Medicare Cap adds a new wrinkle
Neatly tucked in the Middle Class Tax Relief and Job Creation Act of 2012 was the extension for 2012 of the Medicare therapy cap. It is an extension that comes with a whopper of a wrinkle.
Beginning October 1, 2012, CMS is “phasing-in” a Manual Medical Review of all claims for patients who have received more than $3700 worth of benefits in the calendar year 2012. At the same time, any benefits a patient received in 2012 from a hospital outpatient department will retroactively apply to both the $1880 cap and the $3700 manual review process.
The mechanics of the change are pretty straight forward and well documented in this CMS FAQ. Simply put, all providers will receive a letter notifying them whether they are in phase 1,2, or 3. This phase indicates whether they start the review process October 1, November 1, or December 1. CMS has also posted a table where you can now look up your phase at https://data.cms.gov/dataset/Therapy-Provider-Phase-Information/ucun-6i4t .
Once your phase starts, two things happen. The original $1880 eligibility on all active cases needs to be reviewed because those totals retroactively will include any Hospital Outpatient services provided. Then, at least 10 days before a patient is due to hit the $3700 threshold, you will need to request an exception. These exceptions will be handled by your Medicare intermediary so there is no uniform process published.
Anyone who went through the original implementation of the therapy cap as we did, will remember how chaotic and cumbersome the original cap review process was. For that reason, Clinicient is recommending several steps to make these new limits as manageable as possible.
1) Use Clinicient’s Automatic Cap Tracker to track the Cap
Clinicient’s Cap Tracker already automatically tracks all cap amounts you want across patients and cases, separating OT services from PT/SLP services. The cap is adjustable so you can just enter the remaining eligibility. Because it is truly integrated with the claim processing, it uses actual remittance information and the allowed fee schedule to give you up-to-the-minute dollar totals. It will continue to automatically alert the therapist automatically for KX application and the Clinical Issues Listing will continue to point management to patients approaching the limit. This eliminates the need for your front desk staff and therapists to manually track fee schedules and CAP amounts, etc.
2) Use the Medicare Cap Report to get your “true” cap amount
The biggest piece of chaos coming for providers is the retroactive inclusion of hospital outpatient services. As you are phased-in, every active patient’s eligibility will need to get checked again. Some patients may suddenly be past the cap, some may jump all the way to needing immediate application for Medical review. Who to check and where they stand will be made simple by using the Medicare Cap report. This report will break down all services provided into those paid and those submitted, and is hyperlinked to the patient record to make rechecking the eligibility as painless as possible. From there, it is easy to restate the remaining Medicare Cap in the tracker and Clinicient will continue to automatically manage the alerts necessary to prompt your staff on what actions to take.
3) Use the new Medical Review alert to get an updated ABN and kick off the Exemption Process
As providers are phased-in, one enhancement to the Medicare Cap process in Clinicient will be a new Medical Review alert that automatically prompts staff as the $3700 cap is approached. Like other automatic alerts in the system, you can set the threshold and choose which security groups get notified by this alert. It will prompt using the Clinical Issues list and well as prompting front desk staff on the schedule and the therapist at the moment of documentation. One nice additional feature is automatically prompting the front desk to have the patient sign a new ABN when the patient is next arrived. This is a strongly recommendation by CMS and one easily delivered by an integrated system.
4) Use the Authorization tracker to remember to resubmit prior to 20 visits
When Medical Review results in approval to continue delivering services, therapists will be limited to 20 treatment days before having to re-apply. This is easily tracked within the insurance authorization form. Just enter an authorization with start date matching the approval date and set the visit limit at 20. Put a note on the authorization that it is from the Manual Medical Review, and Clinicient will automatically manage the process as it does with any other insurance visit limitation alert.
So, check for that letter and note your phase-in date, start checking HETS early and often to find out which patients are in need of review and use the existing processes in Clinicient to manage yet another wrinkle in the ever changing landscape of Medicare caps.