The following is the December legilslative update from the Brain Injury Association of America (BIAA):
TBI Act Reauthorization 2013
The TBI Act Reauthorization of 2013, H.R. 1098 was approved by voice vote in the House Energy and Commerce Committee markup on Wednesday, December 11, 2013. The Energy and Commerce Subcommittee on Health passed the bill in markup on Tuesday, December 10, 2013 with the following changes:
- Inserted authorization levels for the TBI Act programs based on current appropriations.
- Removed Health Resources and Services Administration (HRSA) giving the discretion to the Health and Human Services (HHS) Secretary to elevate the TBI state grant programs and the Protection and Advocacy (P&A) programs within HHS.
H.R. 1098 will be debated on the House floor early next year. Please contact your member of Congress and ask him or her to cosponsor H.R. 1098.
BIAA continues to work with our Senate Champions to have a companion bill to the TBI Act introduced early in 2014.
Therapy Cap Repeal
This week the Senate Finance Committee released legislation which would permanently address the Sustainable Growth Rate which includes therapy cap repeal. The package includes:
- Repeals the Therapy Cap immediately upon enactment of the legislation.
- Continues manual medical review only through 2014. Manual medical review expires at the end of 2014.
- Requires the Secretary of HHS to establish a new prior authorization medical review process to begin on January 1, 2015. The Secretary retains discretion on what level to apply the review (spending threshold) and in what settings to apply the review.
- In addition, the Secretary would identify the services for medical review, using appropriate factors, which could include (but would not be limited) the following:
(1) Services furnished by a therapy provider whose pattern of billing is higher compared to peers.
(2) Services furnished by a therapy provider who, in a prior period, has a high claims denial percentage or is least compliant with other applicable requirements under this title.
(3) Services furnished by a therapy provider who is newly enrolled in the Medicare program.
(4) Services furnished by a therapy provider who has questionable billing practices, such as billing medically unlikely units of services in a day.
(5) Services furnished to treat a type of medical condition.
(6) Services identified by use of the standardized data elements required to be reported.
(7) Services furnished by a single therapy provider or a group that includes such providers.
(8) Other services as determined appropriate by the Secretary.
A therapy provider could submit for multiple visits under each prior authorization claim and the information necessary for medical review could be submitted by fax, by mail, or by electronic means. As soon as practicable, but not later than 24 months after the date of enactment, the Secretary would have to make available the electronic means necessary to receive information.
The Secretary would make a prior authorization determination within ten business days of receipt of the necessary medical documentation or; otherwise, be deemed to have found the services to meet the applicable requirements for Medicare coverage.
The new medical review system will be established through rule making and will allow for stakeholder input.
The GAO would conduct a study on the new medical review process.
Following a series of defined steps (which include opportunity for stakeholder input- comment, stakeholder townhalls etc), The Secretary will establish a new data collection system to replace the current functional limitation reporting system. Depending on the date of enactment of the legislation, this could occur around the beginning of 2017. Like functional limitation reporting, therapy providers would be required to report on these items to be paid for a claim. Data elements that the Secretary could include in the new data collection system could include:
(1) demographic information
(2) diagnosis
(3) severity
(4) affected body structures and functions
(5) limitations with activities of daily living and participation
(6) functional status
(7) other domains determined to be appropriate by the Secretary
The Secretary is allowed but not required to create a web portal to allow for the submission of this data.
No later than 18 months after the date the data reporting system is operational (depending on the date of enactment this could be in 2018), the Secretary would submit a report to Congress on the design of a new payment system for outpatient therapy services. The report would include an analysis of the standardized data elements collected and other appropriate data and information. It would consider (1) appropriate adjustments to payment (such as case mix and outliers), (2) payments on an episode of care basis, and (3) reduced payment for multiple episodes. The Secretary would consult with stakeholders regarding design of such a new payment system.
The bill would also require that each request for payment, or bill submitted on or after January 1, 2015, by a therapy provider for an outpatient therapy service furnished by a therapy assistant include an indication that the service was furnished by a therapy assistant.
