INITIATIVES
UPDATE
FROM
APTA
PURPOSE
 Define
the current status of developing
and implemented regulatory and payer
policies.
 Identify
barriers and opportunities.
 Increase
your involvement in and
knowledge of issues that have an impact
on the practice of physical therapy.
 Improve
your advocacy efforts.
LEARNER OBJECTIVES
 The
audience members will identify and
discuss the varied regulatory and payment
policies related to Physical Therapy
services.
 The
audience members will outline
strategies for barriers and opportunities.
 The
audience will discuss and develop
strategies for advocacy efforts.
PRACTICE
CHALLENGES
AMA CHALLENGES

The Scope of Practice Partnership (SOPP) formed and
officially rolled out in January 2006.

Comprised of various physician organizations that engage in
tracking scope of practice legislative and regulatory efforts.

Targeted professions: Nurses, Psychologists, Podiatrists,
Naturopaths, Optometrists, Pharmacists, Audiologists, Oral
Surgeons, and Physical Therapists.

In 2006 the Coalition for Patients Rights (CPR) was formed
to counteract the SOPP and consists of more than 35
organizations representing a variety of licensed healthcare
professionals. APTA is a member.
AMA CHALLENGES

AMA published a white paper entitled “ AMA Scope of
Practice Data Series”.

APTA responds
http://www.apta.org/uploadedFiles/APTAorg/Advoca
cy/State/News/CPR/Statement_122209.pdf

January 2011 the APTA publishes “Today’s Physical
Therapist: A Comprehensive Review of a 21st
Century Health Care Profession”.
AMA CHALLENGES

2011 AMA House of delegates publishes a statement:
“physical therapists who are doctors of physical therapy,
recognized by consumers and other health care professionals
as the practitioners of choice to whom consumers have direct
access for the diagnosis of, interventions for, and prevention
of impairments, functional limitations, and disabilities related
to movement, function, and health."

Whereas, Based on education and training, this is beyond the
appropriate scope of practice of physical therapy; and

Whereas, Instead, this would constitute the practice of
medicine.
AMA CHALLENGES

AMA Document, “Creation of State-based Scope-ofPractice Review Committees Legislative Template”.

Idea is to review scope practice changes before they are
allowed to be brought to legislation.

Many physician practice acts are broad and would
probably preclude physicians from this type of process.
AMA CHALLENGES

Dry needling for Also referred to is Intramuscular
needing (IMS) and/or trigger point dry needling.

APTA does not currently have any HOD or BOD policies
or positions on this technique.

AMA fights this based on “invasive” = practice medicine.
INFRINGEMENT


ISSUES
Athletic Trainers legislative agenda has shifted from
securing professional regulation to:

Expanding scope of practice beyond treatment of
athletic injuries in athletes.
 Changing language on population from “athlete” to
“individual”, “person”, or “patient”.

Mandating payment for services provided by athletic
trainers.
Others looking at expanding scope (massage
therapist, exercise phys., personal trainers).
TERM PROTECTION

Language included in the FSBPT Model Practice Act.

18 states have explicit language protecting “physical
therapy.”

14 states have explicit language protecting
“physiotherapy.”

A number of state PT Acts contain vague language.

Key to enforcement is strength of term protection
language + exemption language found in PT Act.
TERM PROTECTION

Chiropractic Practice Acts

17 states + DC use the term “physiotherapy”

2 states contain the term “physical therapy”

2 states explicitly restrict use of term “physical therapy”
(AR + OH)
PRACTICE ACT REVISIONS

State practice acts should reflect current state of
the profession, including scope of practice and
education requirements.

May need to be updated to include emerging areas
of PT practice.

Fifth Edition of the FSBPT Model Practice Act:
Released in August 2011.
MEDICARE

Physical Therapists in Private Practice (PTPPs)
placed in moderate risk category.

PTPPs must have a site visit prior to enrollment as
of March 25, 2011.
“HOW CAN I HELP?”
DES MOINES
UNIVERSITY
“A Comparison of Health Care Use
for Physician-Referred and SelfReferred Episodes of Outpatient”
Jane Pendergast,
Stephanie A. Kliethermes,
Janet K. Freburger,
Pamela A. Duffy
© Health Research and Education Trust
DOI: 10.1111/j.1475-6773.2011.01324.x
Health Services Research
DES MOINES
UNIVERSITY

Collaboration: Agreement between
University of Iowa and Wellmark, Inc.
 Compare
patient profiles and health care
use for physician referred and self-referred
episodes of PT on large, non-Medicare
population.
DES MOINES
UNIVERSITY

Results: Comparison
Physician Referred
Self-Referred
Average Age
45.9
43.5
Average visits / episode
7.0
5.9
$420
$347
Allowable amount /
episode
DES MOINES
UNIVERSITY

Results similar to previous studies, and
differences may be due to controlling for
case-mix.
 Role
of physician as gatekeeper may be
overstated.
 Health
care use in self-referred groups 86%
of physician referred groups.
DES MOINES
UNIVERSITY
 Allowable
amount for self-referred PT
episode 87% of physician referred
episode of care
 Health
care use before and after PT
episode similar in both groups.
 Both
PT and related non-PT
claims/episode were less in self referred
vs. physician-referred group.
PAYMENT
ISSUES
STATE REGULATION OF
PREMIUM HIKES

Beginning to see states develop more regulations
related to premium hikes.

U.S. Department of Health and Human Services
awarded 45 states and DC $1M each to help them
improve their oversight of health insurance
premium increases.
PROMPT PAYMENT LAWS

Prompt payment laws have been enacted in 50
states and the District of Columbia.

Prompt payment laws require “clean claims” to be
submitted.

Payers may still delay and/or deny claims as a
result of what the payer considers to be an
improper, incomplete, or inaccurate claim.
PAYMENT RECOVERY

Retrospective recovery of previously paid claims.

Review state law regarding prompt payment and
payment recovery.

Review individual payer contracts.

Inform patients of collections policy and financial
responsibility.
PRIVATE INSURERS AUDIT ACTIVITY

Estimates by government and law enforcement
agencies place the loss due to health care fraud as
high as 10% of U.S. annual health care
expenditure—or $226 billion / year.

Blue Cross And Blue Shield Companies' Anti-Fraud
Efforts Collect More Than Half A Billion Dollars In
2009

Physical therapy assistants may provide services under
the direction and supervision of a physical therapist.
GET INVOVLED!
MEDICARE

For fiscal year 2010, HHS reported almost $48 billion in
Medicare improper payments, (38 percent of the total
$125.4 billion estimate for the federal government).

Medicare Fee for Service error rate in 2010 was around
10.5% ($34.3 billion).

Governments goal is to reduce the Medicare FFS
improper payment rate to: 8.5% by Nov 2011 and 6.2%
by Nov 2012.
MEDICARE

Post payment Review

Reviews are being conducted by Office of Inspector
General, ZPICs, MACs, Recovery Audit Contractors

RACs identify Medicare underpayments &
overpayments & recover overpayments. (Part A & B-so
any provider can be subject to RAC review)

KANSAS = Region D –HealthDataInsights, Inc. of
Las Vegas, NV
MEDICARE
 RAC’s

Can reopen claims up to three years from the date the claim was
paid.

RACs cannot review claims prior to October 1, 2007

The RAC Program is required to follow all applicable Medicare
regulations such as payment policies, reopening timeframes, and
appeal rights for providers.

RACs required to have a medical director on staff, and to use
nurses, therapists, and certified coders.

Cannot collect contingency fee if claim is being appealed at any
level of appeal.
MEDICARE
 RAC’s

RACs choose issues to review based on data mining
techniques, OIG and GAO reports and experience of
staff.

Two types of review


Automated (no medical record)

Complex (medical records)
New Issues for review will be posted on RAC‘s website.
MEDICARE
 RAC’s

RACs will send request for medical records.

If provider does not submit requested record in 45 days,
the service will be denied.

Records may be submitted via mailed paper copy, fax,
or mailed CD/DVD

CMS has established medical record limits.
MEDICARE
 RAC’s

Medical Record Request Limits

inpatient hospital, IRF, SNF, hospice =10% of avg monthly Medicare claims (max of 45
days) per NPI

Other Part A Billers (outpatient hospital, home health)=1% of avg monthly
Medicare services (max of 200) per 45 days per NPI

Physicians, Physical therapists in private practice
 Solo practitioner = 10 medical records per 45 days per NPI

Partnership of 2-5 individuals: 20 medical records per 45 days per NPI

Group of 6-15 individuals=30 medical records per 45 days per NPI

Large Group (16+ individuals)=50 medical records per 45 days per NPI.
STAY UP TO DATE !
MULTIPLE PROCEDURE PAYMENT
“CASCADING”

BCBS of KC: eff. 3/15/11, reimburse at 100% of the first unit of
each service and 20% reduction to the PE.

Wellmark: eff. 7/1/11, the highest priced procedure (PE) will be
paid at 100% and subsequent procedures are subject to 20%
reduction of PE.

Aetna: eff. 11/14/11, the procedure with the highest practice
expense RVU will be allowed at 100 percent. Each additional
therapy service performed by the same provider group on the
same date of service will be allowed at 80 percent.

More to come???
GROWTH OF CO-PAYS
COST SHARING

Costs for deductibles, copayments, and other cost
sharing rise significantly.

Employers are shifting more responsibility for healthcare decisions to employees.

The Kentuky Law went into effect on June 8, 2011. This
means that a patient that renews their plan or gets a
new plan on or after June 8th will have the benefit of
these reduced co pays.
PTA PAYMENT DIFFERENTIAL:
PRIVATE PAYER PTA POLICIES

United Health Care / Optum Health


UHC certificates of coverage all read that PM&R
services must be performed by a physician, licensed
therapy provider, or provider duly licensed to provide
said services.
Anthem BCBS - Indiana
PTA PAYMENT DIFFERENTIAL:
PRIVATE PAYER PTA POLICIES

TRICARE


Does not cover services provided by PTAs goes back to
the regulations (32 CFR 199.6).
Missouri HealthNet

Therapy treatment services that may be billed to MO
HealthNet are treatment services provided directly to
the patient by the therapist.
SUPER COMMITTEE

Joint Congressional Committee Created to Identify
$1.2-$1.5 trillion in spending cuts

12 Members of Congress – three Republicans & three
Democrats from each chamber.

Must produce savings package by November 23rd.

House and Senate must approve package by December 23rd

Without action, process known as sequestration goes into
effect.

January 15th with impact on 2013 budget.
SUPER COMMITTEE

Scenario #1

Super Committee and Congress approve debt reduction
package

Cuts could affect Medicare, Medicaid and provider
specific accounts

Cuts could be greater than $1.5 trillion
SUPER COMMITTEE

Scenario #2

Super Committee and Congress fail to produce a
package

Sequestration goes into affect

Medicaid is sheltered from cuts

Medicare receives 2% across the board cut which
cannot not touch benefits
SUPER COMMITTEE

Scenario #3

Super Committee produces partial package.

Cuts could affect Medicare, Medicaid and provider
specific accounts.

Sequestration still goes into affect- across the board
cuts occur.
SUPER COMMITTEE

Opportunities

May be the only vehicle for SGR / Therapy Cap
exceptions extension before end of year deadline.

APTA will propose long-term fix for Therapy Cap.
CALL YOUR
SENATOR
OR
CONGRESSPERSON
SNF PPS FY 2012
FINAL RULE
 See
APTA website:
http://www.apta.org/Payment/Medicare
/CodingBilling/SNF/
DIAGNOSIS CODING:
TRANSITION TO ICD‐10 (OCTOBER 2013)

Identify all facility / practice stakeholders and provide
education materials and develop training plans for all levels of
staff (admin. and clinical).

Develop plan for discussing with information technology
vendors and billing clearinghouses to determine their
readiness and plans for updating systems.

Access private sector/or professional resources to provide for
smooth and informed transitions.

CPT will continue to be used on claims when ICD-10 is
implemented.

When appropriate; test, re-test and test some more!
REFORMING PAYMENT FOR
OUTPATIENT
PHYSICAL THERAPY

Alternative to the Therapy Cap

Regulatory Activism
MPPR
 Shrinking of “Skilled” Therapy


Trends in Payment


Increasing Consumer Responsibility
Consistent with Policy Changes
REFORMING PAYMENT FOR
OUTPATIENT
PHYSICAL THERAPY

Based on Clinical Judgment of the PT rather than
selection of intervention and time

Clinical Reasoning Value over solely selection of
procedures

Consolidation of the Code Set

Re-valuing services at a visit level vs. procedural
level

More Consistent with Future Models
(Bundling/Integrated Models
REFORMING PAYMENT FOR
OUTPATIENT
PHYSICAL THERAPY



2-level “Severity and Intensity” system
Evaluation

Severity: Patient Need Over Episode of Care

Intensity: Tiered Evaluation
Examination and Intervention System: Visit Base

Severity: Patient Presentation at Visit

Intensity: Intervention Needed to Address Visit’s
Contribution to Treatment Plan
REFORMING PAYMENT FOR
OUTPATIENT
PHYSICAL THERAPY

Potential Coding System – 18 new codes?

Time Line
Stage
Concept
Timeline
March ’11
Member Action
Board Appointed
Experts to CPT/RUC
Board Action
Stakeholders
Presentation
AMA Meeting
Recommendation
CPT / RUC Meetings
Education / Information
AMA Meeting
Member Survey
Comment /
Support
June ’11
Member Comments
on Concept Paper
CPT / RUC Meetings
Education / Information
Refinement
July ’11 –
October
‘11
Education
Endorsement /
Recommendation
AMA Workgroup
Refinement
Fall ’11
Education
Potential Budget
Implications
Consultant
2012
Education
Education /
Information
AMA
CMS
Congress
Private Payers
Workers Comp
Proposal /
Implementation
JOIN A COMMITTEE TODAY
&
RECRUIT AT LEAST
MEMBER
1