Payment Policy Updates Fall 2019 Steffes & Associates Consulting Group, LLC

WI Medicaid Updated PA Process for 0-21 Years old

Medicare- Med B Functional Reporting- G-Codes stopping 1/1/19 No fee schedule updates in 2020-2025! Merit-based Incentive Program “MIPS” Opportunities: Private Practice Therapists ONLY in 2019 Based on individual PT NPI + Tax ID for Op Facility Low Volume Threshold> will likely affect only 5% of PP PTs! Qualified Providers: PTs, OTs enrolled in MC (NPI) Bill out > 200 MC allowable Services (Units) See > 200 Unique MC pts/yr (Based on 2016 data) Receive > $90,000 allowable MC payments Optional Group Participation if meet 1 Criteria Above Possible Punitive adjustment of 7%- for 2 year following year’s claims Possible incentive UP to 7%

Medicare Updates Congress reduced 2019 Medicare update to Fee Schedule from .50% to .25% 2019-2024: Alternative Payment Models: Eligible for 5% bonus MIPS: Eligible for +/- payment adjustment 2026 and beyond: Providers in Advanced APM will receive .75% update MIPS providers will receive .25% update inflationary adjustment resumes New Modifiers will be added in 2020 for services where PTAs provide 10% or more>

CAP Therapy CAP- increased the KX modifier threshold by 1.5% and rounded up to give rehab therapists a shiny new soft cap of $2,040 for PT and SLP services combined and $2,040 for OT services. Therapy Threshold for targeted medical review (MR) threshold will remain at $3,000, and, as has always been the case, “some, but not all claims exceeding the MR threshold are subject to review.”

Therapy CAP Exceptions Process EXTENDED! 2019 Therapy Threshold= $3000 KX Modifier continues after the Threshold Manual Medical Review may be applied RAC’s are prohibited from doing the Reviews CMS has contracted with Strategic Health Solutions to complete these reviews post-payment Chosen based on High Claims Denial % Aberrant Pattern of Billing Newly enrolled or new to Part B

MIPS- Private Practices Only 2019

MIPS Reporting looks a lot like PQRS Meds on Eval BMI on Eval Pain on eval & re-eval Functional Measure on Eval & Re-eval Falls Risk & Plan on Eval (Combined now) You must be compliant not report code that is not Can do Claims Based Reporting if you have < 15 Providers- RISK Increase! Must use Registry above that threshold APTA has Outcomes Registry CURRENTLY WAIVED!!! $299/Therapist/yr members; $399/Therapist/yr non-members’ Some EMR Integration Automation Ability to track performance Additional Important PT outcomes info

Anthem BCBS- AIM

AIM

AIM Request

AIM Challenges CONTACT: RehabProgram@aimspecialtyhealth.com for program related questions

Network Health Plan: eviCore

Sample Therapy corePathSM Pathway Initial Requests Case Related Questions: Identify new care vs. continuing care based on treatment area, not time Identify primary area of treatment First indicator of complexity – second unrelated treatment area 1 2 3

Sample Therapy corePathSM Pathway Initial Requests, continued…. Initial Clinical Questions: Enter functional score, if available Oswestry Index Neck Disability Index LEFS Dash / QuickDASH Incorporates ROM, Strength, Pain, etc. Complexity: Neural signs Chronicity 4 5 6 High Potential for Immediate Approval When Pathway is Completed!

Sample Therapy corePathSM Pathway Follow-Up Request Follow-Up Clinical Questions: Current and Previous Functional Score Complexity Question – Neural Signs Progress Validated scores have MCD (minimal clinical difference) as progress indicator Clinical Assessment 1 2 3 Be clear – this is for a low back condition. Actual number of questions will differ per request, but the concept is the same, only key clinical information is collected. High Potential for Immediate Approval When Pathway is Completed!

Prior Authorization Process What is used to determine if services are medically necessary? Clinical Criteria Available 24/7 @ www.evicore.com Synthesis of research, guidelines, expert consensus Updated annually and approved by the Health Plan Clinical Information Should be current Adult within the prior 14 days Peds within the prior 20 days; standardized tests 1x/year Complete the questions If there is no information or information has gaps, it will delay the decision Worksheets are available at www.evicore.com to guide your clinical collection

Prior Authorization Process Requesting Authorization For the first request Evaluate the member before you request prior authorization Evaluation codes do not require prior authorization Submit your request within 7 days of the requested start date If additional care is needed You may submit your request as early as 7 days prior to the requested start date This allows time for the request to be reviewed and prevents a gap in care Remember to provide complete, current clinical information including patient reported functional outcome measures Notes: Requests with a start date of > than 7 days in the future will not be accepted. If the member is away from therapy, reassess the condition once therapy has resumed. This allows you to provide current information to allow eviCore to determine medical necessity of ongoing therapy.

Prior Authorization Process Timely Filing Security Health Plan allows providers to evaluate and treat at the initial visit. The evaluation code does not require prior authorization but treatment does. If treatment is provided during the evaluation visit, you have 7 days from the date of service to submit your request for authorization for the initial treatment. Authorization for treatment beyond the initial visit must be requested prior to providing care. Retrospective requests will be accepted up to 7 business days. Please note that any cases after 7 business days will be expired.

Wi Worker’s Compensation Fee Schedule and Policy Updates

Lynn Steffes, PT, DPT Steffes & Associates Consulting Group, LLC steffbiz@gmail.com