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Jane Erwin A new Medicare payment system for outpatient rehabilitation services won’t go into effect Jan. 1 as anticipated, but providers still have to follow the complexities of the new system and start adjusting to some financial realities, experts say. "Medicare changes all the time, from minor items to drastic ones. And there always are many interpretations," said Stephen Campbell, member of the Texas Physical Therapy Association (TPTA) government affairs committee. Congress authorization With passage of the Balanced Budget Act of 1997, Congress authorized the Health Care Financing Administration (HCFA) to implement the Medicare Prospective Payment System for hospital outpatient rehabilitation services and services furnished by community mental health centers. The PPS limits the coverage Medicare beneficiaries will receive for these services. The rehabilitation services comprise occupational therapy, physical therapy, and speech-language pathology. The law sets a limit of $1,500 annually per beneficiary, which has been interpreted as $1,500 per beneficiary per year for OT services and $1,500 per beneficiary per year for PT/SLP. All services paid under the PPS are classified into "ambulatory payment classes." Services in each APC are similar clinically and require similar resources, and a payment rate is established for each group. A current method by which allied health professionals receive payment will be extended to specific types of outpatient care. Therapists in independent practice, physicians, and other practitioners have received payments from the Medicare Physician Fee Schedule in the past and will continue to do so. After Jan. 1, the MPFS will also be the payment method for rehabilitation agencies, hospitals, skilled nursing facilities, and home health agencies when they provide outpatient physical or occupational therapy services. Partial implementation The new system goes into effect on Jan. 1, but not as Congress intended, said Alwyn Cassil, HCFA spokesperson. "Because HCFA needs to marshal its forces to deal with the Year 2000 computer compliance problem, full implementation will be delayed," she said. "The system will be implemented as soon as possible after Jan. 1, 2000." Even with the delay, providers still must comply with PPS billing. As a transitional measure, after Jan. 1, 1999, providers will be held accountable for tracking incurred expenses for each patient and must not bill Medicare for patients who have met the annual $1,500 cap. Once the limit has been met, a provider must get a denial notice from Medicare in order to bill other insurers. Some healthcare professionals are frustrated by the new PPS regulation. "This is not an appropriate way for the government to regulate Medicare. It puts a dollar limit on patient need," said Christina A. Metzler, director of federal affairs for the American Occupational Therapy Association (AOTA). Some shortchanged Metzler said patients who traditionally have had less of a voice in the healthcare system could get shortchanged under the new system. "We think there will be patients who are more vulnerable and will not get the care they need," she said. "Probably patients in nursing homes, for example, who can’t easily access providers." Such a population can’t "walk out and get care" from other providers if they meet the cap, she said, and are limited to the practitioners in their own facilities. Bills to repeal the $1,500 cap were introduced in the House and Senate last session of Congress, but they failed. The AOTA, the TPTA, and other organizations, however, are redoubling their efforts to get legislation passed that repeals the cap .Meanwhile, allied health professionals ponder the ramifications of operating under the new system. "We may be able to handle a $1,500 limit on a patient with a fractured hip or with arthritis, but for an outpatient stroke victim or one with several broken bones, there’s no way to provide that extensive care for that amount," said Campbell, manager of industrial rehabilitation at Matrix Rehabilitation in Dallas. "Like every company, we’ll have to do more with less. We have to look at early intervention before a patient gets debilitated," Campbell said. "There will be more home programs. Patients will have to do more on their own; rather than come to a facility three times a week for exercise, they will have to work out on their own. We also have to be proactive and try to get physicians and patients to understand they have to do more on their own." |
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