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 As of April 16, 2015—after 17 temporary patches—the wizards in Washington have permanently repealed the flawed SGR formula that threatened to significantly cut Medicare payments.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.

Cashing In on Private Pay: The PTs Guide to Going Out-of-Network - Regular BannerCashing In on Private Pay: The PTs Guide to Going Out-of-Network - Small Banner
  • 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 …

  • 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 …

  • 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 …

  • 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, …

  • 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. …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • Fact or Fiction? The Ultimate Medicare Myth [Quiz] Image

    articleOct 12, 2017 | 1 min. read

    Fact or Fiction? The Ultimate Medicare Myth [Quiz]

    You’ve heard the adage that fact can be stranger than fiction, right? After all, fiction has to make sense. Well, when it comes to Medicare rules, neither fact nor fiction makes much sense—at least not on first pass. But, all rehab therapists who work with Medicare patients must be able to tell the difference—if they want to remain compliant and get paid, that is. To help you put your Medicare knowledge to the test, we’ve put together …

  • What the New HCAHPS Proposal Means for the Future of Hospital-Based PT  Image

    articleAug 11, 2016 | 3 min. read

    What the New HCAHPS Proposal Means for the Future of Hospital-Based PT

    When a patient is in pain, that patient wants relief—fast. And even if the patient knows medication is only a temporary fix—and a potentially dangerous one, at that—he or she will probably still choose drugs over longer-lasting, less-instant treatment options like physical therapy. For healthcare providers beholden to payment structures that incentivize patient satisfaction, that preference presents a real pickle: give the patient what he or she wants—long-term consequences be damned—or risk lower satisfaction scores (and potentially …

  • 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 …

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