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Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, June 17, 2013 Posted in: Outpatient Rehab

In an earlier blog I spoke about payment over the therapy cap would be either a pre-payment or post-payment review following a MAC-directed ‘additional development request’ and the pre-post payment decision would depend on what state your practice was in.

Because the provision of therapy submitted to CMS is generally provided with every intent to meet medical necessity/reasonable and necessary care requirements, it would be paid through the beneficiaries benefit. It is not uncommon practice for an outpatient practice to continue treating in good faith and that the selected interventions and documentation will meet scrutiny and ultimately receive compensation. This is why therapists chose their profession; to be compensated at a job we know can reduce pain and suffering and restore function to the many lives we touch over our careers.

In the past, an ABN (Advanced Beneficiary Notice) was always available. In my personal experience they were rarely used in outpatient practice and generally only when the patient or family felt benefit to the care but the professional felt the care was extending beyond the definition of ‘skilled’ because of a specific plateau or inability to demonstrate significant functional benefit. If continued, an ABN was issued and the patient took the chance at self-pay.

Liability has taken on a new definition with the caps process. Pay special attention and educate your staff accordingly.

Times have changed. This is a new world of healthcare with fiscal responsibility and CMS is guarding the Medicare Trust Fund for good purpose as an aging society will enter the age of well-deserved needed care. With this reality comes education to our staff that an ABN  may be used more often. I say ‘may,’ because most therapists still believe that the treatment they render is medically necessary and that the documentation they provide is sufficient to demonstrate that need.

In order to issue an ABN you are sending a mixed message to the patient that the services ‘may not’ be deemed medically necessary and therefore you are asking the patient to accept responsibility above and beyond their normal benefit payment plan because of this ‘specific fact’. This message seems incongruent, since we wholeheartedly believe treatment is medically necessary, yet we are now in a quandary of wondering whether a hindsight audit might not believe so. Alongside our well intended care we specifically feel is medically necessary we now have to struggle with the ethical dilemma of THE CAP. This arbitrary amount that will now scrutinize if extended payment will in fact be permissible. This ethical struggle, I feel our government knows, will be difficult for therapist to face. Mostly we are bleeding hearts. So without an ABN, your facility will absorb this above and beyond care service charges. Liability is now in the lap of providers without an ABN. Get educated on the use of ABN’s.

Now on goes the business hat… your doors must remain open in order to provide additional care. Bills must be covered, staff are still being paid and resources are being consumed, even though in hindsight that bill may be ‘declined’ by a payment review process whether pre or post, it really is still very conflicting to say the least.

Therapists know that all care, specifically care to those that have the greatest physical demands for recovery are also within the limits of the therapy cap. The proactive extension process has been lost. In fact, without Congressional action before Dec. 31, 2013, beneficiaries needing care above the therapy cap will continue to be forced to forgo care or face paying 100 percent of the cost of additional treatment out-of-pocket when coverage expires. I recommend you continue because that started January 1 whether you acted differently or not. If your Medicare Audit Contractor denies payment to your care above the therapy cap this year and you did not provide an ABN since January 1, you the provider are absorbing those costs. The automatic ‘exceptions process’ has long expired. APTA has even campaigned during Stroke Awareness Month for persons to contact their legislators to take action and at least reapply the exceptions process if the cap cannot be lifted in it’s entirety.

Medicare published the following notification in their e-news bulletin to remind providers – liability for care only falls with the provider for care furnished above and beyond caps when the necessary advanced beneficiary notice was provided.

Change to Payment Liability for Therapy Cap Denials

Section 603(c) of the American Taxpayer Relief Act of 2012 (ATRA) changed the payment liability for denials resulting from the outpatient therapy caps from beneficiaries to providers effective January 1, 2013. Medicare systems were not updated in time to accurately represent this change on provider remittance advices (RAs). Medicare contractors may have already processed therapy cap denials for services provided in 2013. These denials incorrectly report on RAs beneficiary liability (Group Code “PR”) when liability legally rests with the provider (Group Code “CO”).

Due to differing claims processing system constraints, this inaccurate RA reporting will be corrected beginning on different dates for different claim formats. For institutional claims, the correct liability will be reported beginning on June 24, 2013. For professional claims, the correct liability will be reported beginning on January 1, 2014.

Since Medicare’s payment amount for these claims is correct, Medicare Administrative Contractors will not adjust claims processed before these dates to correct the Group Code. To do so could create disruptions for providers’ accounts receivable. Instead, therapy providers should review any therapy cap denials for dates of service on or after January 1, 2013, to determine whether any payments have been collected from beneficiaries. Providers should refund any beneficiary payments they find for these services. Additionally, providers should cease to collect payments for therapy cap denials unless the beneficiary was appropriately notified via an Advanced Beneficiary Notice of Noncoverage (ABN).”

Have this discussion with your staff. Ethically speaking it’s one you cannot afford to dismiss.