Medicare and Medicaid Resources:
Frequenlty Asked Questions
Centers for Medicare and Medicaid Services (CMS) Manuals
These manuals provide guidance to support compliance with Medicare and Medicaid “Conditions of Participation” for service delivery, billing of services and payment processes
CMS Benefit Policy Manual
CMS State Operations Manual
CMS Program Integrity Manual
These forms are used to apply for Medicare Provider status as an individual, as a referral source for care of Medicare Beneficiaries or to apply to form a Medicare approved specialty group practice.
Medicare Administrative Contractor (MAC)
The MAC is responsible to monitoring and administer Medicare funds utilized by Medicare beneficiaries and providers. The MAC jurisdiction is determined through contractual arrangement with the CMS federal offices. There is one MAC overseeing all Medicare activity in the state of Pennsylvania: Novitas Solutions, Inc.
MACs control payment for Medicare services through a series of Local Coverage Determinations (LCDs). The LCD for a particular site of service is dependent on the type of Medicare Provider Number assigned to the location. You must know if your location falls under the Medicare Part A or the Medicare Part B program because each may have a different LCD. Be very careful when selecting the LCD for the services you provide! Using the wrong LCD can result in non-payment for your services.
Novitas Medicare Part A
Novitas Medicare Part B
Medicare benefits are calculated and controlled on a calendar year basis of January through December, the Medicare fiscal calendar actually begins October 1. The beginning of the Medicare 2015 fiscal year holds particular significance for those serving the Medicare population. Not only does October 1, 2014 begin the countdown to national implementation of ICD 10 on October 1, 2015, it also begins the countdown to January 1, 2015 for private practitioners who service patients meeting Medicare’s definition for Complex Chronic Care Management. Known by Medicare as “CCM”, this initiative will provide a financial incentive to physicians servicing Medicare beneficiaries with two or more chronic conditions through their physician practices. CCMs include diseases such as Parkinsonism, Diabetes, Congestive Heart Failure, Osteoarthritis and Hypertension. Although the SLP may be addressing only the communication, cognitive or swallowing disorder that is not directly associated with these diseases, the incentive program requires all those servicing the patient and billing Medicare to contribute to the physician’s electronic health record. It remains to be seen whether this will significantly impact SLPs servicing this population but if an SLP in private practice is servicing through a physician’s practice and bills Medicare for treatment of a patient who is under the care of a physician participating in the CCM program, the SLP will be required to provide electronic medical record information to the physician. It is very important to keep in mind that HIPAA requirements do not allow for patient information to be exchanged through non-encrypted, external email systems. If you think the CCM initiative may impact your practice, it would be best to clarify and verify processes with the physician office referring to you in advance of the January 2015 implementation date of the CCM Program.
With respect to this year’s Autumnal legislative elections, we expect to experience multiple changes at both the state and federal levels. As election results are realized, watch carefully to learn what may unfold with respect to both the Medicare and Medicaid systems. At the state level, Pennsylvania did not adopt the Medicaid Expansion Program last year. This resulted in fewer Medicaid dollars being allocated to Pennsylvania through the federal budget. In some school districts, this may have impacted the compensation received through the ACCESS Program. Whether the newly elected state legislators will want to continue to decline the provisions of the expansion program remains to be seen. As we look to post election “lame duck” activity at the federal level, watch carefully what the Congressional leaders in Washington decide to do with the “SGR Fix”. This complicated and convoluted formula definitely impacts Medicare payments through the Physician Fee Schedule (this is used to pay for all Audiology and Speech-Language Pathology services and is known as “extenders” in Medicare vernacular). If you learn there is an “SGR Fix without Extenders”, know that SLP and Audiology payments will probably remain the same or decrease during the latter part of 2015.
The Medicare system continues to become more and more complicated and some members have asked me to provide reference links to allow them to learn more about payment and reimbursement. In addition to the ASHA Reimbursement site I have referenced in the past, I am working with our website support team to provide links on the PSHA website. Please check below for reference information as well as occasional advocacy requests to support ASHA initiatives related to the Medicare and Medicaid systems. Hopefully, this information will provide better understanding of the Medicare and Medicaid related information that impacts our professions.
CMS Fact Sheet
CMS Complex Chronic Care – Chart Book
Proposed Physician Fee Schedule and the SGR Fix
MEASURING FUNCTIONAL OUTCOMES - Inpatient Pediatric Rehab - Does PA Medicaid have a preferred functional outcome measure scale for Inpatient Pediatric Rehab? (We are specifically looking at the WeeFIM and PEDI scales).
The consolidated responses from PSHA Board members indicates that there is not a specific response to your question, and that a 'preferred' scale is not defined. Board members with experience in this area have offered this information for your consideration. We hope that you find this information helpful in making the choice for your organization.
One Board member reported that:
This is a question our center researched extensively. Insurance companies did not recommend any SLT test when we contacted them. NOMs can work for preschoolers and adults but not for school aged children. I discussed this at ASHA with NOMs staff. They told me they started the NOMS for school aged children but stopped. They had no plans to pursue it. I have a copy of this but it was not completed.
The most useful normed test we found for school age was the PEDI-Cat. This is a computer-based version of the PEDI from the folks in Boston Children’s Hospital. We piloted it here for OT /PT and speech. It was useful for the OT and somewhat for PT (PT had other tests available) the SLPs were not totally satisfied. When I asked SLPs at Children’s Institute-Pgh what they were using I was told they are using their own personal non standardized criteria for reporting.
And another reported that:
I agree that NOMS should be considered. ASHA only has norms or standards for pre-k and adult ages currently. School-age ratings are available but not normed yet and probably not any time soon. Since she works at a pediatric facility, perhaps they should consider the FIM. I am not familiar with the PEDI scale she mentioned. There is a cost and training associated with the FIM. NOMS requires training, but I believe it's free (or not?!).