RM, money, medicare card
Photo credit: Getty Images

Even though debate will continue about how much Medicare reimbursement should rise next year, there’s little disagreement that the Centers for Medicare & Medicaid Services got at least a few things right in Thursday’s proposed pay rule.

Along with rebasing rates to 2022 costs, changes to Value-Based Purchasing language are among the most important upgrades, said Maureen McCarthy, president and CEO of Celtic Consulting.

“The ability to review and correct PBJ data is absolutely welcomed by providers,” she explained. “Many of them are not auditing that stuff before it goes in … and then their Five-Star report comes out and they’re shocked that they’ve dropped stars, or something like that.”

She said providers initially may be missing pool nurses or agency nurses in PBJ submissions because they don’t have invoices for them yet. Or maybe a salaried administrative staff member moved to the floor and is providing direct care because there was a call-out. 

Or it could be another “famous” flaw, she said: A new payroll firm is hired and adds a zero to every employee’s ID, “so it looks like every single person in the building is brand-new.”

McCarthy said the ability to review and correct is vital because “there is so much riding on it [PBJ] now.” In addition, payroll staff, who generally fill out the PBJ forms, tend to be “disconnected” from PBJ results. Being able to take another look at data can reveal days that may have gone without data submissions or other anomalies, she added.

The expanded PBJ provisions would kick in Oct. 1, 2025.

The ability for providers to show extenuating circumstances for VBP omissions also is a “great opportunity,” McCarthy believes.

“That was an eye-opener during the MDS transition this past October in 2023,” she said. “The glitches, the EMR issues, the CMS mapping and tech spec issues, the IT issues. Some things are beyond the provider’s ability to be able to control, so that’s another welcome move from CMS.”

NTAs in focus

Many close observers think proposed changes and a request for comments about the Patient Driven Payment Model’s non-therapy ancillary component are good signs. 

Adding additional points and corresponding payments for chemo and autoimmune drugs that are not part of consolidated billing exclusions, for example, are good to contemplate, McCarthy said. She also thinks PET scans, which are increasing in frequency, deserve more attention. Currently, they’re not an exclusion, but CAT scans and MRIs are. 

Not all NTA changes may be considered positive, she acknowledged, but she said she’s generally impressed with the possibilities. NTA changes would start Oct. 1, 2026, for fiscal 2027.

“Overall, [the proposed pay rule] is positive, especially opportunities for some additional corrections. The increase in the [Medicare Part A] rate, obviously, no one’s going to turn that down,” she said. “So I think them asking for information from us is going to be helpful. Overall, it’s a positive proposed rule, for sure.”

The proposed revisions to the PDPM NTA component are the most significant part of the new rule to Joel VanEaton, executive vice president of PAC regulatory affairs and education at Broad River Rehab. In addition to 33 potentially affected NTA designations, several would shift point values.

Nine retained NTAs would decrease in point values, some of them significantly, VanEaton pointed out. For example, Special Treatments/Programs: Ventilator or Respirator Post-admit Code is proposed to be revised from 4 points to 1 point, and Special Treatments/Programs: Ventilator or Respirator Post-admit Code is proposed to be revised from 7 points to 5. 

Conversely, there have been four point values that have increased. For example, Lung Transplant Status is proposed to be revised from 3 points to 5, and Cystic Fibrosis is proposed to be revised from 1 point to 3.

“CMS has revamped its methodology for selecting relevant NTAs and the proposed revisions are significant,” he told McKnight’s, noting 16 would be removed and 17 added. “If these revisions are finalized, this will require a concerted learning effort on the part of providers. Providers will need to get up to speed quickly to understand what will not count as a NTA that they have been used to capturing and, just as important, learn the new categories and ICD-10 requirements.”