Ding-dong—the Sustainable Growth Rate (SGR) formula is dead. As of April 16, 2015—after 17 temporary patches—the wizards in Washington have permanently repealed the flawed SGR formula that threatened to significantly cut Medicare payments. Now, when payments exceed the growth in per-capita gross domestic product, PTs will no longer face reduced payments. Instead, they can look forward to a bit more stability, simplicity, and cash flow for the next decade. The new payment determination process begins with a static increase in payments across the board for the next several years. From July 1, 2015, through the end of 2019, the SGR replacement measure allots providers annual payment increases of 0.5%.

Next, starting in 2019, Medicare quality-reporting and incentive initiatives—like the PQRS, Value-Based Modifier, and Meaningful Use of Electronic Health Records (EHR) programs—will merge into one program, called the Merit-Based Incentive Payment System. The penalties for failure to comply with these individual programs will be abolished as well. Thanks to the new consolidated system’s additional funding, high-performing providers will have the opportunity to “earn additional payments from a pool of up to $500 million per year from 2019 to 2024,” with a pool of $20 million per year set aside specifically for smaller practices.

The new payment measures also make a strong push for value-based payment models. Eventually, providers will be required to adopt either a merit-based or alternative payment model. One hefty reason to select an alternative model: you’ll be eligible for a 5% annual bonus between 2019 and 2024. Plus, as this article explains, the new system will allow providers to choose from a menu of performance measures created by speciality-specific associations (like the APTA). It also will permit “professional organizations and other relevant stakeholders to identify and submit quality measures and updates to be considered for selection and used in the performance program.” Not sure you’re ready to skip down the yellow brick road to one particular model? No worries. Providers can switch models on a yearly basis.

The SGR repeal is certainly good news for practitioners, but permanent improvements to Medicare payments may still be somewhere over the rainbow. According to a report from CMS Chief Actuary Paul Spitalnic, the new payment measures may not be sustainable past 2025, and without subsequent legislation, “access to, and quality of, physicians’ services would deteriorate over time for beneficiaries.” Only time will tell how the measures—and payment reform itself—will shake out, but for now, the government seems to be taking a step in the right direction.

9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs - Regular Banner9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs - Small Banner
  • Senate Repeals SGR in Landslide Vote Image

    articleApr 15, 2015 | 1 min. read

    Senate Repeals SGR in Landslide Vote

    Well, folks, the fix is in—the fix for the sustainable growth rate (SGR), that is. In a 92 to 8 vote, the Senate approved the SGR repeal bill, called HR2. In addition to an SGR repeal, the bill also officially extends the therapy cap exceptions process until December 31, 2017. This result is better than no therapy cap exceptions process at all; however, it’s disappointing to know that we came so close to achieving a full repeal …

  • Brace Yourself: Decreased Payments Might be Coming Image

    articleApr 14, 2015 | 3 min. read

    Brace Yourself: Decreased Payments Might be Coming

    As we warned at the end of last month , the times they are a-changin’. You’re likely well aware of the legislation that could do away with the Sustainable Growth Rate (SGR)—and extend the therapy cap for another two years. We had hoped to have better news for you at this point, but we’re still hanging tight while the Senate sings their own off-key version of Wilson Phillips’ “Hold On.” It’s April 14, 2015. That means the …

  • Why Physical Therapists Should Support the CONNECT for Health Act 2017 Image

    articleAug 14, 2017 | 6 min. read

    Why Physical Therapists Should Support the CONNECT for Health Act 2017

    The US Senate recently introduced the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act 2017 (S.1016) . If passed, the CONNECT for Health Act would remove several barriers to utilizing telehealth with Medicare patients—which would present a valuable opportunity to the physical therapy profession. Here’s why PTs should strongly consider supporting it: It will allow PTs to deliver, and receive reimbursement for, physical therapy telehealth services. As it stands, Medicare only provides …

  • Common Questions from Our New PT and OT Evaluation Codes Webinar Image

    articleDec 19, 2016 | 20 min. read

    Common Questions from Our New PT and OT Evaluation Codes Webinar

    This month’s webinar on the new CPT codes was our biggest one yet—more than 11,000 people registered to attend. With such a large—and clinically diverse—audience, we received a ton of questions. And due to time constraints, our hosts—WebPT’s own Heidi Jannenga and compliance expert Rick Gawenda—weren’t able to get to even a fraction of them during the live broadcast. Not to worry, though; we’ve done our best to answer them all here, in one giant FAQ article. …

  • CMS’s Final Bow: The 2019 Final Rule Image

    articleNov 5, 2018 | 8 min. read

    CMS’s Final Bow: The 2019 Final Rule

    Last week, the Centers for Medicare and Medicaid Services (CMS) published its 2019 final rule . Clocking in at just over 2,300 pages, the final rule isn't exactly a light read—especially because the legal lingo can be harder to interpret than Shakespearean verse. Luckily, we have the script—with all its twists and turns—decoded and ready for you to review. Here's the synopsis of all the physical therapy, occupational therapy, and speech-language pathology Medicare changes for 2019: Out, …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum . As expected, we received more questions than our Medicare experts could answer during the live session, so we've provided the answers to the most frequently asked ones below. Don't see the answer you're looking for? Post your question in the comment section at the end of this …

  • Founder Letter: My Evaluation of the New PT and OT Eval Codes Image

    articleNov 3, 2016 | 5 min. read

    Founder Letter: My Evaluation of the New PT and OT Eval Codes

    Over the last several years, healthcare providers in general—and rehab therapists, specifically—have been hit with a seemingly constant barrage of regulatory requirements. And the vast majority of these initiatives—PQRS, functional limitation reporting, MPPR, ICD-10, and the like—have either: Had a direct negative impact on our payments, or Forced us to devote extra time to satisfying the criteria of the requirements—with zero compensation for that time. So, it should come as no surprise that the rehab therapy community …

  • 2016 CPT Code Changes: What PTs, OTs, and SLPs Need to Know Image

    articleNov 11, 2015 | 2 min. read

    2016 CPT Code Changes: What PTs, OTs, and SLPs Need to Know

    January 1 marks the start of a brand new year. As we clean up the discarded party hats, noise-makers (i.e., pots and pans), and champagne flutes, we tend to reflect on the past year. Upon doing so, we often find that some of our old habits aren’t worth holding onto. That’s why many of us make new resolutions to adopt healthy lifestyle changes (new year, new you!), while simultaneously kicking our bad habits to the curb. But …

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