Progress Seen on Addressing Therapy Cap Problem

Although snowstorms have wreaked havoc on the NASL Winter Legislative and Regulatory Conference while bringing most of Washington to its knees, Capitol Hill is still working behind the scenes on legislation to address several key Medicare issues..  Text of a proposed Senate “jobs bill” was released today, which includes three Medicare provisions important to NASL members: 

• Extension of the therapy cap exceptions process through December 31, 2010 (Sec. 613, Page 107)
• Extension of the current level in the Physician Fee Schedule through September 30, 2010 (Sec. 612, Page 107)
• Extension of the GPCI (rural payments) floor through December 31, 2010 (Sec. 617, Page 113) 

Senate Democrats hope to add Republican support to the bill, which includes a number of tax provisions, and there appears to be sufficient support for quick passage of the bill.

Unfortunately, the approaching winter storm that forced NASL to postpone the Winter Conference also prompted the House to cancel floor votes for the rest of this week. Next week is a scheduled district work period to commemorate the President’s Day holiday. While there had been hope that this legislation might reach the Senate floor by the end of the week, action probably will not be completed until the House and Senate reconvene the week of February 22. However, it appears that we are finally moving closer to restoring access to therapy services for Medicare beneficiaries.

Therapy Cap Update

NASL participated in a meeting of therapy cap stakeholders this afternoon to discuss efforts to promote the passage of legislation to extend the therapy cap exceptions process. The Senate election in Massachusetts last Tuesday has essentially halted health reform negotiations, and it is causing congressional leaders to step back and reassess their strategy for moving forward.  There is now considerable uncertainty about the prospects for passing health reform this year.  

Even if Congress were to proceed with a health reform bill, it could take some time to draft a revised plan, which makes it a less than ideal vehicle for addressing the therapy caps issue. NASL and other therapy organizations are mobilizing to press for the expeditious consideration of therapy cap relief, and we are exploring all avenues to accomplish this goal.

We know that with each passing day, more patients are in danger of hitting or exceeding the caps.  While the congressional commitment to address the therapy caps problem remains strong, and we believe they will make any solution retroactive to January 1, 2010, we cannot take anything for granted. While NASL members can feel optimistic that a solution will occur eventually, providers and patients should plan for further disruptions in the short term. 

As we seek congressional action, we need to continue to generate constituent correspondence. The NASL advocacy website has processed more than 2,300 messages since Friday, but a noisy constituency is necessary to educate legislators and put them on notice that patients are beginning to experience a disruption in care because of the imposition of the therapy caps.

In addition to our electronic advocacy campaign, NASL and its allies are: 

• Contacting key legislators and staff to seek prompt consideration of therapy relief legislation
• Sending a joint letter to congressional leaders signed by a host of provider and patient groups
• Planning a therapy cap press conference featuring legislators and representatives from patient groups
• Preparing to place paid advertising in key Capitol Hill publications
• Engaging other organizations such as American Association of Retired People (AARP) and the Military Officers Association of America (MOAA) to become active on this issue

Action Needed 

• Please urge your employees to visit the NASL Advocacy Center www.capwiz.com/nasl to send messages to their legislators in support of the exceptions process.  NASL has prepared a “Dear Employee” letter that you can use to alert your employees. 

• Please call your legislator to reinforce the message. You can use the NASL Advocacy Center www.capwiz.com/nasl to find contact information for your legislators. Click on the “Elected Officials” tab, and then enter your Zip Code. Click on your representative or senators, and then click the “Contact” tab to find information about contacting them by telephone. You can call either a local office or the Washington office. If you call the Washington office, please ask to speak with the Health Legislative Assistant. These talking points might help you present your message. 

• As your patients reach the cap, please document problems your patients are encountering and provide vignettes to Alan Peterson alan@nasl.org, so we can build an inventory of examples to show Congress. We understand that companies might be reluctant to disclose exact numbers of patients affected, but estimates would be helpful. Things that would be helpful to know with individual case studies include the following: 
  • The diagnosis of the beneficiary, and why they were receiving outpatient therapy
  • Therapy disciplines involved in the treatment
  • The demographics of the beneficiary (Age? Rural? Complicating factors?)
  • How the beneficiary was benefiting from therapy and implications of halting care
  • Why transferring care to a hospital outpatient department for therapy was not appropriate (Cost? Distance? Treatment?)

NASL Advocacy Center

The NASL Advocacy Center www.capwiz.com/nasl is primed to facilitate grassroots action by NASL members and their employees on the therapy cap issue.

The NASL site is easy to use and requires a minimum amount of effort.  A sample letter is posted, and while we encourage people to personalize their messages, it is not required.  Employees can send e-mail messages to their legislators simply by adding their names and addresses to the letter we have prepared.  People sending messages through the site will receive a confirmation message from NASL.

It is not necessary for people to know the names and addresses of their legislators in order to send messages.  All we need is a person’s Zip Code in order to match them with their legislators – the advocacy center does the matching automatically. 

In order for the advocacy center to be effective, we need your help in encouraging employees to visit the site.  The NASL Advocacy Center provides an easy way for your employees to register their concerns on the therapy cap issue with their legislators.

Therapy Cap Advocacy Update

NASL and other therapy stakeholders have been working with patient groups in pressing Congress to pass legislation to extend the therapy cap exceptions process. A letter signed by nearly 40 patient and provider groups has been sent to House and Senate leaders. This has provided some much-needed press coverage about the problem. The newspaper The Hill and two subscription publications carried stories yesterday about the therapy cap problem.

NASL is working with another coalition representing groups supporting 10 of other Medicare “extenders” that were allowed to expire January 1. In addition to therapy caps, these provisions were also allowed to lapse: 

• Work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule
• Payment for technical component of certain physician pathology services
• Ambulance add-ons
• Certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities
• Physician fee schedule mental health add-on
• Outpatient hold harmless provision
• Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas
• Rural Community Hospital Demonstration Program
• Medicare-dependent hospital (MDH) program
• Hospital wage index improvement 

A separate coalition letter representing all of the groups interested in these extenders will be sent to congressional leaders next week.

Meanwhile, the NASL Advocacy Center www.capwiz.com/nasl has generated more than 6,500 messages to congressional offices, and the information you have provided to NASL regarding patient vignettes and numbers of people reaching therapy caps has been used to bolster our advocacy efforts. 

It appears that Congress is finally getting the message. We have received reports from several different sources that Congress intends to address the therapy cap problem later this month. A jobs bill and a tax extenders bill are the likely legislative vehicles for this effort.

We hope to provide more clarity at the NASL Winter Legislative and Regulatory Conference next week. In the meantime, please continue to support our grassroots efforts by directing your employees to the NASL Advocacy Center.  We need to keep up the pressure on this issue.

If you are attending the NASL conference, please consider setting up appointments to see your legislators. Please visit the NASL Advocacy Center www.capwiz.com/nasl and click on “Elected Officials” tab to find your legislator – telephone numbers and addresses are available on the “Contacts tab.”  You might be asked to put your request in writing.

The effective date question has now been answered.  Bundling will become effective for dates of service beginning August 1, 2009.  This means that the over-the-counter pharmacy denials that have been issued recently should be reversed.  The following is the text of the message from ODJFS:

For dates of service on or after August 1, 2009, ODJFS will no longer process claims for custom wheelchairs and repairs; physical, occupational and speech language pathology/audiology therapy; medical transportation; oxygen; and certain over-the counter drugs.  Nursing facilities will now be responsible for providing these services to Medicaid residents and will be reimbursed through the NF per diem.  If you have questions related to claims for these services, please contact Joseph Doodan at 614-752-4765.  If you have questions related to nursing facility reimbursement, please contact Julie Evers at 614/752-3618.

Should you have additional questions, please contact Pete Van Runkle (pvanrunkle@ohca.org), 614/436-4154 or Mike Compton (mcompton@ohca.org), 614/540-1326.

OHCA has recently learned that a number of member facilities have received a case mix penalty letter related to their annual case mix score calculation because of errors in their records at the end of the first quarter of the year, March 31, 2009. The letter cites language in OAC 5101:3-3-43.3 that allows the agency to reduce the quarterly facility average total case mix score five percent less than the quarterly facility average total case mix score from the preceding calendar quarter. ODJFS has explained that when a facility has an assigned or a penalty score that score is not used to calculate the provider's annual facility average case mix score. Rather, instead of averaging four quarterly scores, three quarterly scores will be averaged when there is an assigned and/or penalty score i! mposed (the penalty score will be dropped from the calculation). On the other hand, a penalty or assigned score can be used to calculate a semiannual case mix score. which is the score use to determine direct care rate setting. The annual case mix score is used for calculating one of quality incentive points, whether a facility’s is above the statewide average

In the ODJFS letter, reasons for the penalty are noted as failure to submit appropriate modifications or discharge tracking records by the eightieth day after the reporting period end date. The most frequently reported problems reported historically by ODJFS are facility end of quarter assessment records exceeding their certified capacity, and Social Security Number errors.

ODJFS officials explain that currently there is no appeal process for case mix score penalties as a result of NF submission errors. They explain that skilled nursing facilities are given several opportunities to correct submission errors (weekly reports, two preliminary case mix score reports). Also, as a courtesy, the MDS Help Desk calls facilities with submission errors each time a preliminary report is posted.

A facility’s case mix score is still one part of their reimbursement that a facility can manage and impact, so preventing reductions and penalties should be of a very high priority. In addition to the reports and courtesy calls from ODJFS, there are a variety of MDS Key Reports that can be useful tools for facilities in developing systems to prevent or correct data problems before they even get to the quarter end preliminary reports. One such report is the Roster Report, that lists all residents currently in the system and their last assessment date. At a minimum, facilities need to have a routine system to effectively review and correct problems found on the series of two preliminary scores provided though the submission system. That needs to include comparing all resident assessment reports listed on the preliminary reports with the facility’s census at the end of the ! quarter. If assessments are found in the quarter end batch that were not in the facility census, either actually, or on a bed hold, the facility needs to complete appropriate discharge tracking forms. The problem related to Social Security Number is generally that an individual resident can end up with multiple records as if they were more than one person. When this is found, it is necessary to correct the SSN in all of the resident’s assessment files, even the historical records. The duplicate resident report may assist in finding this type of error.

OHCA has posted the MDS Key Report on the Clinical & Operational page of the Association website under MDS: MDS Key Reports - Revised 10.01.06. This also includes an explanation and example of the preliminary reports that come out of the system and how they must be rectified with the reporting period end date census.

Many of the reports that are available from the MDS system are helpful tools, including validation reports of actual submissions that facilities are advised to keep on file as evidence of successful submissions. They may also be used as gauges of a facility’s MDS process and areas that may need improvement.

OHCA is developing a webinar on this topic that will go into more detail about the importance of these reports.

OHCA members may receive inquiries from local media, consumers and others regarding the impact of the budget on the facility and its services.  We recommend that providers base their comments to the media on the impact the budget will have on their own facility.  Specifically, providers should be ready to discuss:

• Net cost of the franchise permit fee

• Impact of bundling on the cost of services vs. payment provided, and whether facility policies/services will change as a result

• If the facility will need to make additional staff layoffs, cancel raises, make pay cuts (it will also be useful to discuss whether such actions have previously been taken)

• Other policy changes, cost cutting or service reduction measures that may be considered

The following talking points can be used to address the issues broadly:

• Ohio’s skilled nursing facilities – which provide around-the-clock care to 80,000 frail elderly and disabled patients – are now confronted with the harsh reality of meeting increased demand for quality, around-the-clock care with $184 million less in available resources, even though costs continue to climb.

• Many skilled nursing facilities will have to reduce staffing levels even more than they already have. While skilled nursing facilities and their employees strive to provide good quality care at all times, this could result in longer wait times for treatments or some cutbacks in non-critical care.

• While the budget will increase the per diem payment for nursing facility care, additional costs will include a $5.70 increase in the franchise permit fee (per bed tax) to at least $11.95 (from the current $6.25), and will also now include costs for oxygen, transportation, over-the-counter drugs, therapy, and wheelchairs for Medicaid patients, which were previously billed directly from the service provider.  The increase in the Medicaid rate does not cover the full cost of the bed tax or the additional services; as a result nearly 90% of Medicaid-participating facilities will be losing money compared to what they received last year.

• The statewide average Medicaid reimbursement rate is being held flat for the next two years while the costs of providing quality care continue to increase.

• For the last five years, the rate of inflation has been three times greater than the minimal rate increases (1.1% per year) skilled care facilities have received.  Some facilities will not be able to absorb the additional reductions and may have to shut their doors.

• We will continue to serve our residents by providing the best health care and services we can, in a safe and clean environment.

Should you need additional information or have questions regarding taking to media representatives, please contact Steve Mould (smould@ohca.org), 614/540-1325.  For more details regarding the budget and its impact, please contact Pete Van Runkle (pvanrunkle@ohca.org), 614/436-4154 or Mike Compton (mcompton@ohca.org), 614/540-1326.  

Bundling Update

Effective Date 

We are getting more indications that ODJFS does not intend to enforce a July 1, 2009, effective date on bundling.  No official announcement has been made, but signs are pointing that direction.  For instance, a draft administrative rule on wheelchairs states that custom wheelchairs that are “in process” on the effective date of the rule (which is not finalized yet) will be paid through the direct billing mechanism.  We hope to have an answer on effective date in the next couple of days.

Coinsurance 

Although ODJFS has told us verbally on several occasions that Part B coinsurance for therapy is included in bundling (and the cost of coinsurance was factored into the $3.91 consolidated services payment), we are pushing the department not to include coinsurance.  It should be noted that coinsurance for other bundled items that are covered by Part B is not bundled.

Another note on Part B therapy – there is nothing about bundling that prohibits billing Medicare Part B.  The issue is about billing the coinsurance to Medicaid, if the patient does not have other insurance that covers it.

Fee Screens 

When ODJFS established the $3.91 per diem for bundled services, that amount represented the sum of calculated per diems for the five services.  The per diems were determined based on the amounts Medicaid paid for the services under direct billing.  As a result, the fee screens Medicaid uses for payment purposes are relevant for SNFs in determining how much to pay for the services going forward.  The fee screens for transportation, oxygen, and wheelchairs are available at OHCA Online under Ancillary Bundling on the Reimbursement page (www.ohca.org/content/view/93/243/).  

ODJFS, however, did not totally base the per diems on the fee screens.  In the case of oxygen, the per diem was based on $50 per month for concentrator rental, considerably below the current fee screen.  Also in the case of over-the-counter drugs (for which we have not yet received the fee screen), there was a downward adjustment.  We do not believe there were adjustments for wheelchairs, transportation, or therapy, but we are awaiting confirmation of that.

Should you have questions, please contact Pete Van Runkle (pvanrunkle@ohca.org), 614/436-4154 or Mike Compton (mcompton@ohca.org), 614/540-1326.

This bulletin is to address a few very time-sensitive issues about the recently passed state budget (House Bill 1) that we have heard from members.:

• SNF rates will stay the same for now.  Your Medicaid rate will not change for at least the next three months.  Normally new rates apply in mid-August, but that will not be the case this year.  New rates will be paid starting in October, and a retroactive payment will be made to cover the July-October period.

• Bundling took effect July 1, 2009.  Contrary to information that has been disseminated by various parties saying “Senate and Legislative Service Commission sources” indicate bundling will not take effect for 90 days, this is not true.  The specific language of House Bill 1 provides that bundling is effective July 1, 2009.  We are seeking definitive information from the Ohio Department of Job and Family Services (ODJFS) about how this effective date will be implemented and will notify members as soon as we learn something.

• Bundling includes Part B therapy coinsurance.  Again, there has been some confusion about what is included in bundling under the broad rubric of “Medicaid therapy.”  ODJFS has confirmed that both therapy provided to Medicaid-only SNF patients and coinsurance for dual eligible patients who receive Medicare Part B therapy are included in bundling and will not be separately paid by ODJFS.

Should you have questions, please contact Pete Van Runkle (pvanrunkle@ohca.org), 614/436-4154.

Robert D. Robbins (R)

Senate District 50
Butler (part), Crawford, Lawrence (part)
and Mercer Counties.

D.O. ADDRESS: 259 Main Street
Greenville, PA 16125-2054
(724) 588-1323  http://www.senatorrobbins.com

Jim Ferlo (D)

Senate District 38
Allegheny (part), Armstrong (part) and Westmoreland (part) Counties.

ADDRESS:

D.O. ADDRESS: 3519 Butler Street
Pittsburgh, PA 15201
(412) 621-3006 E-MAIL ADDRESS: ferlo@pasenate.com

Jane Clare Orie (R)

Senate District 40
Allegheny (part) and Butler (part) Counties.

D.O. ADDRESS: 9400 McKnight Road
LaCasa Blanca Building, Suite 105
Pittsburgh, PA 15237
(412) 630-9466 E-MAIL ADDRESS: jorie@pasen.gov

Donald C. White (R)

Senate District 41
Armstrong (part), Butler (part), Clearfield (part),
Indiana and Westmoreland (part) Counties.

D.O. ADDRESS: 618 Philadelphia Street
Indiana, PA 15701
(724) 357-0151 E-MAIL ADDRESS: dwhite@pasen.gov

Mary Jo White (R)

Senate District 21
Butler (part), Clarion, Erie (part),
Forest, Venango and Warren (part) Counties.

ADDRESS: Senate Box 203021
Harrisburg, PA 17120-3021 ROOM: 169 Capitol Building TELEPHONE: (717) 787-9684
D.O. ADDRESS: 464 Allegheny Boulevard
Franklin, PA 16323
(814) 432-4345 E-MAIL ADDRESS: mwhite@pasen.gov

Sean Logan (D)

Senate District 45
Allegheny (part) and Westmoreland (part) Counties.

D.O. ADDRESS: One Monroeville Center
3824 Northern Pike, Suite 600
Monroeville, PA 15146
(412) 380-2242
FAX: (412) 380-2249

 E-MAIL ADDRESS: logan@pasenate.com

Hon. Mark Longietti
2213 Shenango Valley Freeway
Unit 2-E
Hermitage, PA 16148
(724) 981-4655
Fax: (724) 981-6528

Hon. Richard R. Stevenson
234 West Pine Street
Grove City, PA 16127
(724) 458-4911
(800) 287-0085
Fax: (724) 450-4104

Hon. Michele Brooks
3 Greenville Plaza-West
Hadley Road
Greenville, PA 16125
(724) 588-8911
Fax: (724) 588-5464

Hon. Brian L. Ellis
6 Chesapeake Place
Suite 200
Lyndora, PA 16045
(724) 283-5852

Hon. Daryl D. Metcalfe
2525 Rochester Road
Municipal Building Suite 201
Cranberry Township, PA 16066
(724) 772-3110
Fax: (724) 772-2922

Hon. Frank Dermody
1331 Freeport Road
Cheswick, PA 15024
(724) 274-4770
Fax: (724) 274-8814

Hon. Jeffrey P. Pyle
208 1/2 N Railroad Ave
Apollo, PA 15613
(724) 478-1050
Fax: (724) 478-1529

Hon. Jaret Gibbons
309 Fifth Street
Ellwood City, PA 16117
(724) 752-1133
Fax: (724) 752-3784

Hon. Scott E. Hutchinson
302 Seneca Street
Oil City, PA 16301
(814) 677-6363
Fax: (814) 676-1653

Hon. John E. Pallone
1625 Fifth Avenue
Arnold, PA 15068
(724) 339-1990
(866) 725-5663
Fax: (724) 339-4030

Hon. Joseph A. Petrarca
239 Longfellow Street
Vandergrift, PA 15690
(724) 567-6982
Fax: (724) 567-0006

Hon. Tim Krieger
101 Ehalt Street
Greensburg, PA 15601
(724) 834-6400
Fax: (724) 834-6799

This is an interesting article - please contact representatives...

PTs in Skilled Nursing Care Contact Conferees

An initiative was proposed by Medicaid to the members of the conference committee to pull down more federal match for Medicaid. The Department would like to bundle ancillary services such as medical transportation, durable medical equipment, OT, PT and over the counter drugs as part of the overall costs of the skilled nursing facilities. This increase in overall costs of the SNFs will allow the state to increase their bed tax and allow the state to pull down more federal Medicaid match. The nursing facilities still lose $184 million over the two years. This means that the nursing facilities will contract directly with these providers and agree upon rates as well as pay them directly.

PTs in skilled nursing care need to contact the following members of the Conference Committee to voice opposition to the bundling of their services: