The Centers for Medicare and Medicaid Services (CMS) spends much of its spring and summer churning out regulatory rules for the coming fiscal and calendar years. That means it's an equally busy time for APTA, its members, and other stakeholders to stay on top of the proposals, respond to whatever challenges emerge, and advocate for change when needed.
This year's standout challenge: advocacy efforts around the CMS proposed physician fee schedule (PFS). The rule as proposed includes at least 2 troubling provisions that demanded a strong response—1 around how CMS would go about determining whether therapy services were delivered "in part" by a physical therapist assistant (PTA) or occupational therapy assistant (OTA), and another that proposes an estimated 8% cut to reimbursement for physical therapists (PTs) and several other professions.
APTA has been aggressively fighting these changes through comments, creating a platform to facilitate a flood of individual member letters to CMS, multiprovider organization sign-on letters, meetings with CMS representatives, and the latest: a bipartisan letter signed by 55 members of Congress urging CMS to rethink the cuts.
So where do things stand with CMS rulemaking, and what is APTA doing around the PFS and other developments? Here's a guide to 3 of the biggest rules issued to date in 2019, along with information on our advocacy efforts.
Medicare Physician Fee Schedule
Status: Proposed (comment period closed); final rule expected in early November
Quick take
A misguided attempt by CMS to define (and pay less) when services are delivered "in part" by a PTA or OTA, and an arbitrary 8% cut in 2021 to PT and OT services as well as similar cuts to services furnished by clinical social workers, clinical psychologists, audiologists, and other providers could have major impacts on patient access to care. The rule also includes changes to the Merit-based Incentive Payment System (MIPs) and other areas.
Our advocacy
- 2 APTA comment letters (1 focused on the PTA/OTA modifiers, 1 focused on the proposed 8% cut and other features of the proposed rule)
- Templated comment letters that helped generate more than 10,000 letters to CMS from individual PTs, PTAs, students, and patients
- In-person meetings with CMS representatives
- Joint letter opposing the cuts from APTA and 9 other professional associations
- Congressional sign-on letter opposing the cuts that includes 55 legislators
Resources: CMS fact sheet; PT in Motion News stories on PTA modifier and proposed cut; recorded webinar (from August 15); upcoming "Insider Intel" phone-in session (November 20)
Skilled Nursing Facilities (SNFs) Prospective Payment System
Status: Final, effective October 1, 2019
Quick take
CMS followed through with plans to dramatically change the payment system for SNFs by adopting the Patient-Driven Payment Model (PDPM), a system based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employing a per diem system that adjusts payment rates over the course of the stay. In a win for APTA and its members around group therapy, CMS moved away from a rigid 4-person definition and adopted the association's recommendation that the definition of group therapy as 2 to 6 patients doing the same or similar activities—the same definition used in inpatient rehabilitation settings.
Our advocacy
- APTA comment letter
- In-person meeting with CMS representatives
- Multiprofession coalition sign-on letter
- Templated comment letters for individual clinicians
Resources: CMS fact sheet; APTA fact sheet; PT in Motion News stories on proposed and final rule; APTA SNF PDPM webpage; recorded webinar series; recorded Insider Intel session (May 22)
Home Health Prospective Payment System
Status: Proposed for 2020 (comment period closed), final rule expected in early November
Quick take
Similar to its efforts around SNFs, CMS wants to transition to a new payment system for home health agencies (HHAs), known as the Patient Driven Groupings Model (PDGM). That system moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The proposed rule would also allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist and would end the HHA split payment approach in favor of a more efficient notice-of-admission approach.
Our advocacy
- APTA comment letter
- APTA Home Health Section comment letter
- In-person meeting with CMS representatives
- Templated comment letters for individual clinicians
Resources: CMS fact sheet; PT in Motion News story on proposed rule; APTA webpage on PDGM; recorded webinar (August 5)
Other advocacy efforts
APTA has also provided comment letters on CMS rules on outpatient payment, Medicaid access, inpatient rehabilitation facilities, and hospital payment; and signed on to multiprofession coalition letters to CMS on outpatient payment and rules around durable medical equipment, prosthetics, orthotics, and supplies.
Stay tuned
As APTA continues to advocate for the profession, the association also provides its members with plenty of opportunities to get up-to-speed with both proposed and final rules. Keep the following upcoming events on your radar for more insight on payment and regulation:
- Home health payment, PFS, MIPs, coding, and commercial payer updates ("Insider Intel" phone-in event); November 20, 2:00 pm-2:45 pm)
- Postacute care webinar with a representative from the Center for Medicare Advocacy and APTA regulatory affairs staff (date TBA)
- PTA modifier update webinar (date TBA)
