This blog will follow
AOTA’s Federal Affairs activities in Washington DC beginning with the Transition and Inauguration and following issues important to
the profession. A hopefully, humorous, open look at the business of Washington as it impacts
This week AOTA is writing comments to the Medicare Payment Advisory Commission (MedPAC) on their report on March 8 about outpatient therapy services in Medicare. MedPAC is an advisory body to the US Congress. The Commission is composed of appointees but the work is generally done by staff. MedPAC is paying attention to therapy because recent legislation, the Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630) that extended the cap exception process until the end of 2012 also required that MedPAC provide reports to Congress in June, 2013. Those reports must make recommendations on how to reform the payment system for therapy under Part B and examine how private sector payers regulate therapy benefits. (More information on the cap at the AOTA Legislative Action Center http://capwiz.com/aota/issues/alert/?alertid=61091881). (More on the issues of coding changes in the "Capital Briefing" in OT Practice for March 12.)
In the overview report provided in March, MedPAC staff noted that there was considerable growth in therapy utilization (more than 11% between 2008-2009). In skilled nursing facilities the growth for that year was 21%. Based on other data on Medicare Part B, AOTA knows that there continues to be considerable growth, well beyond what would be expected with just the growth in the number of Medicare beneficiaries. MedPAC noted that spending per person has increased but the number of therapy users has remained relatively constant. See the slides from the report here http://www.medpac.gov/meeting_search.cfm?SelectedDate=2012-03-08%2000:00:00.0. AOTA will challenge some of the concerns of MedPAC but we also understand that there is a lot of suspicion out there about therapy utilization.
Today, AOTA staff met with the Centers for Medicare and Medicaid Services (CMS) on how they plan to implement the exception process changes just passed. Remember we have the cap because there is a belief that too much therapy is provided that is not needed. Today's meeting focussed on how CMS will conduct medical reviews of claims that go over the over the additional threshhold of $3700; the cap remains at $1880 but additional review is allowed over $3700. Would providers provide services that then would be denied? Denials can mean providers have to pay back Medicare for services judged as not appropriate or not necessary or did not need the skills of a therapist. But in reality, CMS and its contractors have the right to judge appropriateness of billiing of every single submission of a claim. Given this, billing for therapy should always be based on clear and defensible need.
Every time a therapist provides and bills for a service to a patient, that therapist is saying "I believe this to be appropriate therapy. I am basing this on my professional judgment. I am basing this on what I know to be the rules of payment." I believe therapists are making good judgments in most cases but the growth numbers have to be reconciled. Policymakers clearly do not think therapists are using good judgment all the time. And this is a sad state of affairs.
That was brought home to me today when I saw a new report by the federal Department of Health and Human Services Office of Inspector General that began with this statement:
Past OIG work has shown that Medicare- and Medicaid-paid physical, occupational, and speech therapy services were vulnerable to improper payments because (1) plans of care were incomplete or missing; (2) documentation was missing, or providers failed to respond to our request for documentation; or (3) providers lacked proper qualifications, or we could not determine whether they had proper qualifications. (http://oig.hhs.gov/oei/reports/oei-07-10-00370.asp)
While this report did not uncover a huge amount of excess spending, the view of the agency should put all of us on high alert.
When therapy is provided therapists must think about the coverage criteria, the patient's needs, best practice and their own ethical principles. For Medicare, services must require the SKILLS of a professional, substantial IMPROVEMENT should be expected, treatment should be based on accepted practices and must be related to the individual's conditions and functional limitations. It is your profession, your integrity and your future that is on the line when you provide services and bill for them under your name. You as the practitioner attest to the validity of the therapy and the need for the service as soon as you provide it. Occupational therapy practitioners have so much to give that enables living life to its fullest; people need occupational therapy services and benefit by them. The Medicare program will benefit by lower costs in the future if proper therapy is provided.
AOTA will continue to work to make sure that policymakers have all the facts about what you do but practitioners must support this by being responsible for using your best clinical judgment every day in every therapy intervention. It will make all the difference.
Was there any conversation about how much of this might be accounted for by fraud? The automatic assumption of improper 'actual' utilization is a little odd; I think there are many possible factors that could contribute to changes in numbers. Given the specificity of data that they have and are able to analyze it seems prudent to take a hard look at high utilization geographic regions and practice settings. Was this discussed? Or will the data simply be used generically as a justification for utilization control?
Christopher J. Alterio, Dr.OT, OTR
Most policy observers think there is fraud involved in some cases, weak justification in others, and poor practice in others. They could target policies to the regions and practice settings "suspected" of overutilization but that might not be consistent with Medicare law. Those suspected of overutilization at this time are now subject to contractor review and investigation by authorities such as the Department of Justice. While unfair, the "automatic assumption" has been with us for 15 years...since the outpatient cap was put into place.