Transcript exceptional bonus

2016 CAPCSD CONFERENCE
REIMBURSEMENT AND CODING FOR
UNIVERSITY SPEECH & HEARING CLINICS
Part II: Medicare Specifics For Your University Clinic
Dee Adams Nikjeh, PhD, CCC-SLP
Paul Pessis, AuD
Tim Nanof, MSW
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Speaker Disclosures
• Financial
Each speaker received complimentary registration
for this meeting and air fare
• Non-Financial
Nikjeh: Co-chair ASHA Health Care Economics
Committee, Alternate co-chair RUC HCPAC
• Pessis: Reimbursement and practice management
consultant for healthcare providers
• Nanof: Ex-officio of ASHA’s Health Care
Economics Committee
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Agenda Part 2
Medicare Specifics for University Clinics
• Government Health Care Payment Systems
• Medicaid & Medicare – The Very Basics
• ABCDs of Medicare
• Payment Systems
• Supervision Requirements
• Medicare Specifics
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Medicare Enrollment
PQRS
Advance Beneficiary Notice
Incident-to Billing
Audiology services not covered by Medicare
Opting-Out of Medicare
Claims Submission
Appeals and Denials
• Medicare Access & CHIP Reauthorization Act of 2015
• Merit-Based Payment System (MIPS)
• Alternative Payment Models
• Value-Based Payment
• Ethical Considerations
• SLP – Reasonable, Necessary, and Skilled Service
• AUD - Reasonable, Necessary, and Skilled Service
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Medicaid & Medicare
The Very Basics
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Medicaid - Basics
• Enacted in 1965 as part of Title XIX of the Social Security Act
• Partnership program funded jointly between the States and
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Federal government with more than half funded by Fed govt
Intended to cover short-term hardships, not to become the long
term healthcare system
Federal law requires states that participate in Medicaid to cover
certain population groups (mandatory eligibility groups) and
gives them the flexibility to cover other population groups
(optional eligibility groups).
Mandatory service example is Early and Periodic Screening,
Diagnostic and Treatment (EPSDT)
Optional service example is Rehab and other therapies
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MEDICAID - Basics
• Affordable Care Act
• Expanded coverage for the poorest Americans
• Created opportunity for states to provide Medicaid eligibility
• Jan1, 2014, individuals under age 65 with incomes up to 133% of federal
poverty level qualified for Medicaid
• Medicaid signups during open enrollment exceeded 7 million
• Approx 70 million Americans enrolled (Jan 2015)
• In all states, Medicaid provides free or low-cost care for some low-
income people, families and children, pregnant women, the elderly,
and people with disabilities.
• States set individual eligibility criteria within federal minimum
standards
• Medicaid uses the same ICD and CPT health care coding systems
as Medicare and other payers, but payment policies and rates vary
widely from state-to-state.
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Medicaid Resources & References
• Check with your State Medicaid agency for a fee schedule and provider manuals
http://medicaiddirectors.org/about/medicaid.-directors/
• AAA Resources:
http://www.audiology.org/practice_management/reimbursement/medicaid
• ASHA Tool Kit:
www.asha.org/Practice/reimbursement/medicaid/Medicaid-Toolkit/
• ASHA STAR Network: Advocates in your State
www.asha.org/practice/reimbursement/private-plans/reimbursement_network/
References:
• www.medicaid.gov/AffordableCareAct/Provisions/Eligibility.html
• http://obamacarefacts.com/sign-ups/medicaid-enrollment-numbers/
• medicaid-and-chip-january-2015-application-eligibility-and-enrollment-data.pdf
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Medicaid & Medicare
• Both are Government sponsored healthcare programs in the US that differ in
the way they are governed and funded.
• Medicaid is an assistance program that covers low and no income families
and individuals.
• Medicare is an insurance program that primarily covers seniors ages 65 and
older and disabled individuals who qualify for Social Security
• Some may be eligible for both depending on their circumstances
Medicare - Who Decides What?
• Congress
• Controls the Social Security Act, which describes the Medicare
law
• Centers for Medicare & Medicaid Services (CMS)
• Interprets the laws in the Code of Federal Regulation and
Medicare Manuals
• Medicare Administrative Contractors
• A/B MACs process Medicare Part A and B claims for a defined
geographic area or “jurisdiction,”
• Insurance companies are contracted by CMS
• Presently, there are 12 A/B MAC contract workloads
• Interpret the manuals in Local Coverage Determinations (LCDs)
• CMS Medicare Intermediary-Carrier Directory
http://www.cms.gov/MedicareProviderSupEnroll/downloads/
contact_list.pdf
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Local Coverage Determinations (LCDs)
• Policy documents written by the MAC
• May specify what is or is not covered
• Often contain a list of “covered” ICD codes
• There are no national Medicare medical
review guidelines for SLP services*
• If LCDs exist, must refer to them for your
coverage policies
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For ALL Medicare Settings
• Patient is under care of physician and requires skilled therapy services, as
demonstrated by physician’s order for service or signature on the plan of care
(POC)
• All covered Medicare services must be reasonable and necessary and
provided at a level of complexity that requires a qualified professional for safe
and effective care
• Medicare Benefit Policy Manual refers to Medicare Part B outpatient services
as the standards for documentation
• www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf
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ABCDs of Medicare - 4 Types of Coverage
• Medicare is for 65+ population and for certain severe disabilities
A: Everyone 65+ who paid taxes into Medicare has Part A
• Hospital inpatient services, Inpatient psych, Inpatient Rehab Facilities, Skilled
Nursing Facilities, Home Health, Hospice
B: Not everyone has Part B (aka Original Medicare)
• Outpatient services, durable medical equipment, ambulance service, mental
health, clinical research
C: Medicare Replacement Plans
• Medicare Advantage Plan may have different rules, but the plan must give
beneficiary at least the same coverage as Original Medicare and may include drug
coverage
D: Drug coverage
• Part D adds drug coverage to Original Medicare, some Medicare Cost Plans,
some Medicare Private Fee-for-Service (PFFS) Plans, and Medicare Medical
Savings Account (MSA) Plans
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Payment Systems Differ by Settings
Part A - Hospital Inpatient
• Prospective Payment System (PPS)
• Payment is made on a predetermined amount regardless of procedures
performed
• Diagnosis Related Groups (DRGs) – all services provided in hospital with
exception of specific physician services
• DRGs determined by organ system, surgical procedures, co-morbidities, and
gender
• Procedures will be tracked by hospital and reported to CMS as resources, but
are not actually billed using CPT codes
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Hospital Observation Status
Part B may become Part A…or not
• Observation services are hospital outpatient services
rendered while the doctor decides whether to admit the
person as an inpatient or discharge them. Observation
services can be rendered in the emergency department
or another area of the hospital.
• The decision for inpatient hospital admission is a
complex medical decision based on the doctor’s
judgment and the need for medically necessary hospital
care.
• Two midnights
• Qualifying diagnosis
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Payment Systems Differ by Settings
Part A - Skilled Nursing Facility
• Prospective Payment System (PPS)
• Based on patient case-mix determined by assessment
through Minimum Data Set (MDS)
• Resource Utilization Groups (RUGs)
• 66 groups depending on the patient’s needs
• More than 1/3 of groups include PT, OT, or SLP
• Procedures will be tracked by SNF and SLPs may be
asked to use CPT codes, but actually billing does not use
CPT codes
• Part A for first 100 days in SNF; then, Part B may apply
• CPT codes, Medicare Physician Schedule, fee for service
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Payment Systems Differ by Settings
Part A - Skilled Nursing Facility
• Resource Utilization Groups- Therapy level based on minutes per week, frequency of
treatment
• RUG levels for therapy are classified as:
• Ultra high: at least 720 mins; Min 2 disciplines, one at least 5 days/wk
• Very high: at least 500 mins; Min 1 discipline 5 days/wk
• High: at least 325 mins; Min 1 discipline 5 days/wk
• Medium: at least 150 mins; Min 5 days/wk
• Low: at least 45 mins; Min 3 days/wk, +2 restorative nursing services 6 days/wk
• 66 RUGs - SLP falls into about 1/3 of these
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Payment Systems Differ by Settings
Part B - Outpatient Rehabilitation Setting
• Fee-for-Service
• 2016 Medicare Physician Fee Schedule
• Part B is a health care program by choice
• Requires payment of a monthly premium
• Individuals may refuse enrollment and coverage
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STUDENT SUPERVISION
Medicare Part A versus Medicare Part B
Medicare Part A - Hospital Supervision
Students & Unlicensed Clinical Fellows
• Because of the PPS utilized for inpatient hospital
Part A services, claims submitted by hospitals
typically list the “attending physician” as provider of
record
• Assumption - services are provided by
appropriately trained auxiliary personnel and
physicians are readily available in cases of
emergency
• Thus, Part A Hospital supervision is presumed
DIRECT
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Medicare Part A - SNFs - Supervision
Students & Unlicensed Clinical Fellows
• Students are not required to be in the line-of-sight for
supervision at the discretion of supervising provider
within individual facilities (10/01/2011)
• All state and professional practice guidelines for student
supervision must be followed
• Students and unlicensed CFs are considered
extensions, not independent of, the professional provider
• Although SNF supervision rules for Part A services are
less stringent than Part B rules, responsibility of care
remains 100% with supervising provider
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Medicare Part B Supervision
Students and Unlicensed Clinical Fellows
• Medicare Part B requires 100% personal supervision
of SLP students by qualified SLP
• Must be in the room
• Must be directing the service
• Must not be engaged in other activities
• Students and unlicensed clinical fellows are
considered extensions of qualified practitioner
• Does NOT apply to non-Medicare settings unless
specified
MEDICARE ENROLLMENT
Speech Language Pathology and Audiology
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Why Enroll?
Medicare Enrollment
Non-Physician Professionals
60000
50000
Axis Title
40000
30000
20000
10000
0
PT
Social Work
Psychology
Audiology
OT
Dietician
SLP
Actual Medicare Enrollment
76708
58662
51387
11613
9214
7201
2626
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Medicare Provider
How to Enroll…
• First, obtain your National Provider Identifier (NPI)
• apply online at www.nppes.cms.hhs.gov
• free of charge
• Having an NPI number does NOT mean you are a
Medicare Provider
• Medicare enrollment is a separate process
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Medicare Provider
• Application reviewed by the Medicare Administrative
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Contractors for approval
Enroll online at the Medicare Provider Enrollment,
Chain, and Ownership System (PECOS) website:
www.pecos.cms.hhs.gov
See instructions on ASHA’s Website at
www.asha.org/practice/reimbursement/medicare/SLPp
rivatepractice
AAA resources can be found at
http://www.audiology.org/practice_management/reimb
ursement/medicare/participating-medicare
Have a decision-making voice!
UNDERSTANDING PQRS
Audiology
Speech-Language Pathology
Report on a
minimum of 9 quality
measures (across 3
quality domains) and
1 Cross-cutting
measure
(MAV)
For at least 50% of
eligible patients
during 2016
Avoid 2% payment reduction in
2018
SLP PQRS Measures
• Subject to a Measure Applicability Validation (MAV) process that confirms they
have positively reported on a minimum of 50% of the eligible Medicare patient
visits for:
• Measure #130: Documentation of Current Medications in the Medical Record
• Measure #131: Pain Assessment and Follow-Up
• Measure #317: Screening for High Blood Pressure and Follow-Up
Audiology PQRS Measures
• Measure #130: Documentation of Current Medications in the Medical
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Record
Measure #134: Preventative Care and Screening – Screening for Clinical
Depression and Follow-Up Plan
Measure #154: (Falls) Risk Assessment
Measure #155: (Falls) Plan of Care
Measure #226: Preventative Care and Screening (Tobacco Use,
Screening, and Cessation Intervention)
Measure #261: Referral for Otologic Evaluation for Patients with Acute or
Chronic Dizziness
Why report?
• Financial penalty
– Not reporting in 2016 = 2% reduction for ALL Medicare
claims in 2018
• Payment Incentive
– No longer available
National Quality Strategy:
6 Domains
1.
2.
3.
4.
5.
6.
Patient safety – safe care without harm
Patient experience – engage patient and family
Care coordination – effective communication
Clinical care – effective prevention and treatment for
leading causes of mortality
Population/community health – community outreach to
promote better living
Efficiency – more affordable quality care and
implementing new health care delivery models
Things to Know
• Reporting options
• Claims: place appropriate G codes on HCFA 1500
• Registry: a centralized registry for reporting
• EHR: reporting through office EHR
• Cross-cutting measures
• Broadly applicable PQRS measures
Cross-Cutting Measures
• Must report one cross-cutting measure if providers have a face-to-face
encounter
• Provider billed for services associated with face-to-face encounters under the Physician Fee
Schedule
• Includes general office visits, outpatient visits, and surgical procedure codes
• Not tele-health
How to Choose Quality Measures
 Report for all applicable CPT/ICD-10 combinations
that relate to your practice
 Measure #130 is an appropriate measure for both
audiologists and SLPs
 It is now a cross-cutting measure
 Most EHR systems require medication lists
Resources
• AAA http://www.audiology.org/practice/PQRI/Pages/default.aspx
• Audiology Quality Consortium (AQC)http://audiologyquality.org/
• ASHA http://www.asha.org/practice/reimbursement/medicare/
• CMS http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/PQRS/How_To_Get_Started.html
• QualityNet Help Desk
Monday – Friday; 7:00 a.m.–7:00 p.m. CST
Phone: (866) 288-8912
TTY: (877) 715-6222
Email: [email protected]
MEDICARE SPECIFICS
Opting-Out of Medicare
Advance Beneficiary Notice
Incident-to Billing
Audiology services not covered by Medicare
Medicare
• The country is divided into 10 Regions
• Each Region is divided into localities
• Each Region is administered by a Regional
Medicare Carrier
• This Carrier is responsible for processing and
reviewing all MC claims
• Each Regional Carrier has the authority to
interpret Medicare law, so reimbursement
policies are not always consistent from
region to region
Medicare Compliance
• Must use CMS 1500 form and submit electronically
• Unless the facility is a “Small Provider”
• Performs no electronic services at all
• Has fewer than 10 full-time equivalent (FTE) employees
• Physician referral and “Medical Necessity” required;
referral must not be “solicited”
• So, with physician referral, some diagnostic services can
be billed to Medicare even if the evaluation results in a
recommendation for hearing aids
• 20% Co-pay MUST always be collected
Medicare Carrier Regions
Illegal To Bill Medicare For:
• Anything not medically necessary
• What is medical necessity?
• Needed for the diagnosis, direct care and treatment of the
patient’s medical condition
• Meets the standard of good health practice (for defined
diagnostic purpose: not annuals)
• Is not for the convenience of the patient or health care
practitioner
If unsure, consult your Local Coverage Determination
Policy
• http://www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp
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It is illegal for an audiologist to bill “incident
to” (billing services performed with a
physician’s NPI) – Will be covered in Part 2
Maintain the “Status” Quo?
• Provider Status Options:
• Participating Provider (Par): Accept Assignment (AA)
• Medicare payment sent directly to the provider
• Non-Participating Provider (Non-Par):
• Medicare payment sent to the patient
• Limiting Charge under Non-Par
• Non-Par is 5% less than Par (AA)
• Limiting Charge is 10% more than Par (AA)
• Opt Out
• No contractual agreement with Medicare
• Audiologists and SLPs can’t opt out
Audiologists and SLPs
Can’t Opt Out, So…
• CMS requires that covered services must
be submitted for Medicare beneficiaries
(Mandatory Reporting Requirement)
• To bill Medicare, you must be enrolled in
Medicare (can’t opt out)
• Approximately 30 days to obtain provider status
(SLPs my bill ‘incident-to’ but shouldn’t…)
Audiologists Can’t Opt Out, So…
(cont’d)
• Does not apply to non-covered services
• Hearing aids and related testing
• Non-physician referral
• No medical necessity
However, if a beneficiary believes that a service
may be covered, a formal Medicare determination
must be granted
ABN Quick Reference Guide
• Advanced Beneficiary Notice (ABN) of Noncoverage
• Federal law requires an audiologist to notify a Medicare beneficiary in advance, when the
audiologist believes that Medicare will likely deny coverage in a particular instance because the
item or service is not considered by Medicare to be medically reasonable and necessary. The
mandatory ABN fulfills this notice requirement. The ABN allows the audiologist to shift financial
liability to the beneficiary if the claim is submitted and Medicare denies the claim
• Mandatory ABN
• The ABN is only deemed mandatory when an otherwise covered service will likely be denied by
Medicare as not being medically reasonable or necessary.
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Example
A national or local coverage determination indicates that a service does not meet the standard
for medical necessity in a particular instance
• When a mandatory ABN is issued, the entire form must be completed and the beneficiary or their
representative must sign the ABN. (Please consult the instructions for the ABN written by CMS
for complete and the most up-to date information and details)
• Voluntary ABN
• ABN's are not mandatory when an item or service is excluded (never covered) or does not
otherwise meet the technical coverage criteria of the Medicare benefit
The CMS R-131 zip file ink contains up to date ABN instructions and the ABN form in English
and Spanish
“Incident-To” Billing - Audiology
• "Incident to" services are defined as those services that are provided incident to physician
professional services in the physician's office (whether located in a separate office suite or
within an institution) or in a patient's home.
• As the profession of audiology has changed over the years, so has the recognition of the
professional services provided by audiologists. One of the prime examples of this is the policy
changes concerning "incident to" billing for audiology services.
Audiology services must now be billed using the provider number of the audiologist who
provided the service
Available Resource on Topic:
Medicare Benefit Policy Manual Chapter 15 Section 80.3
(search "Audiology Services")
“incident to” for SLP--- 2016
• In general, services and supplies must be furnished under the direct supervision of the
physician (or other practitioner).
• Services and supplies furnished incident to transitional care management and chronic
care management services can be furnished under general supervision of the
physician (or other practitioner) when these services or supplies are provided by
clinical staff.
• The physician (or other practitioner) supervising the auxiliary personnel need not be
the same physician (or other practitioner) who is treating the patient more broadly.
• However, only the supervising physician (or other practitioner) may bill Medicare for
incident to services to exclude all continuing education providers, rather than a select
few. (Code of Federal Regulations, §410.26(b)(5))
More on ‘incident to’ billing – SLP 2016
• Speech-language pathologists are technically allowed to bill “incident
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to” a physician
Billing is under the physician onsite on the date of service
“Incident to” billing is intended for the provision of integral, incidental
services by providers that are not recognized for Medicare enrollment,
such as technicians.
Speech-language pathologists have the ability to enroll as Medicare
providers and transfer the payment of their services to several offices
at once ‘incident to’ if necessary.
Potential financial cost to ‘incident to’ billing (-15% under NPPs)*
MACRA
• April 14, 2015, the Senate passed MACRA with a vote of 92-8
• It established a new payment structure for Medicare
• It abolished the 21% annual threat of reduced payments
• Implemented a 0.5% increase for 2016-2019
• 2019 – 2025 rates will remain constant, but there will be a
chance to have a bonus, or providers may incur a penalty
• After 2025, rates will increase annually by 0.5% annually
• Providers who participate in Alternate Payments Models (APMs)
will be able to earn an additional 0.5%
Pay-For-Performance
• A reimbursement payment model which compensates
professionals for reducing costs without
compromising care
• What happened under FEE-FOR-SERVICE?
• A provider sets his/her own fee schedule, insurance pays
what is “customary and usual” and the patient is billed for
what the insurance company doesn’t pay
Sustainable Growth Rate:
SGR
Sustainable Growth Rate
• Flawed formula that aimed to control spending for
services provided under Part B of Medicare
• Set a spending “target” and then adjusted payment
rates for the following year based on whether or
not actual spending exceeded or remained below
projected figures
• Every year since the inception of the SGR, spending
exceeded targeted amounts resulting in
procedures being paid less (duh…)
• Previously, Congress agreed to “overturn” the
effects of the SGR and provided nominal
increases to practitioners
SGR Replacement
MIPS:
Merit-Based Incentive Payment System
MIPS
Merit-Based Incentive
Payment System
• New payment mechanism that will provide annual
updates to providers effective 2019*
• Essentially replaces SGR with performance targets
• Performance based in 4 categories (100 pts)
• Quality: Value-Based Modifier (30 points)
• Resource use: Value–Based Modifier (30 points)
• Clinical practice improvement activities (15 points)
• Meaningful use of an EHR (25 points)
Two-year lag continues
3 Existing Federal Initiatives are
Incorporated into MIPS
1. Meaningful use – EMR-based program
• The 3% penalty for failure to meet EHR MU
requirements will be eliminated (incentive still exists)
2. PQRS – penalties will sunset at the end of
2018
3. Modifiers associated with the Value-Based
Modifier (VPM) will be less punitive
These 3 programs will be combined and penalties eliminated
Clinical Improvement Category
• Data will be generated from beneficiaries
• Same-day appointments
• Care coordination (telehealth)
• Beneficiary engagement
• Patient safety
• Population management (monitoring population health)
• Participation in APMs
• Others???
MIPS Implementation
• Will begin in 2019*
• A score will be given for the 4 components a and it will be
compared to a composite score. Achievement above the
composite
will yield an incentive
• Adjustments may be as high as 4% in
2019, and 9% by
2022
• Specifics for determining the VPM are still
being determined
*Eligibility for MIPS
• First two years, the following Part B providers are eligible:
• Physicians, physician assistants, nurse practitioners, and nurse
anesthetists
• As of the third year, audiologists and SLPs are likely included (2019
reporting for 2021 payment adjustments)
To Be Determined: how will members will be compensated for the
MU component?
MIPS: Possible Future Incentives
• Will offer even greater bonus if MIPS scores exceed the 25th
percentile (up to an additional 25%) – years 2019-24 known
as the AVERAGE EXCEPTIONAL PERFORMANCE BONUS
• “Over-the-year” improvements; can be low, but if improving,
there will be a bonus
• There is still budget neutrality. There will be a bonus for some
providers and a penalty for others. “Winners
losers”.
take from
• A performance threshold (PT) will be determined annually
based on score between positive and negative. First two years
will be based on PQRS, MU, and the Value-Based Modifier
MIPS - Timeline
• 4/16/15 – MIPS legislation passed
• 7/8/15 – CMS solicited comments through (MPFS) Proposed Rule
• 9/8/15 – MPFS proposed rule comment period ended.
• 9/28/15- CMS issues RFI regarding MIPS/APMs
• Estimated 7/16 –2017 MPFS Proposed Rule issued regarding MIPS
• Estimated 11/16 – Final 2017 MIPS rule (for 2019) in MPFS
Alternate Payment Models
APMS
• Details are not yet clear; 6 different types are being
devised
• Team of providers – some may remain fee-for-service
• Degree of bonus is being speculated – to all?
• If a provider is in an APM, then don’t participate in MIPS
• Currently, doesn’t apply to members- not MIPS eligible
National Quality Strategy:
6 Domains
1. Patient safety – safe care without harm
2. Patient experience – engage patient and family
3. Care coordination – effective communication
4. Clinical care – effective prevention and treatment
for leading causes of mortality
5. Population/community health – community
outreach to promote better living
6. Efficiency – more affordable quality care and
implementing new health care delivery models
ETHICAL CONSIDERATIONS
Reasonable, Necessary and Skilled Service
Fraud and Abuse
Speech-Language Pathology
What is Unskilled Care?
• Unskilled services do not require the special knowledge
and skills of an SLP
• Performance reporting without describing modification,
feedback, or caregiver training that was provided during
the session
• Repetition
of same activities as in previous sessions
without noting modifications or observations
• Activities
without rationale or connection to the goals
Speech Language Pathology
What is Unskilled Care?
• Observing caregivers without providing education or
feedback and/or without modifying plan
• Recording observations of beneficiary without
providing any direct treatment strategies
• Service can be self-administered
• Service may be furnished safely and effectively by an
unskilled person without direct or general supervision
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Speech Language Pathology
What is Unskilled Care?
• Service is related to activities for the general good and
welfare of patient (e.g., fitness, flexibility, motivation,
diversion)
• Therapist provides an important, yet nonskilled service
in the absence or unavailability of a competent person
• Service is NOT considered a skilled therapy service
merely because the activity is provided by a qualified
therapist
• Ask yourself, “Can this be done by someone else?”
Medicare Benefit Policy- Skilled Care
• The services shall be of such a level of complexity and sophistication or the
condition of the patient shall be such that the services required can be safely
and effectively performed only by a therapist…
• The deciding factors are always whether the services are considered
reasonable, effective treatments for the patient’s condition and require the
skills of a therapist, or whether they can be safely and effectively carried out
by nonskilled personnel.
Speech Language Pathology
What is SKILLED Care?
• Analyze medical/behavioral data and select appropriate
evaluation tools/protocols
• Design plan of care (POC)
• Develop and deliver treatment activities that follow a
hierarchy of complexity to achieve the target skills for a
functional goal
• Based on expert observation, modify activities during
treatment sessions to maintain patient motivation and
facilitate success.
• Conduct ongoing assessment of patient response
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Speech Language Pathology
What is SKILLED Care?
• Determine appropriate time for discharge or
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termination of SLP service
Explain rationale and expected results
Develop maintenance program to be carried out by
patient and caregiver
Train patients/caregivers in use of compensatory
skills and strategies
www.asha.org/Practice/reimbursement/medicare/Docu
mentation-of-Skilled-Versus-Unskilled-Care-forMedicare-Beneficiaries
Speech-Language Pathology
THINK QUALITY NOT QUANTITY
Evidence-based decisions – Are you integrating research evidence with clinical
expertise and patient values to determine your plan of care?
• Is professional intervention necessary?
• Do SLP services provide meaningful and functional benefit to the individual?
Audits: Fraud & Abuse
Medicare:
Defining Fraud & Abuse
Unlike Medicare fraud, which involves an intentional
deception or misrepresentation, Medicare abuse occurs
when physicians, providers, or suppliers mistakenly bill for
items or services
Fraud & Abuse
• Providers “have a duty to ensure that the claims submitted to federal health-care
programs are true and accurate”, according to the Office of Inspector General (OIG)
Abuse
Abuse occurs when physicians, providers, or suppliers
mistakenly bill for items or services.
Potential Example:
Mistakenly billing for services provides by an unlicensed student
without personal supervision.
Fraud
Fraud involves an intentional deception or
misrepresentation, for example:
• Submitting an intentionally fraudulent claim in which the
provider has actual knowledge of the falsity of the claim
• The provider has a duty to know what the billing staff is
doing. The provider is ultimately responsible for
claims billed, regardless of who is completing the forms.
Medicare Fraud: Examples
• Billing for services not performed
• Misrepresenting the diagnosis to justify payment
• Soliciting, offering, or receiving a kickback
• Unbundling a CPT code
• Falsifying medical necessity, plans of treatment, or
medical records to justify payment
2016 CAPCSD Presentation Part II
Questions?
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