MPPR Factor) + (A3 x B3)) x Conversion Factor (MPPR Part B Fees), where:

A1 = Physician Work RVU
A2 = Non-Facility Practice Expense RVU
A3 = Malpractice RVU
B1 = Work GPCI
B2 = Practice Expense GPCI
B3 = Malpractice GPCI

Conversion Factor = $35.8279

MPPR Factor = 50%

Tuesday, November 24, 2015

Congress Out for Thanksgiving Week

Drew Thies

Members of Congress returned to their home states last week ahead of a week-long district work period coinciding with the Thanksgiving holiday.

Legislation focusing on the resettlement of Syrian refugees as well as a budget reconciliation measure containing changes to the affordable care act will be at the center of attention when Congress returns next week. Lawmakers also must address appropriations measures should the reconciliation measure fail after a predicted presidential veto.

The deadline for action on the budget is December 11. The House and Senate already passed a budget deal earlier this year which sets top-line spending limits; however debates still exist on how that money should be appropriated. Speaker of the House Paul Ryan announced he will allow policy riders on appropriations legislation, muddying the already murky situation.

AHCA will continue to monitor legislative plans through the Thanksgiving holiday and ensure that long term and post-acute care providers are listened to and taken into account in any laws enacted before the new year.

CMS Announces the Continuation of Recovery Audit Improvements

Dan Ciolek and Dianne De La Mare

On November 6, the Centers for Medicare and Medicaid Services (CMS) provided several updates regarding their efforts to improve the Medicare Recovery Audit program.

First, CMS announced that they have issued new Requests for Proposals (RFPs) for the next round of Recovery Auditor contracts at the Federal Business Opportunity website . The new RFPs were necessary as a Federal Court found the earlier versions were improper. CMS anticipates the new Recovery Audit contracts to be awarded in 2016.

Second, CMS posted a revised Additional Documentation Request Limits document that describes a new process for Recovery Audits beginning January 1, 2016. These limits will apply to all providers except Physicians and Suppliers.

Third, CMS posted an updated Recovery Audit Program Enhancements document showing the status of the enhancements currently in place, in progress, those that require modifications to existing contracts, and those incorporated into the new Recovery Audit Contract RFPs just released.

Overall many of the Recovery Audit Improvements were advocated for by AHCA on numerous occasions and do several positive things for all providers, including skilled nursing facilities (SNF) such as:

Protect providers from overzealous Recovery Audit additional development requests (ADRs)
o Annually limited to no more than 0.5% of provider claims per year

o Limited to sending ADR letters to no more frequently than every 45 days to allow provider to respond to earlier requests

o Providers with low denial rates on Recovery Audit reviews will have their review rate dropped even lower than the starting 0.5% rate (those with high denial rates may see an increase)

Adds Recovery Auditor accountability to reduce risk of overzealous inappropriate denials
o Recovery Auditor s are penalized with overturns on appeal rate of >10%

o Recovery Auditor s are penalized for accuracy rates of <95%

o Recovery Auditor s are now subject to provider satisfaction surveys

o Recovery Auditor s are now subject to public reporting (similar to 5 star) on how they comply with these metrics

Other current and future enhancements are related to improved education, technology use, clinical expertise, timeliness, etc.

Members with questions may contact Dan Ciolek or Dianne De La Mare.

CMS Proposes Changes to the Affordable Care Act

Dana Halvorson

According to a November 21, 2015, Inside Health Policy article written by Amy Lotven, on Friday, November 20, the Centers for Medicare & Medicaid (CMS) “proposed wide-ranging changes to the Affordable Care Act's exchange plans and related policies for 2017, including standardizing plan offerings by metal level, requiring states to select minimum network adequacy standards, counting out-of-network charges toward the maximum limits, changing the risk adjustment methodology and adding new options for the Small Business Health Options Program. The proposed Notice of Benefit and Payment Parameters also sets the 2017 open enrollment period from Nov. 1, 2016 through Jan. 31, 2017, keeps the fee for issuers in federally facilitated marketplace states at 3.5 percent of premiums and suggests a 3 percent user fee for states that opt to ‘lease’ the platform while keeping control of other exchange functions.” 

Comments on the proposed rule are due by December 21, 2015. A CMS press release, FAQ and the proposed rule itself can be found on the CMS website. In addition, more information about the health care law in general is on the AHCA/NCAL website.

Monday, November 23, 2015

Payroll-Based Journal and Electronic Staffing Data Collection: What You Can Do Today

Lyn Bentley and Urvi Patel

On October 1, CMS opened registration for the voluntary period to participate in electronic submission of payroll data, including staff start and end dates (for calculating staff retention and turnover), and census data. The voluntary period from October 1, 2015 until required submission of this data beginning on July 1, 2016 is the ONLY time that providers will have the opportunity to “test” the process and determine how their payroll system interfaces with the Payroll-Based Journal (PBJ).

AHCA/NCAL members can learn more about PBJ and its impact by accessing a free webinar here.

AHCA believes that CMS is unlikely to make any significant changes to the process or the system and we strongly encourage members to consider registering for the voluntary submission period and submitting their data during the voluntary period.

Important information from CMS about the registration process including links for on-line training as well as to other Payroll-Based Journal resources is available on the Staffing Data Collection PBJ website.


The Affordable Care Act requires CMS to collect electronic staffing data from nursing centers. The Act requires this data to be auditable and verifiable. The information is intended to collect direct care staff (employed and contracted), employee turnover and tenure, and must include census data and case mix. Earlier this year, CMS announced they would require this information to be submitted by all nursing centers starting in July 2016.

When the required submission process begins, CMS will continue to require providers to submit Forms CMS 671 & CMS 672 at the time of survey. The data from these Forms will be used in calculating the Staffing Domain of the Five Star Rating System until late 2017 or early 2018.

Questions?   Contact Lyn Bentley or Urvi Patel.

AHCA/NCAL Submits Comments to CMS on Medicare Part-B Fee Schedule Incentive Programs

Dan Ciolek

AHCA/NCAL recently submitted comments  to CMS a Request for Information Regarding Implementation of the Merit-Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models.

Briefly, when the MACRA Act of 2015 (Medicare Access and CHIP Reauthorization Act of 2015) eliminated the sustainable growth formula (SGR) for making annual adjustments to the physician fee schedule (PFS), which is used to pay SNFs for outpatient therapy services, it provided for fixed annual positive PFS payment updates through the end of 2018. After that date, only providers that participate and are successful in the quality-related and to-be-developed, MIPS or APM programs would be eligible for PFS payment adjustments. These new incentive programs would begin for physicians and some specified non-physician practitioners in 2019, and then potentially be extended to other eligible professionals (EPs), including physical therapists (PTs), occupational therapists (OTs,) and speech-language pathologists (SLPs) as early as 2021.

However, in this RFI, CMS proposes to build the MIPS and APM incentive programs for the future PFS model upon the foundation of the existing Physician Quality Reporting System (PQRS), Value-Based Payment Modifier (VM), and Electronic Health Records (EHR) Incentive Program that are to be eliminated with the onset of the MIPS and APM.

In the AHCA/NCAL comments, we note that while CMS recognizes PTs, OTs, and SLPs that work in facility-based provider settings (including SNF) as Eligible Professionals, they have historically excluded SNF therapists from participating in PFS incentive programs due to technology limitations rather than statutory restrictions. In the two specific recommendations, we are asking that CMS include SNF PT, OT, and SLP Medicare Part B therapy services paid under the PFS to be eligible for MIPS or APM adjustments when they become eligible per the MACRA 2021 timeline, and that CMS work with stakeholders to overcome the technological barriers that have prevented SNF therapy providers from participating in PFS incentive programs to date.

HHS Secretary Burwell Releases FY 2015 Agency Financial Report

Dan Ciolek

On November 15, 2015, the U.S. Department of Health and Human Services (HHS) Administrator, Sylvia M. Burwell released the Fiscal Year 2015 Agency Financial Report. In the report, the Secretary highlighted that in FY 2015, Medicare Part A expenditures = $285.1 billion, Medicare Part B = 281.6 billion, Medicare Part D = $80.6 billion, and Medicaid = 378.9 billion.

In the report, the Secretary indicated that the Comprehensive Error Rate Testing (CERT) program used to calculate the improper payment estimate, identified that the Medicare fee-for-service (FFS) gross improper payment estimate for FY 2015 is 12.09 percent or $43.33 billion. Within that rate, insufficient documentation was common for Skilled Nursing Facility (SNF) claims. Specifically, the improper payment rate for SNF claims increased from 6.94 percent in FY 2014 to 11.04 percent in FY 2015.

The Secretary listed corrective actions to address root causes of the errors, and stated the following:

“HHS and its contractors develop medical review strategies using the improper payment data to ensure the areas of highest risk and exposure are targeted. HHS requires its Medicare review contractors to focus on identifying and preventing improper payments due to documentation errors in certain error prone claim types, such as home health, hospital outpatient, and skilled nursing facility (SNF) claims.” 

Several statements in the report were SNF-specific and included the following:

 · Under the Management Challenge 2 section, the report states “Certain payment policies that create incentives for providers to bill for more expensive care instead of the appropriate levels of care result in billions of dollars in wasteful spending and compromised care for beneficiaries. For example, Medicare’s payment policy for skilled nursing facility (SNF) beneficiaries who also need therapy give providers incentive to bill for higher levels of therapy than necessary.”

 · Later in this section the report states “CMS reports that it is working to identify potential alternatives to the existing methodology used to pay for therapy services under the SNF Prospective Payment System (PPS). CMS initiated the SNF PPS Payment Model Research project and reports that it is working to identify potential alternative SNF payment models for further analysis.”

· Under a section titled Management Challenge 6, the report states “In August 2015, CMS finalized a rule for the PPS and Consolidated Billing for SNFs for FY 2016. This rule implemented section 6106 of the Affordable Care Act, which allows for greater oversight and increased accuracy for reporting of nursing home staffing on the Nursing Home Compare website and in the Five Star Quality Rating System. Also, this rule specified a SNF all-cause all-condition hospital readmission measure and adopts that measure for a new SNF Value-Based Purchasing (VBP) Program. Additionally, the rule will implement a new quality reporting program (QRP) for SNFs that authorizes CMS to reduce payments to nursing homes that do not report certain resident assessment items and establishes the plan to standardize certain elements of assessment tools and quality measures across post-acute care settings.”

 · Later in this section the report states “In July 2015, CMS published a proposed rule to improve the quality of nursing home care that updates Medicare requirements for long-term-care facilities. This proposed rule also would implement provisions of the Affordable Care Act, including requirements for facilities to implement a Quality Assurance and Performance Improvement (QAPI) program that would ensure that facilities continuously identify and correct quality deficiencies and promote and sustain performance improvement. Additional provisions would implement requirements for a Compliance and Ethics program, requirements for dementia and abuse prevention training, and requirements for reporting suspected crimes.”

While the updated utilization and error rate figures are new, the remainder of the Secretary’s report does not contain any new information related to SNF services, and what activities that agency is taking to assure that Medicare dollars are being spent wisely on high-quality services. 

Friday, November 20, 2015

Be Sure to Carefully Read New VA Contracts Before Signing Them

Dana Halvorson

 On February 12, 2014, President Obama signed Executive Order 13658, Establishing a Minimum Wage for Contractors. The Executive Order raises the hourly minimum wage paid by contractors to workers performing on covered Federal contracts to: (i) $10.10 per hour, beginning January 1, 2015; and (ii) beginning January 1, 2016, and annually thereafter, an amount determined by the Secretary of the Department of Labor (DOL) in accordance with the Order. On October 1, 2014, DOL published the final rule implementing the provisions of Executive Order 13658. DOL announced earlier this year that the minimum wage for certain federal contracts will increase to $10.15 per hour beginning January 1, 2016. The DOL notice on this increase can be found here. Should your current VA contract be up in the near future, be sure to carefully review and read your new VA contract before signing it for any new additions that could be in the contract that weren’t in your previous contract.  

Medicare (Parts A and B) or Medicaid providers are not considered to be federal contractors. However, if a provider currently has VA patients and a VA contract, they are considered to be a federal contractor. Since VA contracts are covered by the Service Contract Act, this Executive Order applies to such contracts. AHCA continues to work with our Congressional champions on getting VA provider agreements across the finish line, and taking those with VA contracts out of the scope of being deemed a federal contractor.  

Wednesday, November 18, 2015

CDC: National Influenza Vaccination Week (NIVW)

Mark your calendars for National Influenza Vaccination Week (NIVW) during December 6-12, 2015. All are welcome to join the CDC in promoting flu vaccination before and during NIVW. The CDC plans to host several activities in support of NIVW, including a Twitter chat and Thunderclap campaign. Details will be shared soon regarding when and how to participate.

If you wish to receive email updates directly from CDC’s Flu Inbox. You can unsubscribe at any time by emailing Also, follow CDC updates on Twitter and Facebook.

Access print and digital resources, including their series of animated images.
Order free printed copies of CDC flu materials if you wish to distribute hard copies.

Registration Is Now Open for the 2016 AHCA/NCAL Independent Owner (IO) Leadership Conference

This year’s IO Leadership Conference promises to be better than ever with all the networking opportunities you love and educational sessions you need in an energizing and engaging atmosphere you can’t get anywhere else. The town hall format allows you to discuss all the important issues with your peers as well as a slew of top-notch speakers. Earn up to 11.5 CEUs and enjoy the beauty of sunny San Diego at the stunning Manchester Grand Hyatt.

You’ll be raving about this conference for the rest of the year.

Learn more, see the complete agenda, and register today!

Sponsors as of November 10, 2015: Direct Suppl; Kronos; matrixcare; Schryver Medical, LLC