AHCA pitches 'permanent' therapy payment system

Mark Parkinson, head of AHCA/NCAL
Mark Parkinson, head of AHCA/NCAL

Nursing homes' biggest national ally and advocate is making the rounds on Capitol Hill this week in an effort to convince Congress to let die a lengthy experiment to withhold therapy claims while it roots out fraud. It has also pledged to work with lawmakers and CMS officials toward a more permanent payment solution.

“We're pushing for this release with a legislative solution,” Greg Crist, senior vice president of the American Health Care Association, told McKnight's while being holed up in his Washington, D.C. offices Thursday as he and others endured a massive government snow day. “That's why we're on the Hill this week pushing for opening up talks about a ‘doc fix' and looking for a permanent solution.” Crist said AHCA's proposal has been met with mostly positive and “receptive” ears, but declined to elaborate further on ongoing talks.

In a joint public statement released this week, AHCA and the National Center for Assisted Living said they backed a “permanent and targeted anti-fraud therapy claims review initiative to replace an existing temporary data collection system” that has effectively choked therapy provider claims and slowed needed therapy services.

“Rather than extend the existing claims review program, which expires March 31, 2015, Congress should instead move the manual therapy review program from a broad data gathering exercise into a targeted, anti-fraud program until larger reforms, like those reported out by the Senate Finance Committee in the 113th Congress,” the statement added.

Three years ago, Congress modified the Medicare's Part B Therapy Cap and instructed CMS to manually review all claims that exceeded a $3,700 per beneficiary threshold. The rationale for this review was to force CMS to collect data that would allow policymakers to better understand which types of conditions were in need of significant therapy so that a better, more patient friendly therapy benefit could be designed for Medicare beneficiaries. In February 2014, the government ordered claim reviews on hold, creating a significant backlog of claims. Recently, CMS resumed these reviews and providers claim the same "familiar problems" have arisen.

AHCA has argued the efforts have outlived their usefulness.

“Such claims review was never intended to be permanent as it is burdensome for providers, costly for CMS and taxpayers, and, given the pre-payment nature in which CMS has chosen to implement it in the past, delays access to needed care for beneficiaries,” AHCA argues. 

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