New Medicare Guidelines Limit Physician Orders for Hospital Rehabilitation Patients
On November 18, 2011, the Centers for Medicare and Medicaid Services (CMS) released guidance (CMS Transmittal 72) to reportedly reflect regulatory changes in hospital rehabilitation and respiratory care services. The current regulations include broad language stating that services must be ordered by a qualified and licensed practitioner who is responsible for the care of the patient and who is authorized by the hospital medical staff to order the services. However, Transmittal 72, which is an interpretive guideline, indicates the practitioner must have medical staff privileges.
ASHA recognizes the barriers to care that result in this guidance as well as the inconsistencies with previous publications by CMS in the Federal Register (August 16, 2010 and October 24, 2011). ASHA staff are partnering with representatives from the American Physical Therapy Association (APTA), the American Occupational Therapy Association (AOTA), the American Medical Rehabilitation Providers Association (AMRPA), the Federation of American Hospitals (FAH), and the American Hospital Association (AHA) to request CMS to rescind Transmittal 72 and amend the guidelines to be consistent with previous CMS policy statements which allow state laws and regulations as well as hospital policy and staff, to determine ordering privileges of rehabilitation services.
Please contact Lisa Satterfield, ASHA’s director of health care regulatory advocacy, at lsatterfield@asha.org with any questions or concerns
Lemmietta G. McNeilly, PhD, CCC-SLP, CAE, ASHA Fellow
Chief Staff Officer, Speech-Language Pathology
American Speech-Language-Hearing Association
2200 Research Boulevard, #229
Rockville, MD 20850-3289
+1 301-296-5705 telephone
BCBS & Cognitive Therapy
BlueCross BlueShield Association
(BCBSA) recently removed its report that regarded cognitive rehab as
investigational. Here is what I can tell you and what actions you might
consider at this time:
The BlueCross and BlueShield Association (BCBSA) 2008 Technology
Evaluation Center assessment report, Cognitive Rehabilitation for Traumatic
Brain Injury in Adults, was recently removed from the company’s public website.
The report noted that data were insufficient to determine whether cognitive
rehabilitation results in beneficial health outcomes, and concluded the
treatment was investigational. ASHA disputed that position, providing
supportive evidence for the treatment, including data from ASHA’s National
Outcomes Measurement System.
BCBSA posts assessment reports on its public website for three
years, and recently removed the cognitive rehabilitation report without a
revised version in its place. This may signal a change in BCBSA policy on
cognitive rehabilitation and clinicians may be better positioned to negotiate
for improved coverage of this treatment area with local BlueCross BlueShield
Plans. BCBSA policies are made available to the 39 independently owned and
operated BlueCross BlueShield plans; the plans can choose whether or not to
follow current policies when creating or updating their individual medical
policies.
Speech-language pathologists can use BCBSA’s removal of its policy
on cognitive rehabilitation for TBI patients as a signal to advocate for
coverage with local and regional BCBS plans. In requesting coverage, SLPs
should provide the health plans with a rationale on why the service should be
covered, along with published reports and research supporting treatment (e-mailjmcarty@asha.org to receive this information).
Additionally, SLPs can contact the BCBSA to inquire about the
recently removed report, and to ask if there is a new or current policy that
replaces the removed report. SLPs can also encourage regional BCBS Plans to
check with BCBSA on its current assessment of cognitive rehabilitation for TBI.
Keep in mind that each regional BCBS plan operates independently
and coverage contracts differ among the plans. Noncoverage may be due to
a contractual requirement (e.g., the contract specifies that cognitive
rehabilitation is not covered) rather than, say, a medical necessity decision.
Nevertheless, BCBSA’s removal of its assessment report on cognitive
rehabilitation from its public website may be an opportunity for SLPs and
consumers to advocate for improved coverage of medically necessary
cognitive rehabilitation for TBI patients.
Let me know if I can assist you and your colleagues in your
efforts to improve coverage for cognitive rehabilitation. This appears to be a
good time for taking action.
Janet McCarty, M.Ed.
Private Health Plans Advisor
American Speech-Language-Hearing Association
Government Relations and Public Policy
2200 Research Boulevard, #220
Rockville, MD 20850
Direct Line: 301-296-5674
National Office: 301-296-5700
jmccarty@asha.org
Fax: 301-296-8577
http://www.asha.org
Forwarded from: Mark Kander
Director, Health Care Regulatory Analysis
mkander@asha.org
Direct: 301-296-5669
Posted
October 21, 2011
SNF Medicare Rules Finalized for FY2012
The Centers for Medicare and Medicaid Services (CMS) issued final regulations for Part A services in skilled nursing facilities (SNFs) on July 29, 2011, effective October 1, 2011. Overall payments to SNFs in FY2012 will be reduced by 11.1%, mainly due to the overutilization of therapy payment categories compared to expected projections.
Reduced supervision of therapy students. CMS has removed specific student supervision restrictions in SNFs because hospitals have no such restrictions for Part A patients. The objective was to promote greater conformity with other inpatient settings. As stated in the proposed rule, the new requirement is that “each SNF will determine for itself the appropriate manner of supervision of therapy students consistent with applicable state and local laws and practice standards.” CMS emphasized that a new, different method of supervision would in no way alter the individual’s basic status as a student operating under the therapist’s supervision and “the time the student spends with a patient will continue to be billed as if it were the supervising therapist alone providing the therapy.”
Group therapy. The CMS proposal that defines optimal group treatment as requiring four-persons remains unchanged in the final regulation. Thus, if a group therapy session consists of two or three patients, the session length must be divided by four (e.g., a 30-minute session with three patients yields 30 ÷ 4 = 7 minutes counted toward the Resource Utilization Group (RUG) level of care). The proposed four-person group treatment standard was protested by ASHA, noting that there is no research to support the assumption that four persons are optimal. A longstanding SNF Part A rule remains, allowing up to 25% of therapy per discipline per week to be group therapy.
End of therapy OMRAs. Changes also affect Other Medicare Required Assessments (OMRAs). CMS proposed that an interruption of three days of therapy would require that the patient be discharged from therapy and require an OMRA when restarting therapy, whether or not the SNF maintained a five-day or seven-day therapy schedule. For example, if the patient received no therapy on Friday, Saturday, and Sunday then an assessment would be required, even though such an OMRA serves no purpose as a clinical management tool. ASHA pointed out that there are many reasons for a missed treatment on the last day of the work week – Friday (e.g., patient illness, therapist illness, patient refusal, visit to physician’s office) extending the interrupted therapy to three days. We recommended the requirement be revised to four days to avoid many unnecessary discharges and reassessments, but the minimum missed treatment period will stand at three days.
The final rule is posted on the Office of the Federal Register’s Web site at http://www.ofr.gov/OFRUpload/OFRData/2011-19544_PI.pdf. For additional information, please contact Mark Kander, ASHA’s director of health care regulatory analysis, by e-mail at mkander@asha.org.
Posted August 8, 2011
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