Reimbursement Update 11/2/19
CSCR MEMBERS PLEASE TAKE ACTION!
HR #4838- S.O.S: Sustaining Outpatient Services Act.
“AACVPR members have been going to Washington D.C. since 2018, asking for a correction to drastic reimbursement reductions for cardiac and pulmonary rehabilitation (CR/PR) services that are located off-campus.We are ready to get this bill passed, but that will only happen with your help.”AACVPR now has a virtual lobbying tool on the Advocacy web page, accessible to anyone. This tool will make it very simple to send an email to the U.S. Representative for your district. There are three template letters available that can easily be personalized: patients, physcians and providers.
Most importantly, there is a letter for practitioners who provide CR and PR, to voice concern about the adverse effect that reduced reimbursement in an off-campus location will have on patient access to these services. Please note: you would be sending this letter as a professional unless you have the authority to send it representing your institution.
There is also a letter for physicians, such as your medical director and your CR/PR physician champions in your institution. There is an additional letter for grateful patients to send who appreciate how CR/PR has helped them. Your rehabilitation participants would be sending it as concerned individual constituents of your state, also not representing your hospital. Please share the link to the virtual lobbying tool far and wide within your networks.
We would recommend these letters be sent in the next 2-3 week time frame, so our follow-up with Congressional offices can be more effective.
Further negative consequences of Section 603
As more Medicare beneficiaries choose Medicare Advantage (MA) plans, there are severe implications for non-excepted (non-grandfathered) CR and PR programs that are located off-campus. Because reimbursement for these services is reduced to roughly 40% or more compared to reimbursement of outpatient programs on campus, co-payments are exceeding the amount that is reimbursed. MA plans are held to the same cap of $50 co-pay for CR and $30 co-pay for PR; however, reimbursement is less than the co-payment cap. As clinically absurd as this is, it is legal and allowed. This is more evidence of the extent to which this bill is needed asap.
AACVPR is working to provide a companion bill in the U.S. Senate, but now is the time to ask for sponsorship of HR 4838. If this bill is not part of a year-end “package” (larger Medicare fix bill) in this session of Congress, it will be our focus throughout 2020 with special attention on March 2-3, 2020 at AACVPR’s Day on the Hill (DOTH). This issue has been our mission the past two years and last year we found much more receptivity from both sides of the aisle. Now with a bill number, we expect to be successful obtaining a significant number of U.S. House member signatures – but only if you ask.”
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CMS Audits some California Programs 9/5/19
We have learned that at least one California Cardiac Rehab program has received notice of a CMS RAC Audit. Please review the below information. We ask that you please inform CSCR if you find out that your program is being audited.The following is from AACVPR’s Legislative Update:“CMS has employed a Recovery Audit Contractor (RAC) to review medical necessity for CR and ICR. Several CR programs have recently received a notice of this audit with request for documentation. Read more.The request for records may go back 3 years from the ADR (Additional Documentation Request). Affected codes are:
- 93797-Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session)
- 93798-Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)
- G0422-Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session
- G0423-Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session
Programs that participated in the 2017 CMS CR audit may relate to a recent CMS blog. It reported numerous complaints from providers, such as lengthy appeals, very time-consuming, high administrative expenses, and inaccurate denials that were overturned when appealed. In response to those concerns, CMS has given RACs new guidance, including:
- Holding RACs accountable to maintain a 95% accuracy score
- Requiring RACs to maintain an overturn rate of less than 10%
- Enhanced provider portals for better transparency on status of claims
- Payment to RACs held until after second level of appeal is completed
It will be important that you are informed if your CR program has received a RAC audit notice. Check regularly with your business/billing office, ask to be contacted if an ADR arrives, and be sure you’re included in the documentation retrieval process. You want to be sure no documentation is inadvertently excluded, which would prompt a denial of that claim(s).”Please email cscrmedia@gmail.com if your program is being audited.
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Legislative Update 8/2/19:
Non-Physician Provider bill: There is now a US House bill for the NPP bill-HR 3911. Work continues a Senate companion bill introduction. This bill will move up the effective date (presently stands at 2024) This bill will allow NPPs to independently order CR/PR services. It will also allow NPPs to serve in the capacity of “immediately available”. The hope is that this bill is attached to whatever “Medicare fix package” passes in this fall’s Congressional session. AACVPR will work with AHA, ACC, PCNA, AAPA, and other professional organizations this fall on passage of this bill.
Site of Service bill: AACVPR continues to believe this is the most important legislative initiative currently being undertaken. Given the increasing Congressional recommendations to remove grandfathered status for various aspects of hospital outpatient services. Legislative Counsel is writing the bill language, so we are encouraged that we will have a bill # to push this issue in the fall session.
CR/PR Regulations: AACVPR and NAMDRC met with the CMS Coverage & Analysis Group (CAG wrote the CR/PR regulations) to discuss common confusion among providers, MACs, and auditors over some requirements. While no decisions were offered, our points are under consideration and we were optimistic that a need for more clarity is appropriate.