Question:

In the state of NJ how often can we bill for a Re-evaluation after 10 visits, 60 days... Is it different for Medicare? Just wondering what the state regulation was on that, thanks.

 

Response:  

There is nothing in the NJ regulations specifying how often a re-evaluation may be billed or conducted. As such, the PT is responsible and accountable for this decision. The Highmark Medicare LCD for PM&R, which can be accessed here; https://www.highmarkmedicareservices.com/policy/mac-ab/l27513-r7.html , states the following:

    

Coverage Limitations

 

Reimbursement for an evaluation will be limited to once per episode. Many patients may complete their course of physical medicine and rehabilitative services without ever needing a re-evaluation service, while others may need one or more re-evaluations performed during their course of treatment because of a change in status or needs.

 

Question:

With the upcoming Medicare audits, is there a concern if you charge self pay patients less than your Medicare patients? For instance, if I have a flat fee for self pay patients that is less than the average total for each Medicare visit, is that "an issue" per the Medicare regulations and if so, do you have the reference?

 

Response:

The short answer to your question is a qualified yes; this could be a concern on audit. Please keep in mind, however, that we cannot answer for the Medicare program or a Recovery Audit Contractor (RAC), and that there is not always a specific reference for every question or situation. Also keep in mind that "fees", "charges" and collections"are not synonymous terms, and present unique issues with significant legal implications.

 

Section 1833 of the Social Security Act, which addresses the Medicare program, mandates that the program will reimburse 80% of the Medicare fee schedule or 80% of the "customary charge", whichever is less. As such, this language presents an opportunity for a RAC auditor to argue that your charge to self pay patients is your "customary charge". Also keep in mind that NJ regulations require that you provide a written fee schedule available upon request.

 

This message is probably a good illustration why we often say that some issues do not generally lend themselves well to simple responses, and are better suited for direct conversation, given the significant implications of the issue.

   

Reference:

Social Security Act: http://www.socialsecurity.gov/OP_Home/ssact/title18/1833.htm

 

NJ Fee Schedule Regulation, 13:39A-3.4 Financial arrangements with clients and third party payors: http://www.njconsumeraffairs.gov/laws/ptregs.pdf

    

Question:

I have heard something that I'm not sure is correct. Are we now going to have pay a fee to enroll in Medicare?

 

Response:

The short answer is no, but it's not quite that simple. There have been many significant changes to the enrollment process, which were included in H.R. 3590, Patient Protection and Affordable Care Act,sometimes referred to as "Obamacare".Implementation of these statutory changes is outlined in the Final Rule published by CMS on 2/2/11 in the Federal Register. While it is not true that an enrollment fee will be charged for initial enrollment, except for those PTs who also wish to enroll as DMEPOS providers, Medicare contractors will perform the following when enrolling PTs and PT groups.

1. Verify that a provider or supplier meets all applicable Federal regulations and State requirements for the provider or supplier type prior to making an enrollment determination.
2.  Conduct license verifications, including licensure verifications across State lines for physicians or non-physician practitioners and providers and suppliers that obtain or maintain Medicare billing privileges as a result of State licensure, including State licensure in States other than where the provider or supplier is enrolling.
3. Conduct database checks on a pre-and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type.
4. Conduct an on-site visit.

While a fee will not be charged upon initial enrollment there is much more to these regulations than can be adequately summarized here, and the regulations themselves are already being challenged by many national provider organizations, including APTA. For example, the response above is applicable to PTs in Private Practice (PTPPs) but not to CORFs or Rehab Agencies. 

 

Reference:

Federal Register / Vol. 76, No. 22, pp. 5862-5971 Hyperlink: http://edocket.access.gpo.gov/2011/pdf/2011-1686.pdf