New CMS Rules on Manual Medical Reviews in Outpatient Therapy

The Centers for Medicare & Medicaid Services (CMS) has published new information on manual medical review (MMR) processes for outpatient therapy services over the $3,700 threshold ($3,700 for occupational therapy and $3,700 for physical therapy and speech-language pathology, combined). See: CMS Therapy Cap Web page. Medicare Administrative Contractors (MACs) will continue to conduct prepayment review of claims above $3,700 until March 31 (with the agency “requesting” that MACs complete reviews within 10 business days). On April 1, Recovery Audit Contractors (RACs) will take over the process, conducting a prepayment review demonstration for Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri and postpayment review in all other states. Neither the MACs nor the RACs are precluded from reviewing therapy services below the $3,700 threshold.

(3/13) Latest MedPAC report contains four reform recommendations for post-acute care

On March 15, the Medicare Payment Advisory Commission (MedPAC) issued its March 2013 Report to the Congress on Medicare payment policy. The report provides recommendations to increase the efficiency of Medicare by finding ways to provide high-quality care for Medicare beneficiaries at lower costs to the program.

In this report, MedPAC recommends no update in 2014 for five fee-for-service payment systems and a 1% update for the hospital inpatient and outpatient payment systems. In three sectors (physician, skilled nursing, and home health), the report evaluates current payment adequacy indicators but does not take new votes on recommended payment updates.

The report also contains a summary chapter on post-acute care settings, which says that Medicare’s definition of and payments for post-acute care services fail to establish incentives for providers to deliver efficient, high-value care. As a result of these “shortcomings,” the MedPAC has developed four broad reforms to encourage a more seamless, patient-centered approach to match services and settings to the needs of each patient:

  • Bundled payments and ACOs
  • A common patient assessment instrument
  • New quality measures
  • Expanded readmission policies

Under these reforms, payments would reflect the characteristics of the patient, not the services furnished or the setting, and would encourage the use of the lowest cost mix of services necessary to achieve the best outcomes, according to the report.

Read more about these reforms and the other MedPAC recommendations byclicking here.

Lethal Germ Affecting Short-Stay Hospitals, Long-Term Care Facilities

A lethal germ found in short-stay hospitals and long-term care facilities called carbapenem-resistant Enterobacteriaceae (CRE) has been overpowering antibiotics and could possibly be the beginning of the end of antibiotics, according to the CDC.

CRE affects people who are in or who recently had inpatient medical care, and when someone gets a serious infection from it, there are very few or no antibiotics to cure the issue. CRE can also spread its antibiotic-fighting weapons to other bacteria, potentially creating additional untreatable bacteria. Up to half of patients who become infected will die, says the CDC, which lists some important facts about the germ:

  • About 4% of US short-stay hospitals had at least one patient with a serious CRE infection during the first half of 2012. About 18% of long-term acute care hospitals had one. This totals almost 200 facilities.
  • One type of CRE has been reported in medical facilities in 42 states.
  • The most common type of CRE is also rising rapidly – there has been a seven-fold increase in its presence during the last 10 years.

The CDC has mapped out specific guidelines that, when followed, can halt CRE infections before they become widespread in facilities and before they spread to otherwise people. In addition, the CDC has issued a comprehensive CRE Prevention Toolkit, which provides guidelines for physicians and nurses, hospitals, long-term care hospitals, nursing homes, and health departments.

OIG: SNFs Fail to Meet Basic Care Plans

Skilled nursing facilities (SNF) often fail to meet care planning and discharge planning requirements, according to a recent Office of Inspector General (OIG) report. The OIG found that 37% of resident stays, SNFs did not develop care plans that met requirements or did not provide services in accordance with care plans. While 31% of resident stays, SNFs did not meet discharge planning requirements. SNFs received $5.1 billion in Medicare reimbursement for stays where quality-of-care requirements were not met. The OIG report also found examples of poor quality of care related to wound care, medication management, and therapy.

The OIG recommends that the Centers for Medicare & Medicaid Services (CMS):

  • Strengthen the regulations on care planning and discharge planning
  • Provide guidance to SNFs to improve care planning and discharge planning
  • Increase surveyor efforts to identify SNFs that do not meet care planning and discharge planning requirements and hold these SNFs accountable
  • Link payments to meeting quality-of-care requirements
  • Follow up with the SNFs that failed to meet care planning and discharge planning requirements or that provided poor quality of care