Summary: The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries. From 2007-2014, the financial incentive for successful measure reporting is a bonus payment on allowable charges. Beginning in 2015, the financial incentive changes to a negative payment update for not reporting measures that would otherwise have been appropriate. However, that negative payment update in 2015 will be on allowable charges submitted for FY 2013.

The 2012 Physician Quality Reporting System (PQRS) measure list and specifications should be utilized to help with successful reporting of quality measures. The following individual measures are available to physical therapists in 2012:

124:   Health Information Technology (HIT):
126:   Diabetes Mellitus: Neurological Evaluation
127:   Diabetes Mellitus: Evaluation of Footwear
128:   BMI Screening &Follow Up
130:   Documentation & Verification of Current Medications
131:   Pain Assessment Prior to Initiation of Therapy &Follow up
154:   Falls: Risk Assessment
155:   Falls: Plan of Care
182:   Functional Outcome Assessment [NEW]

One group measure for Back Pain is available to physical therapists in 2012 and all four measures must be included in the reporting:

148:   Back Pain: Initial Visit
149:   Back Pain: Physical Exam
150:   Back Pain: Advice for Normal Activities
151:   Back Pain: Advice Against Bed Rest

Providers should refer to the measure list and the Measure Specification Guide linked on the webpage below for individual measure reporting information. For any therapist participating in FOTO, please refer to measures 217-223.

Summary: The Guide Reducing Unintended Consequences of Electronic Health Records contains practical, troubleshooting knowledge and resources for all settings where healthcare services are delivered. It is written to address issues of interest for Chief Information Officers, "superusers", administrators, and clinicians involved in training. Front line users may also find the information useful, but it is of significant value to those on the front line of implementation and training.

The Guide is based on the research literature, other practice-oriented guides for EHR implementation and use, research by its authors, and interviews with organizations that have recently implemented EHR. But since this area of application of technology is still growing, the authors invite the user to revise as best fits their needs and in order to continue to respond to emerging information and research in this area.

Summary: The healthcare industry will implement use of the ICD-10 CM/PCS code set on October 1, 2013. All stakeholders, including but not limited to providers, hospitals, payers, billers, and clearinghouses, must be actively engaged in transition activities that will facilitate a successful transition to ICD-10. Unsuccessful transition will result in denied claims and potentially a significant loss or delay in revenues.

The American Health Information Management Association (AHIMA) published a planning and preparation checklist to assist all entities involved in the transition to ICD-10. Successful transition and implementation of ICD-10 requires a well organized planning and implementation process that involves both clinicians and office staff. AHIMA has divided the process into four phases and highlights what personnel should be involved during each phase:

• Phase 1: Implementation plan development and impact assessment (first quarter 2009-second quarter 2011)
• Phase 2: Implementation preparation (first quarter 2011 to second quarter 2013)
• Phase 3: "Go live" preparation (first quarter 2013 to third quarter 2013)
• Phase 4: Post Implementation follow-up (fourth quarter 2013 to fourth quarter 2014)

Summary: The language in Transmittal 72 states that rehabilitation services must be ordered by a qualified practitioner who is responsible for the care of the patient and who has medical staff privileges to write orders for these services. The policies set forth in this Transmittal are far-reaching as they apply to both inpatient and outpatient hospital based settings and apply not only to Medicare beneficiaries but to all patients who receive services at the hospital.

Summary: Public Law 112-078 provided for a zero percent update to the Medicare conversion factor, the final rule indicated that there would be a 0.18% increase in the conversion factor for budget neutrality and this change will also be effective Jan. 1, 2012. The budget neutrality increase is due to CMS adoption of the RVS Update Committee recommendations for misvalued codes. The 2011 conversion factor was $33.9764. The 2012 conversion factor will be $34.0376.

CMS also has indicated that because Congress acted so late in 2011 to prevent the SGR cut, claims must still be held for a period of time to allow CMS time to develop the new payment rate files and the Medicare claims administration contractors time to install and test the files. CMS expects that most if not all contractors will be ready to process claims under the revised rates on or before Jan. 18, 2012, which is the end of the 10-business-day claims hold period previously announced, but contractors' time frames may differ. Contractors are expected to have the new rates posted to their web sites by Jan. 11th.

Finally, CMS published in the Jan. 4, 2012, Federal Register a correction notice to the 2012 final rule that modifies the relative values for a number of services. The agency also posted to its web site a revised relative value file reflecting both the corrections and the legislation that stopped the 27.4% cut.

Summary: The federal government continues to roll out resources aimed at improving provider compliance so that the incidence of fraud and abuse will decrease. An audio podcast on the False Claims Act has been developed and posted on the HEAT Provider Compliance website. The podcast includes examples of violations under the false claims act (e.g. billing for services not rendered, upcoding, billed services not supported by the medical record documentation, and billing for services covered under another claim). The podcast emphasizes that providers cannot claim deliberate ignorance regarding submission of false claims. Also included is information on the mandatory return of overpayments within 60 days of receipt and a detailed description of the financial penalties for violations of the Act.

Summary: The new letters will be sent by Medicare Administrative Contractors beginning in January, 2012, following a policy change that addressed concerns raised by hospitals about timeliness. The revised sample letters are going to contain some changes that will make Demand Letters that are specific to Recovery Audits more easily identifiable. There will be a letter "R" before the letter number that will indicate the Demand Letter was due to a RAC audit. The letter number containing the "R" will be present on each page of the Demand Letter. In addition, the body of the letter will specifically spell out that the finding was due to a Recovery Audit review. It's important to put processes in place within your organization to be on the lookout for these identifiers in the Demand Letters so that they can be routed to the appropriate individuals who are responsible for managing & tracking RAC audits within your organization.

CMS indicates that the ultimate goal of this change in process should give more accurate and timely information to providers.

Summary: The Centers for Medicare and Medicaid Services (CMS), in its continuing efforts to provide education and outreach to providers, has released a 7.5 minute podcast detailing the Medicare Overpayment Collection Process. This MP3 audio file is accompanied by a transcript and is intended to be useful for providers and suppliers of services to Medicare beneficiaries in the fee-for-service program.

The podcast has information on the definition of overpayment, the process of overpayment, and additional resources that will assist providers and suppliers who report services to Medicare Administrative Contractors (MACs). There are four possible ways that overpayments can occur:

• Duplicate claim submission
• Claim to the wrong provider
• Payment for excluded or medically unnecessary services
• A pattern of furnishing and billing for excessive or non-covered services

Summary:

Summary: The $3 billion total in settlements and judgments in civil cases for fiscal year 2011 includes a record $2.8 billion in recoveries under the whistleblower provisions of the False Claims Act, which is the government's primary civil remedy to redress false claims for federal money or property, such as Medicare benefits, payments on military contracts, and federal subsidies and loans. The department has recovered more than $30 billion under the False Claims Act since the act was substantially amended in 1986. The 1986 amendments strengthened the act and increased the incentives for whistle blowers to file lawsuits on behalf of the government. That in turn led to an unprecedented number of investigations and greater recoveries.

"Twenty-eight percent of the recoveries in the last 25 years were obtained since President Obama took office," according to Tony West, Assistant Attorney General for the Civil Division. "These record-setting results reflect the extraordinary determination and effort that this administration, and Attorney General Eric Holder in particular, have put into rooting out fraud, recovering taxpayer money and protecting the integrity of government programs."

Assistant Attorney General West noted that the $3 billion recovered this year included $2.4 billion in recoveries involving fraud committed against federal health care programs. Most of these recoveries are attributable to the Medicare and Medicaid programs administered by the Department of Health and Human Services (HHS). They also include the TRICARE program administered by Department of Defense (DoD), the Federal Employees Health Benefits program administered by the Office of Personnel Management and Veterans Administration health programs.

The historic $2.8 billion recovered in whistle blower cases came from suits filed under the qui tam, or whistleblower, provisions of the False Claims Act. These provisions allow private citizens, known as relators, to file lawsuits on behalf of the government. In the 25 years since the False Claims Act was substantially amended, whistle blowers have filed more than 7,800 actions under the qui tam provisions. Qui tam suits hit a peak of 638 this past year, after hovering in the 300s and low 400s for much of the decade.

Enforcement actions involving the pharmaceutical industry were the source of the largest recoveries this year. In all, the department recovered nearly $2.2 billion in civil claims against the pharmaceutical industry in fiscal year 2011, including $1.76 billion in federal recoveries and $421 million in state Medicaid recoveries.