• The SGH Total Joint Program received Joint Commission certification in a one-day survey.
• The CDPH conducated a Medication Error Reducation Program (MERP) survey.
• A "tiered" pay-for-peer review program will be implemented effective 1-1-13. The tiers will differentiate between cases that require less than 20 minutes to review and more complex reviews.
• Proposed bylaws revisions were approved. Those revisions included increases to medical staff dues effective 1-1-13. Active and Provisional Staff $250, Consulting and Affiliate Staff $150. A second tier to the increase will be implemented on 1-1-14.
• Response rate for the MD Satisfaction Survey was 40%.
• A second 64-slice CT scanner is operational and is available 16 hours per day.
• The "ring road" will be available again in approximately one month.
• A PET scanner is being purchased and will be housed at the GMT.
• MD handwashing compliance is at 82%.

Effective October 1, 2012, the Centers for Medicare and Medicaid Services, have added a financial limitation on hospital-based outpatient therapy departments with an Outpatient Therapy cap for Occupational Therapy of $1,880 and a combined cap for Physical Therapy and Speech Language Pathology of $1,880. This is an annual per beneficiary therapy cap amount determined for each calendar year. Medicare allowable charges, which include both Medicare payments to providers and beneficiary coinsurance, are counted toward the therapy cap. The first therapy visit starts the accrual toward the annual threshold cap. This begins with dates of service on and after January 1 and continues through December 31 of each year.

Services that can be medically justified AND are granted a pre-approval exception, by CMS, can be provided beyond the dollar limit. However; these services must meet the qualifications set by CMS and the exception must be filed by the provider. Pre-authorization itself is not a guarantee of payment. Retrospective review may still be performed. The following basic criteria must be met to request pre-approval:
* Therapy must be of such a level of complexity and sophistication, or the condition of the patient must be such that the services required can only be performed by a qualified therapist.
* Therapy must be reasonable and necessary
* Therapy must improve function for sustained recovery and the patient must demonstrate objective, measurable progress.
* Amount, frequency and duration must be consistent with the standard of care for the patient's particular treatment diagnosis.
* If there has been previous treatment for the condition, there has to have been a significant change to require further treatment.

Any claim that is submitted beyond the cap amount will be reviewed by our Medicare contractor and a determination will be made to either pay for deny the claim. Should Medicare deny a claim as not medically necessary, the patient will be held responsible and billed for the services provided beyond the cap.

Physician requirements become extremely important to avoid denials. All reviewed claims must have the following physical documentation:
* A physician's written approval of the initial plan of care is required.
* Physician signature re-certifying the treatment plan and continued need for therapy is required once the initial plan of care has expired.
* Any significant changes to the plan of care (i.e. changes to long-term goals) require physician written approval.

Therapist requirements will include:
* If the patient no longer requires the skills of a qualified therapist, and the patient can continue with a home exercise program, the patient must be discharged from therapy.
* The therapist will send the plan of care to the physician for signature.
* At a minimum, the treatment plan includes: the diagnosis, treatment frequency, treatment duration, and long-term goals.
* A progress report will be sent to the physician every 30 days or 10 treatments, whatever comes first.
* A re-certification note will be sent to the physician for signature if the patient requires continued skilled therapy beyond the duration stated in the original plan of care.
* If the patient has met treatment goals or if the patient is no longer making measurable gains, the patient must be discharged from therapy.

September 19 - General Medical Staff Meeting
December 4 - SGH Medical Staff Holiday Party

Watch for specific details on each event or call Lesley Bradley at 619-740-4145 or email her at lesley.bradley@sharp.com.

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