Important Insurance Update

Payer Relations Update 12/6/12

Submitted by Patti Taira-Tokuuke

On December 1-3, 2012 APTA held their annual State Policy & Payment Forum in Alexandria, VA.  We (Elyse Nakama and I) were updated on trends in healthcare policy, current reform efforts and payer/payment trends.  Many changes are ahead for all of healthcare let alone physical therapy.

If you haven’t sent a note to our state’s congressional folk (Inouye, Akaka, Hanabusa, Hirono), please do regarding Medicare cuts coming up in 2013 and the end of the therapy cap exceptions process.  Right now there is potential for a 26.5% Physician Fee Schedule cut which will impact not only Medicare patients, but our state WC and MVA payments as well.  Cap is set to be $1900 (PT and SLP combined) for 2013.  If you want additional reading take a look at the MedPAC recommendations to Congress (scary stuff as far as reimbursement goes).

The Middle Class Tax Relief Act of 2012 is requiring CMS (Medicare/Medicaid) to report on function and condition of patients.  Therefore, beginning January 1, 2013 all therapist that are Part B providers will need to report outcome measures on ALL of your Medicare patients (these are patients that you bill directly to Palmetto GBA).  If you do not comply, beginning July 1, 2013, Medicare will return your claims UNPAID.  Yikes! Below are 2 links on the APTA website that has information regarding this change.  CMS will be having an audio conference on December 12, 2012 to inform therapist on what we need to do.  APTA will have a Webinar on December 13, 2012.  Please sign up and include your billing folks if possible because they will need to make the reports via G-Codes and C-modifiers on your claim forms.

As for the PQRS (Physician Quality Reporting System), up until 2013-2014, you will get a 0.5% bonus for reporting to CMS.  What will change in 2015, is that Medicare will REQUIRE all Part B providers to report for PQRS and they will use calendar year 2013 data to let them know who is participating or not.  From 2015, they will DECREASE your payment by 1.5%.  The point to drive home is that therapist should start to do PQRS reporting from January 1, 2013 or be subject to fee reductions from 2015.  Right now, you are not mandated to do PQRS until 2015, but you risk a reduction in fees.  Please see the link below and from that link members can look at a FAQ on PQRS.

Finally, a big thing on the horizon is APTA will be submitting in January 2013 a new payment model for the CPT advisory panel to review.  It will move us from a current fee-for-service, procedural-based payment system to a per session payment system.   They hope to implement this in calendar year 2015.   Below is a link to an overview of the system.  After reviewing the system, I know there will be a huge learning curve for therapist, so stay informed because change is coming.

Some trends happening across the nation is for non-payment or reduced payment from services rendered by a PTA.  In Hawaii we are affected by this in the Work Comp arena (payments are reduced by 40% if a PTA renders care) and I believe Tri-care is the only payer that does not reimburse for PTA services at all. I will try to keep my eyes/ears open if I hear of any other payers start to move in this direction locally.  Another trend happening across the nation is high out of pocket co-payments.  Some states were reporting insurance companies placing PT in the “Specialty” provider category and this gives them the ability to link it outside of the normal office visit charge (like what they would pay if they saw their PCP). Some states were reporting upwards of $75/visit co-payment amounts.  In Hawaii, I have only heard of Secure Horizons (A UHC Affiliate plan for seniors) that are placing us in the “Specialty” list and so seniors are paying $35-40/visit which is a lot for our seniors that are on fixed incomes (that could be like around $80/week for some patients).  Please let me know if you hear of other payers that are doing that. And finally, nationally private practices are being targeted for fraud investigation.  Medicare is doing more fraud investigation because of initial reports coming out showing up-coding and over utilization issues in the out-patient arena.

I think overall, I came away from this year’s Policy and Payment Forum with a sense that changes are happening and happening faster than I anticipated.  It’s not a matter of what will change but when.  Please contact me at (808) 969-3811(office) or e-mail if you have a question, comment or concerns regarding payment issues.