The Centers for Medicare and Medicaid Services issued a fact sheet outlining the settlement in Jimmo v. Sebelius, including their next steps. To access the fact sheet, click HERE.

The Centers for Medicare and Medicaid Services (CMS) has updated their survey and certification guidelines for outpatient rehabilitation facilities (i.e. Rehab Agencies). CMS released transmittal

On March 14, 2013, Representatives Joe Courtney and Tom Latham introduced H.R. 1179 that would count a period of receipt of outpatient observation services in a hospital toward satisfying the 3-day inpatient hospital requirement for coverage of skilled nursing facility services under Medicare. Currently patients under observation status at a hospital do not qualify as meeting the required three days for coverage in the SNF setting. This legislation would insure patients have access to their SNF benefits when being hospitalized. To read the full text of the bill, click HERE.

On March 21, 2013, Representative Tom Price (R-GA) introduced the Medicare Patient Empowerment Act of 2013 (HR 1310), which would provide physical therapists and other providers with the ability to privately contract with Medicare beneficiaries. To read the full text of the bill, click HERE.

A redetermination is an independent review of an initial claim determination performed by the same contractor that processed the original claim. This independent review is performed by staff not involved with making the original claim determination. A request for a redetermination must be submitted in writing and should be made on the standard Centers for Medicare & Medicaid (CMS)

On March 21, 2013, the Centers for Medicare and Medicaid Services (CMS) released additional guidance on manual medical review for outpatient therapy services exceeding $3,700 in calendar year 2013. This applies to all Part B outpatient therapy settings except critical access hospitals. Medicare Administrative Contractors (MACs) will conduct prepayment review on claims reaching the $3,700 threshold with dates of service January 1, 2013 to March 31, 2013.  CMS requested MACs conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process. Effective April 1, 2013, the Recovery Auditors will conduct review

The Centers for Medicare & Medicaid Services (CMS) released transmittal 1196 on March 8, 2013 with an effective an implementation date of April 1, 2013 regarding outpatient therapy functional reporting non-compliance alerts. For therapy claims, with dates of service on and after January 1, 2013, processed on and after April 1, 2013 through June 30, 2013, contractors shall alert providers to

From UnitedHealthcare March 2013 Network Bulletin CMS issued National Coverage Determination (NCD) 160.27 Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) effective June 8, 2012, limiting coverage of TENS for CLBP to members who are enrolled in a CMS approved clinical trial and meet certain criteria. When coverage requirements are met original Medicare will be responsible for payment of TENS for CLBP under the clinical trial, NCD 310.1 Routine Costs in Clinical Trials. Otherwise, TENS for CLBP is not covered and UnitedHealthcare Medicare Advantage Plans will no longer be responsible for payment. This applies to all members