On February 9, 2016, a federal appeals court reversed a lower court’s dismissal of a lawsuit brought by the AHA and several hospitals, which sought to compel the Department of Health and Human Services to meet its congressionally mandated deadlines for reviewing Medicare claims denials. Saying that the backlog of delays has gotten “worse, not better,” the appeals court sent the case back to the lower court, noting that, “in all likelihood,” the lower court should order the administration to comply with the appeals deadlines if HHS or Congress fails to make meaningful progress toward solving the problem within a reasonable period of time, pointing to the close of the next appropriations cycle as the deadline for resolution. The AHA and several hospitals sued HHS in May 2014 over the backlog at the administrative law judge level, the third levels of appeals. An ALJ has 90 days to decide an appeal. To read the decision, click HERE.
Two weeks ago, I wrote an article on “One-on-One: Does It Only Apply to Medicare“. The article definitely stirred up some conversation and hopefully cleared up several of the myths that exist concerning one-on-one and Medicare versus private insurance carriers. In this weeks article, I thought I would try and clear up another huge issue and that is what is the difference between individual therapy and group therapy and how do I know which one I am doing? I will also answer the question “When I am working one-on-one with Patient A and observing Patient B doing their exercises, is that an example of group therapy with Patient B” while I bill Patient A for one-on-one time?
To begin, lets define group therapy and individual therapy. According to
The Centers for Medicare and Medicaid Services is proposing to implement a Medicare demonstration project, which they believe will help assist in developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to Medicare beneficiaries.
This demonstration would help assure that payments for home health services are appropriate before the claims are paid, thereby preventing fraud, waste, and abuse. As part of this demonstration, CMS proposes performing prior authorization before processing claims for home health services in: Florida, Texas, Illinois, Michigan, and Massachusetts. CMS would establish a prior authorization procedure that is similar to the Prior Authorization of Power Mobility Device (PMD) Demonstration, which was implemented by CMS in 2012. This demonstration would also follow and adopt prior authorization processes that currently exist in other health care programs such as TRICARE, certain state Medicaid programs, and in private insurance.
Comments on the proposal must be received by April 5, 2016. To view the proposal, click HERE.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), signed into law on April 16, 2015, extended the therapy cap exception process through December 31, 2017 and modified the requirement for manual medical review for services over the $3,700 therapy thresholds. MACRA eliminated the requirement for manual medical review of all claims exceeding the thresholds and instead allows a targeted review process. MACRA also prohibits the use of Recovery Auditors to conduct the reviews.
CMS has tasked Strategic Health Solutions as the Supplemental Medical Review Contractor (SMRC) with performing this medical review on a post-payment basis. The SMRC will be selecting claims for review based on the following:
I receive many questions at my in-person seminars and via email that begin something like “I know we can’t have 2 Medicare patient’s being treated at the same time, but how about 2 patient’s with private insurance”? Or, “I know I need to be one-on-one with Medicare patient’s, but that does not apply to patient’s with private insurance, right”? Lastly, “I know if I have 2 Medicare patient’s in my facility for one hour during the same time period, I have to split the time between them, but if the 2 patient’s had private insurance, I could bill each for the entire one hour as one-on-one time, correct”?
I think it is finally time to answer the above questions and put a stop to the myth that you can’t have 2 or more Medicare patient’s in your facility at the same time or that it is okay to bill 2 non-Medicare patient’s for 4 time-based units when they were each in your facility during the same one hour time frame being treated by just one therapist or assistant. The answer, or should I say, where the answer comes from, will surprise many of you. The answer does not come from the Medicare program, private insurance carriers, workers compensation programs, auto no-fault insurance carriers or state practice acts and administrative rules. The answer to all of the above questions comes from the American Medical Association (AMA).
Surprised? I bet you are! How is it that the AMA is the one that provides the answer to the above questions? It is because the AMA is the organization that creates, defines and maintains the CPT codes that providers use to submit claims to insurance carriers to be paid for services rendered to their clients. The federal government, Medicare program, and insurance carriers do not create and define the CPT codes, rather, they use the CPT codes as created by the AMA to pay us for our services. So since insurance carriers, not just the Medicare program, use the CPT codes developed and defined by the AMA to pay us for our services, the definition of “direct one-on-one patient contact” as defined by the AMA in some of the CPT codes apply to the insurance carriers, workers compensation programs and auto no-fault insurances as well and not just the Medicare program.
Regarding the one-on-one CPT codes, I will use 97035, 97110 and 97530 as examples. In the CPT book, CPT codes 97110 – 97124 fall under the heading of “Therapeutic Procedures”. Under “Therapeutic Procedures”, it states “physician or other qualified health care professional (ie, therapist), required to have direct (one-on-one) patient contact. This means that CPT codes 97110, 97112, 97113, 97116 and 97124 all
The Centers for Medicare and Medicaid Services has a booklet on Medicare Advance Beneficiary Notices. The booklet includes information on the following topics:
- Types of ABNs
- Prohibitions and Frequency Limits
- Completing the ABN
- Collecting Payment from the Beneficiary
- Financial Liability and the ABN
- Claim Reporting Modifiers
To access the complete booklet, click