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SC Medicaid Announces Limitations on Therapy Services

This is an update to the January 31, 2011, Medicaid bulletin which addresses the requirements for additional units request for Private Rehabilitative Therapy Services (speech-language pathology, occupational, and/or physical therapy). Individuals under age 21 will require prior approval once they have reached a combined total of 75 hours (300 units) per fiscal year. The hours used as of April 1st will count toward this checkpoint for the fiscal year ending June 30. The state fiscal year begins July 1st and ends June 30th of each year.

 

To receive payment for services that exceed the frequency checkpoint there must be documentation of medical necessity as well as a pre-approval (PA) by the South Carolina Department of Health and Human Services (SCDHHS). Effective immediately, the request letter from the Primary Care Physician (PCP) must contain the following:

 

• PCP’s clinical office notes, preferably an EPSDT exam, from the recipient’s visit not to exceed 60 days prior to the date of the PA request

 

• number of units needed for the remainder of the fiscal year

 

• diagnosis and/or functional impairment that establishes medical necessity

 

• specific therapy or therapies requested (PT, OT, ST)

 

• the Medicaid ID number of the recipient

 

• therapist’s notes which include an evaluation overview, proposed treatment plan with expected outcomes, and relative progress notes.

 

Documentation must be faxed to SCDHHS at 803-255-8222, Attention Private Rehabilitative Therapy Services Authorization, prior to providing the additional rehabilitative therapy service that exceeds the 75 hour checkpoint. Failure to comply with these requirements will delay the approval process.

 

This policy only applies to Private Rehabilitative Therapy Services. These checkpoints do not apply to School-Based Rehabilitative Therapy Services provided under the Individuals with Disabilities Education Act (IDEA) which are exempt from the yearly frequency checkpoint. There are different criteria for therapy provided as an Outpatient Hospital Service which must not be used to circumvent this process.

 

For beneficiaries enrolled in a Managed Care Organization (MCO), please refer to the individual MCO plan regarding their services.

CMS Proposes Rule for Accountable Care Organizations

On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS) proposed guidelines for
doctors, hospitals, and other health care providers to establish Accountable Care Organizations (ACOs).

Health care experts hope that ACOs will put an end to fragmented care methods by creating a “shared savings program” to incentivize caregivers across all care settings to work together to provide high-quality,
coordinated care for Medicare beneficiaries. CMS has proposed the guidelines in advance of the program
becoming permanently established on January 1, 2012 in order to receive feedback from providers,
suppliers, Medicare beneficiaries and other interested members.

Theoretically, ACOs facilitate better care and bring down costs by establishing financial incentives for providers and suppliers (ie. physicians, hospitals, long-term care facilities) to monitor patients from start to finish.  ACOs that make sure that patients receive appropriate care at the appropriate time and limit waste and abuse of procedures and tests will be eligible for additional Medicare payments. However, those who fail to meet the defined standards effectively could be held financially responsible for increasing costs in the health care system.                          

 

According to CMS, cost savings are not the sole goal of the program as ACOs would have to meet high quality standards measured by patient experience, care coordination, patient safety, preventive health, and at-risk population/frail elderly health to ensure that patients are “happy with the care they receive and have better health outcomes.”

 

2011 SCOA Annual Meeting - Call for Abstracts

 Call for abstracts and Residents Research Competition Submissions for 2011 SCOA Annual Meeting!    Deadline to submit materials is March 1, 2011!

 The South Carolina Orthopaedic Association is now accepting abstract submissions and Resident Research Competition submissions for the 2011 SCOA Annual Meeting.  The 2011 Annual Meeting is taking place August 4-7, 2011 at The Sanctuary at Kiawah Island.  All of the information you will need to secure your participation has been added below.

 All abstracts and Resident Competition papers must be submitted by March 1, 2011 to be considered by the Program Committee.  Instructions for regular abstract submissions and the 2011 Resident Research Competition are included on the SCOA website.   In addition to the abstract information, all submissions should be accompanied by a completed AAOS Financial Disclosure Form and an AAOS FDA Disclosure Form.   

 Download 2011 Abstract Submission Instructions SCOA

Download 2011 Abstract Application SCOA

Download 2011 financial disclosure SCOA

Download 2011 AAOS FDA disclosure

 

Initial EHR Certification Bodies Named

The Certification Commission for Health Information Technology (CCHIT), Chicago, Ill. and the Drummond Group Inc. (DGI), Austin, Texas, were named today by the Office of the National Coordinator for Health Information Technology (ONC) as the first technology review bodies that have been authorized to test and certify electronic health record (EHR) systems for compliance with the standards and certification criteria that were issued by the U.S. Department of Health and Human Services earlier this year.

http://www.hhs.gov/news/press/2010pres/08/20100830d.html

CBO states reform laws will save government money…if SGR cuts are allowed to take effect

The U.S. Congressional Budget Office (CBO) estimates that recently enacted healthcare reform legislation will produce a net budget savings to the federal government of $143 billion during the period 2010 to 2019. In a letter to Sen. Mike Crapo (R-Idaho), however, the director of the CBO points out that the savings figure is based on estimates that assume that physician pay cuts mandated by the Medicare Sustainable Growth Rate (SGR) formula will take effect as planned on Dec. 1, 2010. Should Congress act to prevent such cuts and allow for inflation updates to physician pay, the net cost to the federal government will be $272 billion.

Read More (pdf)

Congress to take up SGR fix, but too late to stop cuts.

The Hill reports that the U.S. Senate is prepared to consider a 19-month delay in Medicare reimbursement cuts currently mandated under the Sustainable Growth Rate (SGR) formula, but a vote may not take place until early next week. Observers say it is likely that physicians will begin receiving Medicare payments reflecting a 21.3 percent reduction starting June 15. The cuts went into effect on June 1, but the U.S. Centers for Medicare & Medicaid Services (CMS) has held off processing payments for 10 business days to give Congress time to act.
Read more...

FTC Extends Enforcement Deadline for Identity Theft Red Flags Rule

At the request of several Members of Congress, the Federal Trade Commission is further delaying enforcement of the “Red Flags” Rule through December 31, 2010, while Congress considers legislation that would affect the scope of entities covered by the Rule. Today’s announcement and the release of an Enforcement Policy Statement do not affect other federal agencies’ enforcement of the original November 1, 2008 deadline for institutions subject to their oversight to be in compliance.

“Congress needs to fix the unintended consequences of the legislation establishing the Red Flags Rule – and to fix this problem quickly. We appreciate the efforts of Congressmen Barney Frank and John Adler for getting a clarifying measure passed in the House, and hope action in the Senate will be swift,” FTC Chairman Jon Leibowitz said. “As an agency we’re charged with enforcing the law, and endless extensions delay enforcement.”

The Rule was developed under the Fair and Accurate Credit Transactions Act, in which Congress directed the FTC and other agencies to develop regulations requiring “creditors” and “financial institutions” to address the risk of identity theft. The resulting Red Flags Rule requires all such entities that have “covered accounts” to develop and implement written identity theft prevention programs to help identify, detect, and respond to patterns, practices, or specific activities – known as “red flags” – that could indicate identity theft.

The Rule became effective on January 1, 2008, with full compliance for all covered entities originally required by November 1, 2008. The Commission has issued several Enforcement Policies delaying enforcement of the Rule. Most recently, the Commission announced in October 2009 that at the request of certain Members of Congress, it was delaying enforcement of the Rule until June 1, 2010, to allow Congress time to finalize legislation that would limit the scope of business covered by the Rule. Since then, the Commission has received another request from Members of Congress for another delay in enforcement of the Rule beyond June 1, 2010.

The Commission urges Congress to act quickly to pass legislation that will resolve any questions as to which entities are covered by the Rule and obviate the need for further enforcement delays. If Congress passes legislation limiting the scope of the Red Flags Rule with an effective date earlier than December 31, 2010, the Commission will begin enforcement as of that effective date.

In the interim, FTC staff has continued to provide guidance, both through materials posted on www.ftc.gov/redflagsrule, and in speeches and participation in seminars, conferences and other training events to numerous groups. The FTC also published a compliance guide for business, and created a template that enables low risk entities to create an identity theft program with an easy-to-use online form (www.ftc.gov/bcp/edu/microsites/redflagsrule/get-started.shtm). The FTC staff also has published numerous general and industry-specific articles, released a video explaining the Rule, and continues to respond to inquiries from the public. To assist further with compliance, FTC staff has worked with a number of trade associations that have chosen to develop model policies or specialized guidance for their members.

As was the case previously, this enforcement delay is limited to the Red Flags Rule and does not extend to the rule regarding address discrepancies applicable to users of consumer reports (16 C.F.R.§641), or to the rule regarding changes of address applicable to card issuers (16 C.F.R.§681.2).

For questions regarding this Enforcement Policy, please contact Naomi Lefkovitz or Pavneet Singh, Bureau of Consumer Protection, 202-326-2252.

The Federal Trade Commission works for consumers to prevent fraudulent, deceptive, and unfair business practices and to provide information to help spot, stop, and avoid them.  To file a complaint in English or Spanish, visit the FTC’s online Complaint Assistant or call 1-877-FTC-HELP (1-877-382-4357).  The FTC enters complaints into Consumer Sentinel, a secure, online database available to more than 1,800 civil and criminal law enforcement agencies in the U.S. and abroad.  The FTC’s Web site provides free information on a variety of consumer topics.

MEDIA CONTACT:

Office of Public Affairs
202-326-2180

 

“CMS Holding Claims as of June 2010 Pending Congressional Action on Physician Fee Schedule”

 

“The Continuing Extension Act of 2010, enacted on April 15, 2010, extended the zero percent (0%) update to the 2010 Medicare Physician Fee Schedule (MPFS) through May 31, 2010.  The Centers for Medicare & Medicaid Services (CMS) believes Congress is working to avert the negative update scheduled to take effect June 1, 2010.  To avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the MPFS, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of June.  This hold will only affect MPFS claims with dates of service June 1, 2010, and later. 

 

This hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt. 

Be on the alert for more information about the 2010 Medicare Physician Fee Schedule Update.” 

Dear Colleagues,

Since the last update, much has happened. It seems that finally, the log jam is loosening. We have received numerous reports that orthopaedic aid organizations are on their way to Haiti, and some—such as Operation Walk/Haiti, SIGN, CURE International, and many academic institutions—are already on the ground. The AAOS is continuing to work with other orthopaedic organizations, the State Department, and other government entities to ensure that orthopaedic surgeons and medical equipment are rapidly deployed.

The scene in Haiti, however, remains chaotic, as we can tell from various news reports, and from communications with AAOS members who are there. With such widespread destruction, it is not only the needs of the injured that must be addressed, but also the need for feeding and housing the many volunteer rescue workers. Careful planning and coordination are needed to address issues resulting from the lack of an organized, functioning infrastructure in Haiti. We wish to minimize waste and ensure that your skills as orthopaedic surgeons are optimized in the operating room, not spent in debris removal.

AAOS members have been instrumental in facilitating the movement of medical equipment and healthcare personnel to Haiti. Carlos Lavernia, MD, has access to a 40,000 sq. ft. warehouse in Miami, where equipment can be sent and held until arrangements for shipping it into Haiti can be made. Groups that have or are in the process of making arrangements to go to Haiti can also use the warehouse as a holding space. Dr. Lavernia is also establishing a list of who needs equipment and where it is most needed so that delivery arrangements can be made. He may also be able to assist in arranging transport to Haiti. Shipping information follows:

Operation Walk Haiti

Orthopedics Inc.

2860 W. State Rd 84, Suite 113

Ft. Lauderdale, FL 33312

If you are part of a group planning to go to Haiti, please forward contact information to Lynne Dowling, director of the AAOS International Department, using our dedicated e-mail (Haiti@aaos.org). The International Department is tracking participation by AAOS members and coordinating efforts to match people and resources. If you’ve already registered with the AAOS as a volunteer, you should be aware that we have submitted your contact information to a variety of aid groups. They will contact you directly as openings occur.

Specific needs that we have been made aware of include the following:

Personnel

o   Trauma surgeons, pediatric orthopaedists, nurses, and others who are experienced and capable of treating crush injuries and are willing to commit to spending at least 2 weeks on the ground, living in austere conditions

o   French or Creole speakers

Equipment

o   Gigli saws or power saws

o   Vacuum-assisted closure (VAC) dressings

o   Tourniquets/inflatable blood pressure cuffs with valve releases

o   Antibiotics—all types, as much as possible (will take antibiotics that have passed their expiration dates)

o   Anesthesia machines

o   Endotracheal tubes or laryngeal mask airways (LMAs)

o   Lavage irrigation equipment

o   Small fluoroscopy machines

o   Electrocautery machines (for amputations)

o    Amputation kits

o    External fixators, nails, and plates (okay if used, as long as they are clean)

We are working with our industry partners to make arrangements for ensuring that orthopaedic equipment reaches the devastated areas. We have also begun to compile a list of U.S. hospitals that are willing to take Haitian patients and provide direct care assistance. If your hospital is willing to support this effort, please forward the following information to Haiti@aaos.org :

o        Name of hospital

o        Number of patients you can accept

o        Pediatric or other specialty patients you will accept

o        Availability of housing for family members

Thank you all for your outpouring of support. We realize that the first few days after such as a disaster are critical, but the devastation in Haiti will have a long-term impact on the delivery of health care there, and the need for orthopaedic services will continue over several months.

We will continue to keep you updated as we receive information. We urge you to visit www.aaos.org/Haiti regularly for the latest information.

Joseph D. Zuckerman, MD- AAOS President

John J. Callaghan, MD- First Vice President               

Daniel J. Berry, MD- Second Vice President

 

Modern Physician Reports on CMS Concerns that Senate Bill will Drive Providers out of Medicare

Modern Physician is reporting on a new report released by the Centers for Medicare & Medicaid Services that expresses concern that the current health care reform legislation in the Senate will drive providers out of the Medicare program. 

Clear here to read the full story:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20100109/MODERNPHYSICIAN/301099995/-1