ISS CRT Clinical Service: Challenges and Strategies of Operating a Seating Clinic. Objectives

Transcription

1 ISS 2015 CRT Clinical Service: Challenges and Strategies of Operating a Seating Clinic Laura Cohen,PhD, PT, ATP/SMS Barbara Crume, PT, ATP Laura Cohen, PhD, PT, ATP/SMS Principal, Rehabilitation & Technology Consultants, LLC- Arlington, VA Executive Director, Clinician Task Force (CTF) Barbara Crume, PT, ATP Seating and Mobility Specialist with CarePartners Health Services- Asheville, NC Member CTF, Ex-Officio Executive Board Member Objectives Explain 3 threats to sustainability of Seating and Wheeled Mobility (SWM) Clinics Describe 3 strategies to improve seating clinic quality and efficiency Identify therapy payment issues driving SWM clinic practices Describe how to advocate to ensure clinical CRT services are incorporated into CRT legislative and regulatory initiatives ISS 2015 IC42 1

2 CRT Team Approach Critical to Service Delivery Process Trends Influencing CRT Team Approach Supplier Trends Mergers/acquisitions Negative impact of policy trends resulting in shrinking margins Redesigning services Availability/participation in SWM clinics Availability of loaner/trial equipment In Clinic In Home Dedicated rotating schedule based on location Patient s responsible for bringing equipment to supplier or waiting until service tech will be in area Trends Influencing CRT Team Approach Therapist Trends Negative impact of policy trends resulting in shrinking margins Therapy cap and other payment regulations Unsustainable contracts (e.g. Medicaid, private payers) Consolidated billing/capitated service agreements Mergers/acquisitions Non-profit hospitals converting to for-profit Shift in mission/purpose/priorities to serve the community Diminishing research funds Increased competition and fewer awards for Model System Centers of Excellence and related services Redesigning services to align with ACA and new models of care ISS 2015 IC42 2

3 Building Capacity Threats to SWM clinics directly impact supplier access to qualified LCMP s Jeopardize access to complete medical documentation required to justify patients need for CRT Need to engage/educate therapists beyond specialty SWM clinics to meet public need Home Health Care (HHC) Extended Care Facilities (ECF) Assisted Living IP Rehab Challenges to Building Capacity Difficult to identify therapists (e.g rural areas) Critical mass Due to low reimbursement Medicare Cap limiting access Extensive paperwork- time consuming/redundant processes PT/OT LCD documentation requirements PLUS DME LCD documentation requirements Therapists/MDs are not interested in learning for occasional/infrequent referral do not know how to document, OR do not want to provide documentation Poll for Suppliers Where do you obtain most of your clinical documentation for CRT requests? A. Physician only B. Specialty SWM clinic C. Other specialty clinic (ALS, MS, CP, etc.) D. Physician plus OP clinician E. Physician plus Home Health clinician F. Inpatient rehab team G. Inpatient acute care team H. Other ISS 2015 IC42 3

4 Internal Supplier Study Results 90% denial rate for PMD requests with no therapy evaluation provided Only 10% of referrals had complete physician documentation Dedicated SWM Clinics SWM Locations University/Medical Centers Regional Referral Centers (e.g. Mayo Clinic) Dedicated Model Centers Regional and Local Rehab Centers Specialty Clinics ALS, MD, MS, Spina Bifida, Pediatric clinics ISS 2015 IC42 4

5 SWM Clinics Viewed as service to community not money makers, usually lose money or break even Increasing trend in facility acquisitions converting non-profit to for-profit centers Several clinics have been downsized or eliminated around the country Schwab Rehab, Braintree Rehab Survey Monkey How is your wheelchair seating and mobility clinic funded? (13 responds) Medical insurance payments -8 Medicare, Medicaid and private health insurance Facility/school, unable to bill for services -2 Pro bono clinic-1 Funded by business owner -1 Grant 1 (10% funding from grant) CarePartners (CP) Report Card Salary and overhead cost = >150% productivity CP considers SWM services to be a value added service to community Contractual adjustments average 60% of UCC Payor mix - 36% Medicare, 32% Medicaid, 34% other Example: Charge for evaluation is $215.00, our cost is $ Medicare allowable is $ Medicaid reimbursement is $61.83 BCBS reimbursement is $ ISS 2015 IC42 5

6 Reimbursement Data Few clinics have access to payment data to identify problems and errors Survey Monkey (14 respondents) Do you at least break even after contractual adjustments? Yes 4 No 2 Don t know or unsure 5 N/A - 2 Clinic Referral Management Referrals Ideally support staff manages referrals Receive phone calls/faxes/ s from doctors, patients, caregivers, therapists, case managers, suppliers When a supplier refers to SWM helpful if supplier obtains MD order for PT/OT to evaluate and treat obtain copy of MD medical records H&P, annual exam, admit/dc notes, test results, last 2 progress notes Obtains demographic & insurance information Schedules evaluation with therapist Inquires about Home Health services ISS 2015 IC42 6

7 Education of Referral Sources Should begin upon referral Explain process to complete CRT recommendations Physician role with F2F requirements Dear Physician Letter DMAC Education Tools help_aid.html Consolidated Billing Home Health Agencies (HHA) Paid under prospective payment system Consolidated Billing Per patient/episode of care Specialty Clinic OP Facility may contract with HHA provide services facility cannot bill Medicare directly if under HHA episode HHA episode of care may not appear for 30 days in system (Medicare Database verification) HHA not permitted to discharge patient to receive OP SWM services CarePartners Home Health CarePartners has a HH agency HH therapists contact HH Case Manager for approval of referral to seating clinic SC Patient Access contacts HH Case Manager for approval when referrals received direct from doctors Procedures billed are transferred to HH cost center Therapist time is transferred to HH cost center ISS 2015 IC42 7

8 Other HH Agencies Other HHAs contract with CP and are billed Medicare allowable rate Companies without contract are billed usual and customary rate Access staff obtain signed approval for payment of services stating expected CPT codes and cost per code Acute Care Hospitals Skilled Nursing Facilities (SNFs) Consolidated Billing applies for IP Acute Care Hospitals and SNF (under Part A) OP SC cannot bill Medicare for an OP visit when patient is an IP at another facility CP does have a contract with acute care hospital. Access Staff obtains signed agreement for payment of services. ISS 2015 IC42 8

9 Prior Authorization Access staff contacts private insurance prior to initial evaluation Insurance Verification Form Preferred provider Amount of deductible Co-insurance Out Of Pocket- met for year Visit limitations, visits used Access Staff Obtain PA for evaluation and therapy visits Confirm if time limitation per visit Many Insurance companies only pay for 1 hour of therapy per visit Confirm CPT codes covered NC Medicaid does not cover Some plans may not cover or Alert therapist to obtain Medicaid PA ISS 2015 IC42 9

10 Completion of insurance forms Signatures Copy cards for our records and supplier Collect co-pay Medical Intake Form Access Staff Medical Intake form Diagnoses, impairments, medications, surgeries past and future, pain, skin condition, current equip receipt date/supplier, problems, goals Send form to patient to complete and return prior to appointment- often forget to bring with them Complete over the phone very time consuming for access staff Complete upon arrival in clinic- time consuming, therefore request they arrive early ISS 2015 IC42 10

11 Intake Information Supplier assistance necessary for Information on current equipment, age, condition, repair history, cost to repair Home assessment when already completed (or if completed following evaluation), provide your documentation to therapist! Functional issues observed during home assessment Coding & Payment Viable SWM outpatient clinics use appropriate CPT coding to maximize payment Multiple visits Time limited appointments Proper utilization of codes and modifiers on same date of service Codes primarily used for Evaluation, Fitting and Training 97001or Evaluation PT or OT Wheelchair management Physical Performance Test or Measurement AT Assessment Orthotics Fitting & Training ISS 2015 IC42 11

12 CPT Codes Reference your PT/OT LCD criteria Each Fiscal Intermediary has different LCD Locate an LCD: Payment Policies Medicare Fee Schedule Fee Schedule: allowed charge, the lower of the actual charge or fee schedule amount. Medicare Payment is 80% of allowed charge after deductible met. Medicare patients must meet annual deductible ($147) and pay 20%, or their secondary insurance pays 20% ISS 2015 IC42 12

13 Threat # 1 Medicare Cap Therapy cap amount $1940 for OT and $1940 for PT and Speech therapy combined Recipients still pay $147 deductible and 20% of the $1940 ($388) Evaluation to determine need for therapy is covered even if patient has exceeded therapy cap Therapy Cap Exceptions Process($1940-$3700) when medially necessary and documented Provider must use KX Modifier with codes billed Medicare Cap Manual medical review When the $3,700 threshold is exceeded No pre approval process Collecting Out of Pocket Patient doesn t qualify for exception Obtain signed Advanced Beneficiary Notice (ABN) Collect from beneficiary &/or bill secondary insurance Insurance may require denial from Medicare SGR Legislation Long Term Fix for SGR Therapy Cap Senate Finance Committee Proposal Repeals SGR Freezes Medicare Fee Schedule for 10 years Provisions for payment incentives above base rate Value based quality performance incentive programs Alternative payment methods New medical review & PA program in 2015 New data collection system for functional reporting House Ways & Means Proposal Repeals SGR Allows.5% payment increase/year until payment system based on quality/performance ISS 2015 IC42 13

14 Threat # 2 Sequestration 2% payment cut for all Medicare providers Began April 1, 2013 Applies to the Medicare payment, not beneficiary copayment Threat # 3 Multiple Procedure Payment Reduction (MPPR) Originally went into effect January 1, 2011 with 25% reduction Applies to Practice Expense (PE) portion of each code 50% reduction began April 1, 2013 Example 4 units billed in NC would normally be $118.66, with MPPR and Sequestration, payment is now $97.13 ($21.53 less) MPPR Adoption by private payers (UHC, BCBS, Aetna, Humana, Worker s Comp) (APTA Fee Calculator) Functional Limitation Reporting Medicare requirement beginning July 1, 2013 Condition for payment Submit Functional G code and modifier on the claim forms At time of evaluation, re-evaluation, minimum of 10th visit, changing of primary limitation and at time of discharge Documentation in the medical record must include the G-code and modifier, and state how the modifier was selected ISS 2015 IC42 14

15 Functional Limitation Reporting Medicare will automatically discharge the functional episode after 60 days of inactivity (no claims submissions) APTA recommends submitting 3 G codes for each visit The goal of the functional limitation reporting is data collection only, but in the future may be used for outcome based payment. Modifier selected based on objective, measurable standardized test or by the therapist based on clinical judgment using multiple tools during evaluation process CTF working on recommendations for SWM measures for therapists providing wheelchair seating services Strategy to Maximize Efficiency and Payment Pre-appointment Paperwork Schedule 90 min. PT only Intake Register, complete medical history form, functional reporting form Options Preadmission process Telephone interview process Pt instructed to arrive 30 minutes prior to appt ISS 2015 IC42 15

16 Evaluation Only perform evaluation at first appointment without supplier Obtain medical and functional status Equipment status and posture Pressure map if needed Mat assessment Establishing a plan of care for future appts Identifying necessary trial equipment Communicating with supplier Second visit Supplier responsible for preparing equipment for assessment Configuring based on eval notes Equipment trials, simulation, and problem solving Order forms completed Documentation completed with patient present Poll for Suppliers Do you obtain detailed clinical information specifying configuration of trial equipment needed for clinic visit? What % of therapists that you work with provide this detailed information? A. 0-25% B % C % D % ISS 2015 IC42 16

17 Paperwork Therapist forwards all documentation to supplier Supplier responsible to send all documents to physician for concurrence & signature (except the POC) SWM Clinic Constraints Excessive UOS may be denied May not be billed to the beneficiary Cannot be waived or subject to ABN. Maximum time/eval limited to hours Business decision Collect co-pay at time of visit! Necessary to provide charges before end of visit Documentation Meditech EHR system with custom SWM template Leverages efficiencies for documentation Checklists, comment boxes and text boxes. EHR environment changing Administrative decisions often without clinical input Interfacing systems challenging International EHR standards constantly changing Tension between requirements & functionality ISS 2015 IC42 17

18 CarePartners Productivity 1993 productivity target = 50%, actual = 34% Reasons labor intensive service handwritten notes complete evaluation/trials/recommendations in one visit Improvements Computer documentation (Meditech, Redoc) 2014 productivity target = 75% (24 UOS), actual = 60% (19 UOS) Target 5 patients/day Strategies Minimize cancellation/no show rate to <10% Utilize nonbillable time for case management, communications, PAs, inventory maintenance, calibrating FSA, etc Survey Monkey What is your SWM clinic productivity expectation? Not sure, encouraged to meet 75% 60% 5 appts per day 3-4 visits per day for 90 mins each Unknown, not sure, no idea, don t have one, trying to figure that out, too difficult to ascertain, Appeals Critical to work with business office to identify denials for clinical services Few clinics are notified of denials in clinical services Must appeal denials in a timely manner A facility may submit an appeal to insurance as the patient s representative Sustainable SWM clinics seek access to this info Support staff can obtain PA and restrictions in coverage prior to provision of clinical services ISS 2015 IC42 18

19 Ideas and Strategies Need models that support sustainability Efficient & productive systems/operations Administrative system design to eliminate redundancies Adoption of program efficiencies Administrative program support Scheduling Confirming appointments/ no-show policies Cancellation call lists Pre-appointment intake forms Ideas and Strategies Need models that support sustainability (cont) Adoption of EHR systems Auto-population of redundant information (pt identifiers, ICD-9, PMH) Development/implementation of custom templates for SWM esmd S&I Framework Initiative CTF participating as industry dedicated member Pilot projects for PMD Clinical Template underway Ideas and Strategies Need models that support sustainability (cont.) Access to data about fiscal health of clinic Reasonable payment for services access to codes, coverage and payment multitude of fiscal intermediaries with dissimilar coverage policies Contracts with payers for niche services SWM evaluation services (HHA, SNFs, ACOs, Medical Homes) Wheelchair skills training clinics/camps Public Relations Opportunities Wheelchair wash clinic Wheelchair maintenance clinics Donations, grants, foundation support, fundraising ISS 2015 IC42 19

20 Ideas and Strategies Compliance with infection control & other requirements Cleaning/sanitizing products for trials Charging schedule for PWCs Stocking linen Inventory management Cleaning tools, mat, FSA etc. Strategies to Stay Alive Templates for evaluations, interventions and LMNs Reminder calls to pts to reduce no show/cx Flexibility to schedule another pt when cx occurs Review plan with supplier prior to appt to make sure equipment is ready Consider double booking patients for fitting appts Questions/Discussion ISS 2015 IC42 20

21 References Medicare Therapy Services: /index.html?redirect=/therapyservices/ To locate an LCD: Mobility Device Clinical Documentation Guide Contact Information Laura J. Cohen PhD, PT, ATP/SMS Rehabilitation & Technology Consultants, LLC Arlington, VA Barbara Crume, PT, ATP CarePartners Health Services Asheville, NC ext ISS 2015 IC42 21

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