Wednesday, September 14, 2016

AHCA/NCAL Submits Comments to CMS Regarding CY 2016 Medicare Part B Fee Schedule/Other Related Policies Proposed Rule

Dan Ciolek

On September 6, AHCA/NCAL submitted an 11 page comments document to the Centers for Medicare and Medicaid Services (CMS) in response to a proposed rule titled Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2017; Medicare Advantage Pricing Data Release; Medicare Advantage and Part D Medical Low Ratio Data Release; Medicare Advantage Provider Network Requirements; Expansion of Medicare Diabetes Prevention Program Model, July 15, 2016.

The AHCA/NCAL comments focused on 6 specific subject areas within the proposed rule.

1. New PT and OT Evaluation and Re-evaluation Codes

CMS is proposing to replace the existing physical therapy (PT) and occupational therapy (OT) evaluation and re-evaluation codes with new and expanded evaluation Current Procedural Terminology (CPT-4) codes developed and adopted by the American Medical Association (AMA). The new codes would be effective January 1, 2017. AHCA supports the adoption of the new codes. While the new PT and OT initial evaluation codes would reflect three tiers of complexity, CMS is rejecting a recommendation to introduce tiered pricing, and proposes to pay one fixed price for initial PT and OT evaluations regardless of the complexity of the evaluation as reflected by the new codes. AHCA recommended that CMS reconsider their proposal and that PT and OT evaluation prices should be tiered to reflect the complexity of that service. AHCA also recommended that CMS work with stakeholders to provide adequate education before the new codes are implemented in 2017.

2. Potentially Misvalued Therapy Codes

CMS listed 10 CPT codes commonly used to bill for Part B therapy services that are subject to a statutory pricing review and solicited comments on how they should be revalued, if necessary. No specific code value changes were proposed at this time. AHCA commented that it supports efforts at determining proper payment rates, but noted that the historical process to develop values for therapy-related codes has not been transparent, and has requested more transparency.

3. Medicare Telehealth Services

CMS noted that several procedure codes commonly used for Part B PT, OT, and speech-language pathology (SLP) services were requested to be included in the list of allowed telehealth services, but they rejected the request citing that the Medicare statute does not list PT, OT, and SLP professionals as individuals that can furnish telehealth services under Medicare. AHCA noted that several states permit PT, OT, and SLP services via telehealth and requested that CMS use its authority under the Center for Medicare and Medicaid Innovation to conduct a demonstration of telehealth therapy services in states that permit this service delivery method. AHCA also recommended that CMS eliminate or soften the current SNF telehealth frequency limitations that prevent a patient’s admitting physician from furnishing telehealth services more than once per month.

4. SNF 3-Day Rule Waiver Beneficiary Protections in the Medicare Shared Savings Program (MSSP)

CMS is proposing two policies that aim to protect beneficiaries in Track 3 MSSP ACO programs in rare cases where they were admitted to a SNF with fewer than three qualifying hospital days when they were not eligible for the 3-day waiver. In the first scenario, the beneficiary became ineligible for the waiver, but the ACO was not informed by CMS due to a government time lag. In this scenario, CMS proposes that neither the beneficiary, the ACO, or the SNF would be financially liable. AHCA supports the adoption of this proposal. In the second scenario, the ACO has the information to be aware that the beneficiary is not eligible for the 3-day stay waiver, but proceeds to transfer the patient to a SNF early by improperly applying the 3-day waiver. In this scenario, CMS proposes to waive the beneficiary liability, but would hold the ACO and the SNF financially liable for the SNF services that did not meet the hospital 3-day stay requirement. AHCA supports the beneficiary protections portion of this proposal, but opposes the proposal to hold the SNF financially liable because of information received in good faith from an ACO referring hospital, but which the SNF cannot independently verify.

5. Release of MA Plan Bid Pricing Data and Medical Loss Ratio (MLR) Data

Under the proposed rule, CMS would release on an annual basis Medicare Advantage (MA) and Part D data that has historically considered to be proprietary and confidential. AHCA supports the proposal but encouraged CMS to publish more current data than is proposed.

6. Medicare Advantage Provider Enrollment

Under the proposed rule CMS would require providers and suppliers that contract with MA organizations (including first-tier, downstream, and related entities (FDR)) to also be enrolled as approved Medicare providers and suppliers through the Provider Enrollment, Chain, and Ownership System (PECOS) as is currently required for Medicare fee-for-service (FFS) payment. While AHCA supports the intent of the proposed requirement, there is some concern that the proposed language is unclear and could become overly burdensome to SNFs if misinterpreted. AHCA seeks clarification from CMS that employees or contracted service professionals or agencies of providers of service, including SNF, do not meet the definition of first-tier, downstream, and related entities (FDR) as described in the proposed rule.

If you have questions regarding the AHCA/NCAL comments please contact Daniel E. Ciolek, Associate Vice President, Therapy Advocacy at

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