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Information Regarding the Holding of April Claims for Services Paid Under the 2010 Medicare Physician Fee Schedule (03/26/2010)

The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule (MPFS). As you are aware, the Temporary Extension Act of 2010, enacted on March 2, 2010, extended the zero percent (0%) update to the 2010 MPFS through March 31, 2010.

The Centers for Medicare & Medicaid Services believes Congress is working to avert the negative update that will take effect April 1. Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of April. This hold will only affect claims with dates of service April 1, 2010, and forward. In addition, the hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.

Be on the alert for more information about the 2010 MPFS update.

CQ HEALTHBEAT NEWS: Advocates for Lifting Therapy Caps Push for Long-Term Solution (March 3, 2010) By Jane Norman, CQ HealthBeat Associate Editor

Advocates for patients and providers said at a Capitol Hill news conference on Wednesday that they’re grateful for a brief reprieve from caps on Medicare Part B therapy services enacted by Congress, but remain worried about what’s going to happen yet this year and the impact on individuals.

Seniors and people with disabilities who receive therapy services in connection with strokes, Parkinson’s disease or other debilitating conditions have again become caught up in congressional disputes over spending. The Senate late Tuesday cleared a package (HR4691) on a 78-19 vote that will extend a host of programs, including a Medicare exceptions process for therapy caps, through March 31. President Obama signed the bill into law a short time later. The bill had been blocked by Sen.JimBunning, R-Ky., who had demanded spending offsets.

Despite the breathing room until the end of March, elderly people, their families and providers are left in confusion and uncertainty about what happens next, advocates said. “This is not an easy thing to explain to patients,” said John Schall, deputy CEO of the Parkinson’s Action Network. It’s also a nightmare for administration of services, advocates said.

At issue is the “therapy cap” at which Medicare cuts off payments for physical and occupational therapy and speech-language pathology services once reimbursements reach $1,860 in a calendar year. The cap was enacted in 1997 as part of a balanced budget law, but Congress has acted many times to keep it from taking effect.

The cap is subject to an exceptions process that exempts virtually all Medicare patients. However, legislation that provides for exceptions to the cap ran out at the end of 2009. The Senate health care overhaul bill (HR3590) contained a one-year extension and the House version (HR3962) provided for a two-year extension, but with those bills stalled, the caps kicked in.

A legislative proposal unveiled Monday by Senate Majority LeaderHarryReid, D-Nev., and Finance ChairmanMaxBaucus, D-Mont., would extend through the end of the year the exceptions process. The 10-year cost would be $400 million.

More than 40 groups, also including the American Occupational Therapy Association and the American Speech-Language Hearing Association, have united to push for a long-term solution when it comes to therapy under Medicare. Eric Aldrich, professor of neurology and physical medicine and rehabilitation at Johns Hopkins School of Medicine in Baltimore, said that “the job is not done until Medicare patients are protected from these caps.” He said that about 70 percent of the 6.4 million people annually who suffer from a stroke are Medicare beneficiaries.

Between half and 70 percent of stroke survivors regain their independence but they need therapy to make it work, said Aldrich, who’s also president of the board of directors of the Mid-Atlantic Affiliate of the American Heart Association/American Stroke Association. Advocates estimate that, based on claims data, as many as 5 to 15 percent of Medicare beneficiaries who have strokes receive therapy that costs more than the cap.

The American Health Care Association, which represents nursing homes, estimates that more than 10,000 patients in its member facilities hit the therapy cap in January and February and had to give up on services.

The advocate groups collected anecdotes from members about patients’ experiences with the cap, including one submitted to the American Physical Therapy Association from a physical therapist. She said she works in a skilled nursing facility with a long-term resident who was a college athlete and state record holder when he was young. The man has had to have a below-knee amputation of one leg and couldn’t bear weight on his second leg. Following a hospitalization, through therapy the man became able to move himself from his bed to his wheelchair using his prosthesis. Therapists were hoping for more but as of mid-January he had met the cap on therapy and can’t pay on his own for services.

 

 

 

 

 

 

 

 

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