Important Recommendations To Mitigate Provider Payment Risk During Doc Fix Delay

The U.S. Senate will return to the Capitol from its two week Easter recess on April 13th. Reports out of Washington project that, upon its return, the Senate will likely vote to support of the permanent Doc Fix legislation (H.R.2) that was overwhelmingly approved in the House of Representatives last Thursday. It is likewise expected that the effective date of the bill they enact will be retroactive to April 1st.

However, the fact remains that by the Senate not taking action in recent weeks, the (1) -21.2% adjustment in the Medicare Part B physician fee schedules technically went into\effect on April 1st and, (2) the Medicare Therapy Cap exceptions process expired on March 31st. These two events potentially put provider claims payments at risk during the period of uncertainty while we await the Senate return and action on the House's Doc Fix package.

To identify the risks involved and to provide recommendations for providers to mitigate that risk, AHCA's Senior Director for Therapy Advocacy, Dan Ciolek, has prepared the following memo:

"Facility operators are entering a period of operational uncertainty and risk related to Medicare Part B services due to the U.S. Senate's not voting on a new Sustainable Growth Rate (SGR) bill - also known as the Doc Fix - prior to the March 31 expiration of the current SGR and therapy cap exceptions process. There are two major issues that we want to alert you to and provide preliminary recommendations, as there is no current guidance from the Centers for Medicare and Medicaid Services (CMS).

These recommendations, as well as the content provided in the detailed

FAQ document, are based upon current available information and have been reviewed and commented on by the AHCA Finance Committee's Billing and Operations Subcommittee and the Therapy Policy Advisory Group. We encourage SNF operators to review and consider these recommendations within the context of their current operational policies.

First Issue 

Technically, a -21.2 percent adjustment would apply to the Part B fee schedule effective April 1. However, if the SGR bill is enacted when the Senate returns from recess, this will not apply and there will be a 0.0 percent adjustment from April 1 - June 30. CMS will most likely hold processing of Part B claims for up to 14 days to avoid changing its billing systems while Congress acts.

To mitigate this risk, AHCA recommends that SNF operators hold any Part B claims with dates of services on or after April 1 until it is clearer what will happen in the Senate. 

Most SNF operators typically bill on a monthly basis so that April dates of service would not be billed until May. We believe this will be sufficient time to let the legislative process proceed so that care centers will not have to change charge masters or resubmit claims, assuming the SGR bill is enacted after the Senate returns from recess in two weeks.

Second Issue 

Technically, the therapy caps exceptions process expires on March 31 and there will be a hard $1,940 therapy cap with no exceptions. However, if the SGR bill is enacted when the Senate returns from recess, this will not apply. The problem is that until Congress acts, any therapy services furnished over the $1,940 threshold during this period of uncertainty could pose payment liability risks. 

To mitigate this risk, AHCA recommends that SNF operators issue Advance Beneficiary Notices (ABNs) to beneficiaries needing Part B therapy services beyond the $1,940 threshold as of April 1, 2015. This notice will provide necessary beneficiary and provider payment liability protections depending on the resolution of the current SGR vote delay in the Senate.

For a more detailed explanation of these risks, please review the

SGR Delay Impact on SNF Operations FAQ

and share within your billing, therapy and other affected operational personnel."

For questions, please contact Dan Ciolek at