An under-the-radar effort to protect Medicare payments to long term and post-acute care providers continues on Capitol Hill and in official Washington, according to a source with the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) who tells Provider the Calendar Year (CY) 2021 Medicare Physician Fee Schedule Rule is a top priority.

Daniel Ciolek, associate vice president for therapy advocacy at AHCA/NCAL, said the proposed rule has been out of mind for many providers due to the attention required for battling the COVID pandemic. If finalized, he says the rule could result in significant payment cuts in 2021 for Part B therapy, and other cuts to skilled nursing facility (SNF) physicians and portable X-ray providers that may impact the service residents in SNFs may receive.
The proposed cuts could also negatively impact assisted living (AL) communities and access to care for residents with intellectual/developmental disabilities (ID/DD).

For more than a year, Ciolek says AHCA/NCAL has worked with a coalition of 47 provider organizations to head off the cuts with the Centers for Medicare & Medicaid Services (CMS). In addition, the coalition has worked on the issue with Congress since part of the problem with the proposed rule is a result of statutory budget-neutrality restrictions.

“We recognize that part of the problem is that statutory budget neutrality limits placed on the Medicare Part B physician fee schedule payment methodology create a situation that CMS is forced to ‘rob Peter to pay Paul,’” he says.

As way of background, in the CY 2020 Physician Fee Schedule (PFS) Final Rule (84 FR 62568), CMS finalized broad changes related to physician evaluation and management (E/M) services to reduce administrative burden, improve payment rates, and reflect current clinical practice.

The health care community supported restructuring and revaluing the office-based E/M codes, which will increase payments for primary care and other office-based services. Unfortunately, by law, any changes to the PFS cannot increase or decrease expenditures by more than $20 million. To comply with this budget-neutrality requirement, any increases must, therefore, be offset by corresponding decreases, Ciolek says.

CMS estimates that the 2021 proposed rule policies will increase Medicare spending by $10.2 billion, necessitating steep cuts by reducing the Medicare conversion factor from $36.0896 to $32.2605, or a 10.6 percent decrease.

As reflected in Table 90 of the proposed rule, payments for common PFS services furnished to residents in SNF, AL, and ID/DD residences will be cut 9 percent for physical therapy (PT) and occupational therapy (OT) services and 6 percent for portable X-ray services. In addition, the proposed rate tables for individual procedures indicates that speech language pathology (SLP) services as well as physician E/M services furnished to SNF residents will be cut up to 11 percent.

Speaking on the overall payment cut proposal, Ciolek says AHCA/NCAL realizes that in asking for the changes CMS wants to improve the fairness of payments to physicians who manage patients with complex conditions in their offices.

“However, the solution, especially during a worldwide pandemic that most impacts patients in our AHCA/NCAL member facilities that are older and have multiple comorbidities, is not to cut payments to providers including physicians, portable X-ray providers, and therapists who furnish care to these individuals,” he says.
 
Ciolek adds that the association and coalition are hopeful that CMS will be responsive to the massive number of submitted comments from 42,640 provider and consumer stakeholders as well as members of Congress and put a pause on the planned payment cuts.

“While CMS may be able to offer some relief in the upcoming Final Rule, Congress will need to step up to the plate to fix this permanently,” he notes.

In addition to opposing the proposed rule payment rate cuts, AHCA/NCAL also is concerned about the following topics:
--Medicare telehealth and other services involving communication technology;
--Refinements to values for outpatient therapy evaluations analogous to office/outpatient E/M visits;
--Revised medical record documentation requirements for physical and occupational therapists and speech-language pathologists; and
--Planned 30-day delayed effective date for the final rule.