Tag: declining reimbursements

Mary Daulong, Founder and CEO of BCMS, discusses the final rule of the 2023 CMS Physician Fee Schedule.

Medicare reimbursement cuts for physical therapists have been finalized for 2023.

On November 01, 2022, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the Medicare Physician Fee Schedule (PFS) and other Medicare Part B issues, effective on or after January 1, 2023. Here’s what we know. 

To help physical therapists and practice owners understand the final cuts to Medicare reimbursements in 2023, we’ve reassembled last year’s panel which discussed the 2022 Medicare Cuts.

Chad Madden, co-founder of Breakthrough, Mary Daulong and Alicia Mahoney—CEO and COO at Business & Clinical Management Services (BCMS)—linked up once more to discuss the 2023 changes to the CMS Physician Fee Schedule. They hosted a live Q&A with hundreds of interested practice owners and therapists. 

When you next have time, we highly recommend checking out the webinar recording. 

A summary of that conversation, including the key things you need to know about next year’s Medicare Cuts, is documented in this article.  

Q: What are the key changes proposed for the 2023 medicare payments?

A: In a nutshell…

  • The CY 2023 fee schedule conversion factor is $33.08, a 4.42% decrease (or $1.53) from the CY 2022—the lowest since the 1990s.
  • The Assistant Payment Differential (APD) is here to stay.
  • Assistant supervision is scheduled to expire at the end of 2022, but Medicare is proposing to extend the ability for therapists to conduct general supervision.
  • Therapists are still not on the permanent list of telehealth suppliers/providers.

Q: How can we minimize revenue reductions caused by the APD?

A: As much as many of us would love for this not to be the case, Assistant Payment Differential (APD) is looking more and more like it’s here to stay. When we look at our neighboring professions, we see how they have been dealing with it in a similar way for years. The good news is, there are actionable steps we can take to minimize revenue reductions caused by APD. These include:

  1. Avoiding co-managing a visit with an assistant. It lessens the administrative burden of counting time, which saves money
  2. Do not use assistants to help with evaluations and re-evaluations, as it will decrease the fee paid by Medicare
  3. Use assistants to perform the objective elements of Progress Reports, as this is not billable to Medicare

Q: Will Assistant Supervision rules be adapted or changed in 2023?

A: As many of you will know, during the pandemic therapists were allowed to conduct ‘general supervision’ of clients and patients which allowed for audio-visual supervision to take place as opposed to direct supervision. General supervision however is scheduled to expire at the end of 2022, although Medicare is proposing that it continues—despite not providing a clear target on the calendar. We will update our community as soon as we have a clearer consensus.  

Q: Are there any changes about who can and cannot provide Telehealth in 2023?

A: Therapists are still not on the permanent list of telehealth suppliers/providers. However, the House has passed the Advancing Telehealth Beyond COVID-19 Act. This bill that would extend the CMS waiver permits for telehealth by therapists until December 31st, 2024, regardless of the status of the Public Health Emergency (PHE). This is a great opportunity to write or call your state representatives and senators to see if they can take this further than 2024. 

Because of the PHE—as mentioned above—there is a temporary public health emergency waiver that allows telehealth to continue through the year that the PHE ends (currently set for 2023) +151 days. After these 151 days, practitioners will be required to use the following updated POS indicators for telehealth services:

  1. POS “02” – This code will be redefined if finalized as Telehealth Provided Other than in Patient’s Home
  2. POS “10” – This code would be redefined if finalized as Telehealth Provided in Patient’s Home

There are still geographical laws and regulations that must be abided by at a state level. For example, if you wish to provide telehealth to a patient in Florida whilst you’re in New York, your practice act must permit you to perform telehealth in both states.  

Q: What are the most common causes of Medicare audits and compliance costs?

A: Being routinely compliant across the board can save your business large amounts of money. This is especially important in today’s climate, as Medicare audits have skyrocketed and many private practices are getting stung simply by being underprepared and unorganized.

For Medicare, the most common audits were Post Payments, Supplemental Medical Review Contractors, and TPE audits. The most common HIPAA violations in 2021 were Illegal Access to PHI, Lack of Security Risk Analysis, and failure to have a Risk Management Process. OSHA violations that tripped up private practices included Failure to Provide Respiratory Protection, effective Hazard Communication, and PPE. 

Q: As practice owners, how do we deal with rising inflation and cuts to Medicare reimbursements?

A: A 4.4% decrease in Medicare reimbursements paired with 8-9% inflation (with a possibility of going higher) will be costly. Practices need to plan for a counteroffensive if they want to stay open and maintain profitability. The good news is, there are lots of tactics one can employ to improve profit margins, save on expenses and survive trying times such as these. You can: 

  • Optimizing staff schedules
  •  Minimize unnecessary overheads (like unused rental space)
  •  Attract patients — new and past patients

Q: What are 3 ways to increase our practice’s topline revenue?

A: In theory, it’s remarkably simple…

  1. Attract new patients
  2. Increase per patient revenue
  3. Reactivate past patients

It’s the execution that is the hard part. 

Breakthrough’s leading Patient Demand Platform makes it easy. Designed specifically for physical thearpy practices, the tool offers pre-built campaigns and automation that generate consistent, predictable revenue growth. 

Click here to schedule a demo.

Q: In our electronic medical records, why can’t both names show on the progress report document, or have a statement describing the exact involvement of the therapist and PTA?

A: Both names can appear on a Progress Report document, but the exact involvement of all parties from a regulatory perspective must be extremely clear so that when Medicare audits you, everything is above board. There must be proof the PTA has not done more than what they are allowed to. This is particularly important to do when you cannot simply eliminate your PTA from signing the report altogether. This doesn’t have to be a complex legal dissertation every time—it could be a previously written succinct statement that’s used universally throughout your clinic.

Q: Will we require an order from an MD in order to be paid from Medicare?

A: No. In short, to be paid by Medicare, your patient’s certified plan of care just needs to be laid out and accepted by their physician. It is always worth double-checking the legislation in your state of practice though. 

Q: How often are progress reports required, and does a Plan of Care certification need to be completed every 90 days? 

A: A progress report is required every 10th visit or less—there is no specific time frame attached to how often this is on a time/calendar basis. Plan of Care certification on the other hand, is on a time basis, and must be re-certified every 90 days

Q: How can we get reimbursed for treatments rendered if a patient self refers and begins the 10 sessions Medicare allows, but doesn’t get sign-off from their physician?

A: It is rare that a patient’s physician doesn’t sign the Plan of Care, as the physician has to comply with Medicare regulations. But in the rare case a patient’s physician doesn’t sign the Plan of Care, a Technical Denial occurs and the financial liability is then passed onto the patient. This is why it is really important to inform the patient that you are operating under a Plan of Care to avoid placing them in this financially vulnerable situation. If the physician still refuses to sign, speak with your patient and let them know that they will need to contact their doctor and request signature for the rest of the Plan of Care to continue under Medicare. 

Still unsure how you will navigate your business through the proposed 2023 medicare cuts? 

With proven tools, tactics, and strategies, the experts at Breakthrough can help you boost your profit margins, streamline your private practice and get you through 2023 and beyond. 

Schedule a call with our team today and we’ll plan your next step together.

2022 medicare reimbursements and guidelines

CMS Releases the 2022 Fee Schedule and Final Rule

Earlier this month, CMS published the final 2022 fee schedule and complete final rule for Medicare payment policies. Chad Madden, Breakthrough co-founder, teamed up with Mary Daulong, President and CEO at Business & Clinical Management Services (BCMS) to discuss the new rules shortly after they were finalized, on a Live Q&A with hundreds of private practice owners and therapists. 

This article summarizes a number of questions and answers that came up around the fee schedules and the new 2022 Medicare rules. We have been inundated by questions on Medicare PTA reimbursements, Medicare PT guidelines, and more upcoming cuts and implications. 

If you’re in the process of planning for the impacts of the 2022 Medicare cuts, check out Breakthrough’s 2022 Planning Tool for Private Practice Owners. As private practice owners, it’s important to regularly assess the financial health of your practice and identify strategies to increase top-line revenue. Use this tool in your annual planning process to develop strategies that will boost profitability in spite of declining reimbursements. 

We held a webinar recently that covered a number of user questions and had a really great turnout. Take a look at the replay below:

Q: What are the key changes in the 2022 fee schedule and final ruling?

A: Here’s the big picture:

  • PTs will see a ~3.7% reduction in payment and OTs will see a ~3.9% reduction in payment.
  • PTAs using the CQ modifier and OTAs using the CO modifier will see a 15% payment reduction
  • PTAs and OTAs may be virtually supervised using A/V communications until 2023.
  • Remote Therapeutic Monitoring (RTM) codes can be billed by physical & occupational therapists, nurses, etc.
  • Therapy KX Modifier Threshold = $2,150 PT/SLP & $2,150 OT.
  • Medical Review Threshold = $,3000. Hitting the threshold does not provoke an audit automatically – they are looking for aberrant billing behavior.
  • MIPS changes Multiple adjustments to the program, but they re-established Q 154 Falls Assessment.

Q: What is the order of payment reductions on a claim with the CQ or CO modifier? 

A: For the therapy services to which the 15% reduction applies, payment will be made at 85% of Medicare’s (80% payment). This is based on the lesser of the actual charge or applicable fee schedule amount for claims with a CQ or CO modifier. The beneficiary’s co-insurance is deducted after the application of the MPPR to the PE Payment for all “always therapy” codes. The 2% sequestration reduction is always applied last.

Q: Regarding Remote Therapeutic Monitoring…can patients self-report their medical data? What about non-physiological data? 

A: Yes, patients can log their own data into RTM portals using a medical device. Patients can report non-physiological data such as their home program compliance, pain level, medication, etc.

Q: Do we still have the direct supervision rule where a PT has to be present in an outpatient private setting? 

A: The physical therapist is required to be onsite with the PTA as part of the Direct Supervision rule in a private practice under Medicare. During the pandemic, therapists were granted a form of “general supervision” which allows audio-visual supervision as an alternative to direct supervision. General supervision is expiring at the end of 2022, meaning the A/V supervision option will be eliminated and therapists in private practice will be required to utilize “direct supervision” i.e., on-site. Changing this rule would require legislative action. 

Follow and support the bill for PTA/OTA General Supervision, called the HR 5536 “SMART” ACT. Write and talk to your congressman about it. It makes no sense for therapists in private practice to be held to the direct supervision requirement, while other comparable settings have general supervision prerogatives.

Q: How many evaluations can we bill in a year? What length of time? ex: every 30 days, 60 days etc. 

A: There are multiple considerations to keep in mind, including:

  • What does your Practice Act state regarding the therapist’s responsibility/requirement for evaluating new patients and/or conditions? If it stipulates specific requirements, those must be followed regardless of payment for services.
  • An evaluation or reevaluation is required by Medicare if the patient presents with new conditions or diagnoses. These can impact the Plan of Care Goals and Treatment Plan and should be performed and billed accordingly. Medicare typically expects a change/modification in an existing Plan of Care if an Evaluation or Reevaluation is billed. Of course, recertification of the new Plan of Care is also required.

Q: We’ve noticed that the G0283 CPT code is being denied as not medically necessary. Is this a trend for the future? Is there some other way we should be billing this code? 

A: The G0283 modifier is not a bundled code, so that is not the problem. Have you affixed the appropriate other modifiers i.e., GP or KX, if applicable?

Some Medicare Administrative Contractors (MACs) have Local Coverage Determinations (LCDs) that limit the frequency of certain modalities. Visit your MAC’s website to see if there is an LCD for Physical Therapy/Therapy Services.

There is no other way to bill G0283, and doing so could constitute a False Claims Act violation. Always bill according to the CPT code’s definition.

Q: If the owner/PT signs all notes, will there be any reductions for PTA’s?

A: An owner or other therapist cannot circumvent the intent of this rule by signing notes for services performed by a PTA/OTA. If the owner is not the person providing the service, that could become a False Claims Act violation. There is CQ or CO exemption by cosigning for services provided by an assistant. 

If the PTA treats the patient, you must comply with the regulation that specifies when the CQ or CO modifiers must be used. There are a number of scenarios that are included in the Medicare Physician Fee Schedule Proposed Rule (July 2021) which you can reference. 

Q: What is Locum Tenens? 

A: Locum Tenens (Fee-for-Time) is the use of a substitute provider to cover for an enrolled provider in his or her absence in specific situations. There is an important bill on the Hill entitled Nationwide PT/OT Access to Locum Tenens, S2612 & HB1611, which we encourage you to support. 

Access to Locum Tenens would give therapists the ability to be in compliance with Medicare rules in situations where they need someone to cover for them. Just like any other type of provider, therapists run into situations where they have emergencies, personal matters, or are short-staffede, and have to get another therapist to provide care to active patients. Today, therapists don’t have that prerogative. If you’re using a PRN therapist who is not enrolled and you choose to bill under someone’s number who is not the providing therapist, you have a potential False Claims Act violation.

If this bill goes through, therapists would be able to utilize another therapist who is not enrolled in Medicare. The clinic would bill under the therapist being replaced and would pay the locum tenens therapist for the time or per visit. If you’re using a PRN therapist who is not enrolled and you choose to bill under someone’s number who is not the providing therapist, you have a potential False Claims Act violation.

Q: If the Access to Locum Tenens bill goes through, will it be available for Medicaid as well?

A: We don’t know. Medicaid has state policies, and those policies have to be dealt with on the state level. Policies can vary from state to state and that may be one area that may not follow Medicare coverage policies.

Q: What is the status of Sequestration going into 2022? Will the sequestration be reinstated?

A: Sequestration is a 2% reduction in payment that has been mandated since 2013. It was suspended during the pandemic, but yes, it will eventually be reinstated. It is legislatively required and would take congressional action before 2022 to be halted. 

Q: What if you choose to go non-par w/ Medicare and/or refuse to see Medicare patients? 

A: You can choose non-participation, but you still must be enrolled in Medicare. Therapists do not have the prerogative to “Opt-Out” of Medicare. You can either enroll or not enroll. If you are enrolled, you can participate by accepting assignments of benefits. If you choose not to participate, you are choosing not to accept assignments, but you still must be enrolled and file claims for the patient. Under non-participation enrollment, you may bill up to the limiting charge, which is 15% more than Medicare. In order for that to work, you have to be prepared to collect cash at the time of service. 

Those therapists with cash-based practices typically have a population of patients that are willing and able to pay cash upfront. In the non-participation situation, the patient will get reimbursed at 95% of the Medicare allowable within a few weeks of claim submission by the clinic. Remember, they will also be paying up to the additional 15% allowable upcharge. 

The success potential of choosing to be a non-participating provider is slim if your practice serves patients on a fixed or limited budget. The result of electing this payment strategy will limit patient access due to financial constraints. 

Q: Is there any update from Medicare and/or other commercial or federal payers regarding covering telehealth (or virtual visits) for PT?  

A: Today, telehealth services provided by therapists are allowed through the end of the year in which the year the pandemic is declared over. Since the Public Health Emergency was extended on October 15th, telehealth services by therapists will be permitted through 2022. If there is no congressional action and the pandemic is declared over in 2022, therapists will no longer be able to provide services via telehealth in 2023. We are not statutorily listed as telehealth providers. 

Q: Does the Emergency Regulation Requiring COVID-19 Vaccination for Health Care Workers apply to outpatient clinic employees, regardless of # of Employees? If so, does it apply to ALL employees, regardless of contact with patients?

A: What we know right now is that OSHA’s COVID-19 Vaccination Emergency Temporary Standard took effect upon its publication in the Federal Register (November 4, 2021). Employers must comply with most requirements within 30 days of the publication and with testing requirements within 60 days of publication. Employees will have the option of vaccination or weekly testing. There are medical, religious and other exceptions. Employer fines for non-compliance are massive.

Unsure how to plan for 2022 given the looming reimbursement cuts?

Download the 2022 Planning Tool for Private Practice Owners.