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 As of April 16, 2015—after 17 temporary patches—the wizards in Washington have permanently repealed the flawed SGR formula that threatened to significantly cut Medicare payments.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

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  • 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 …

  • 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, …

  • 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. …

  • Evaluation Exam: Do You Know How to Use the New PT and OT Eval Codes? [Quiz] Image

    articleMar 3, 2017 | 1 min. read

    Evaluation Exam: Do You Know How to Use the New PT and OT Eval Codes? [Quiz]

    On January 1, 2017, new CPT codes went into effect for PT and OT evaluations and reevaluations. To use these new codes correctly, PTs and OTs must determine—and code for—the correct level of complexity associated with each patient evaluation. As with anything new, the implementation of these codes stirred up quite a few tough questions. Think you know how to use them? Test your skills on this quiz to be sure. After all, incorrect code selection could …

  • Video Tutorial: Selecting the Correct Complexity Level for PT and OT Evals Image

    articleOct 13, 2016 | 1 min. read

    Video Tutorial: Selecting the Correct Complexity Level for PT and OT Evals

    The holidays will be here before we know it—and that means PTs and OTs will be required to use the new evaluation and re-evaluation CPT codes before we know it, too. And these codes bring with them the gift of complexity. But, unlike that snowman sweater from Great Aunt Sheila, therapists can't exchange these codes; so, whether they want to or not, PTs and OTs have to learn the ins and outs of coding for evaluative complexity …

  • The PT’s Guide to Surviving a Medicare Audit Image

    articleMay 30, 2016 | 5 min. read

    The PT’s Guide to Surviving a Medicare Audit

    “How can I avoid being audited by Medicare?” This is one of the compliance questions I hear most frequently, and the honest answer is, quite simply, that you can’t. Just because CMS or one of its auditing entities hasn’t come knocking on your door doesn’t mean you’re not being audited. In fact, every claim you submit undergoes statistical analysis, and Medicare compares your claims data to the data for all other claims submitted. Furthermore, Medicare now analyzes …

  • 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 …

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