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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.

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.
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“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.” 

House passes two-month delay on SGR cuts.

Modern Healthcare reports that the U.S. House of Representatives has approved a fiscal 2010 defense appropriations bill that includes a rider to stave off cuts in Medicare reimbursement under the sustainable growth rate (SGR) formula through Feb. 28, 2010. Currently, a 21 percent reduction in Medicare reimbursement is planned to go into effect on Jan. 1, 2010. The Senate is scheduled to vote on the appropriations bill by Friday.

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CMS issues instructions on new reimbursement policy for consultation services.

The U.S. Centers for Medicare & Medicaid Services (CMS) has released detailed instructions for providers on how to adjust their coding for consultative evaluation and management (E/M) services. As of Jan. 1, 2010, CMS will no longer recognize Current Procedural Terminology codes 99241-99245 and 99251-99255, which reimburse physicians for providing consultative E/M services. Providers will instead be expected to use the appropriate new or established patient office, outpatient, or inpatient visit code. This change is effective for Medicare only; other carriers have not yet stated whether they will adopt similar policies for consultative services.
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Proposed Workers Compensation Fee Schedule Released

Dear Workers’ Compensation System Stakeholder,

Attached you will find a copy of the recommendations for revisions to the 2003 Medical Services Provider Manual (MSPM).  I am providing you this information because of your interest in the workers’ compensation system.

The process to update the MSPM began on May 22, 2009 when a notice of public interest and a public hearing date was published in the State Register. On June 19, 2009 the Commission conducted a public hearing to receive comments. Written comments were accepted through August 25, 2009.  On September 28, 2009 recommended MSPM revisions were presented to the Full Commission at the Business Meeting. After hearing the presentation of the recommendations, the Commission discussed the concept of eliminating the maximum allowable payment for Independent Medical Examinations. The Commission took no action and carried over making a decision on the recommended revisions until the Business Meeting on October 26, 2009.  In an effort to provide full transparency to this process, the Commission asked that we provide a copy to interested stakeholders and post a copy on the Commission’s website www.wcc.sc.gov. The formal comment period has concluded however, the Commission will accept written comments concerning the proposed MSPM.

If you have any questions regarding these recommendations or would like to submit comments please contact Jennifer Neese at Jneese@wcc.sc.gov or 803-737-5713.

Gary M. Cannon

Executive Director

SC Workers' Compensation Commission

1333 Main Street

P.O. Box 1715

Columbia, SC 29202-1715

Download 2010 MSPM Recommendation

Small percentage of Medicaid and CHIP enrollees account for majority of spending.

A study published online in the journal Health Affairs finds a strong contrast in demographic differences between heavy users and non-users of Medicaid and the Children's Health Insurance Program (CHIP). The authors found that 10 percent of enrollees in such systems account for 72 percent of the spending, and that 30 percent of enrolled children receive little or no care. Additionally, non-users receive little preventive care such as well-child visits and dental checkups, putting them at increased risk of having health problems that go undiagnosed and untreated. The authors state that the results highlight the importance of cost containment strategies designed to reduce avoidable hospitalizations.
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P4P improves performance in short-term at the expense of other factors.

The results of an English study on the effects of pay-for-performance (P4P) have been published in the New England Journal of Medicine. Although P4P accelerated improvements in quality for two of three chronic conditions in the short term, long-term effects were less pronounced, and quality of care declined for conditions not linked to incentives. The authors analyzed quality of care in 42 representative family practices, with data collected both before and after implementation of P4P in 2004. They found that, between 2003 and 2005, the rate of improvement in quality of care increased for asthma and diabetes (P<0.001) but not for heart disease. By 2007, the rate of improvement had slowed for all three conditions (P<0.001), and the quality of those aspects of care that were not associated with an incentive had declined for patients with asthma or heart disease. Compared to the period before P4P, the improvement rate after 2005 was unchanged for asthma or diabetes and was reduced for heart disease (P=0.02).

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MEDICAID BULLETIN

TO: All Medicaid Providers

SUBJECT: Program Integrity Overpayment Identification Contractor

The South Carolina Department of Health and Human Services (SCDHHS) is implementing an expansion of its program Integrity review function in order to provide more efficient and effective oversight of the Medicaid program. In order to meet this objective, we have awarded a competitive procurement to Health Management Systems, Inc. (HMS). Founded in 1974, HMS provides cost containment, recovery, and program integrity services to government healthcare agencies nationwide. HMS will assist the Division of Program Integrity in the identification and recovery of overpayments made to Medicaid providers. SCDHHS will work with HMS to alleviate undue burdens on providers that may be caused by requests for information needed for the audits. All audits will be carried out under SCDHHS oversight and in accordance with SCDHHS policies and procedures.

If you have any questions, please call Sherry Ward, RN, Director, Division of Program Integrity, at (803) 898-2640.

Thank you for your continued participation in the Medicaid program.
/S/
Emma Forkner
Director

Uncompensated care cost each insured family $1,017 last year.

A report released by not-for-profit advocacy group Families USA states that subsidizing uncompensated health care for the uninsured cost insured American families an average of $1,017 each during 2008. According to the report, which was based on data from the Medical Expenditures Panel Survey and other federal and private sources, 37 percent of care is paid for out-of-pocket by the uninsured, with third-party sources such as government programs and charities, paying for another 26 percent of care for the uninsured. The remaining costs were considered uncompensated and totaled $42.7 billion across the United States in 2008.
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