The IRG Report


24

Nov 2014

Humana Resumes MPPR Policy

According to a recent release by the APTA, Humana has restarted its multiple procedure payment reduction (MPPR) policy that applies to Medicare Advantage and commercial insurance plans.  The policy, which Humana had temporarily ceased back in January, was reinstated for non-facility providers as of October 29th, per the APTA’s update.  Humana’s MPPR policy uses the same formula as Medicare in...

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07

Nov 2014

Final 2015 Physician Fee Schedule Rule Includes Changes for Therapy Providers

CMS released the Final 2015 Physician Fee Schedule Rule on October 31st, 2014.  Some highlights from the rule which will directly impact PT and OT providers: Physical and occupational therapists will benefit from a 1% aggregate increase in payment for services provided in 2015 assuming Congress stops the implementation of the SGR payment cut prior to April 1st, 2015. The...

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30

Sep 2014

Legislative Update: Locum Tenens and Medicare Therapy Caps

There have been some recent developments regarding legislation which should be of interest to physical therapists.  First, the “Prevent Interruptions in Physical Therapy Act of 2014” (S.2818) was introduced in the Senate on 9/16/14 and subsequently referred to the Committee on Finance.  The bill aims to amend title XVIII of the Social Security Act to add physical therapists to the...

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17

Sep 2014

CMS Establishes New Modifiers to Define Subsets of -59 Modifier

CMS announced last month that it is establishing four new HCPCS modifiers to define subsets of the -59 modifier.  To review, providers may currently use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.  According to CMS, because of its...

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07

Aug 2014

The Jimmo v. Sebelius Agreement: What It Means to Providers and Patients

I was recently approached by two different therapists with the same question pertaining to a very similar chain of events.  While that is not an unusual occurrence, the particulars of these scenarios were interesting and made me think that this may be something that other clinicians are facing as well.  In both instances, the therapists were preparing to discharge patients...

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01

Aug 2014

Update on FLR for UHC Medicare Advantage Plans

I wanted to share a quick update regarding UHC’s functional limitation reporting policy for its Medicare Advantage plans.  As noted in my previous blog entry, UHC had announced in its May Network Bulletin that PT and OT claims with dates of service on or after Aug. 1, 2014, would require functional G-codes and severity modifiers be appended whenever a PT or...

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24

Jul 2014

UHC to Implement FLR for Medicare Advantage Plans Starting August 1st

We have known for a couple of months now that United Healthcare plans to implement functional limitation reporting for its Medicare Advantage Plans effective August 1st, 2014.  Per United Healthcare’s May 2014 Network Bulletin, contracted physical, occupational, and speech therapist claims with dates of service on or after 8/1/14 will require functional G-codes and accompanying severity modifiers to be appended...

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GAO Releases Report on Self-Referral of Therapy Services

02

Jul 2014

GAO Releases Report on Self-Referral of Therapy Services

For some time now, we have anxiously awaited the Government Accountability Office (GAO) report on physician self-referral for physical therapy. Originally expected to be released last fall, the report is the fourth and final in a series of GAO reports examining medical self-referral. The three previously published GAO reports focused on self-referral for imaging services (October 2012 http://www.gao.gov/products/GAO-12-966), anatomic pathology...

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02

Jul 2014

CMS Alerts Providers About Additional FLR Issues

As a follow-up to my previous blog entry on functional limitation reporting issues, I wanted to share a few additional points that have come to light in the last few weeks.  We previously discussed the fact that CMS has acknowledged multiple issues with the processing of claims with functional G-codes including the splitting of claims, MACs incorrectly counting visits toward...

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02

Jul 2014

Just When You Thought You Had It All Figured Out

You did everything you knew to do. You educated yourself. You trained your staff. You knew this stuff backwards and forwards. Yet, here you are in the first quarter of 2014 scratching your head trying to figure out why your Medicare claims are being returned unpaid because of functional limitation reporting issues. Well, you’re not alone. Providers everywhere are having...

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