Sec. 202. Medicare payment for therapy services
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Section 1833(g) of the Social Security Act ( 42 U.S.C. 1395l(g) ) is amended— in paragraph (4)— by striking This subsection and inserting Except as provided in paragraph (5)(C)(iii), this subsection ; and by inserting the following before the period at the end: or with respect to services furnished on or after the date of enactment of the ; and Commonsense Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014 in paragraph (5)(C), by adding at the end the following new clause:
Beginning on the date of enactment of the Commonsense Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014 and ending on the day before the date that is 12 months after such date of enactment, the manual medical review process described in clause
(i)shall apply with respect to expenses incurred in a year for services described in paragraphs
(1)and
(3)that exceed the threshold described in clause
(ii)for the year. . Section 1833 of the Social Security Act ( 42 U.S.C. 1395l ), as amended by section 101(e)(2), is amended by adding at the end the following new subsection: The Secretary shall implement a process for the medical review (as described in paragraph (2)) of outpatient therapy services (as defined in paragraph (10)) and, subject to paragraph (12), apply such process to such services furnished on or after the date that is 12 months after the date of enactment of the Commonsense Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014 , focusing on services identified under subparagraph (B). Under the process, the Secretary shall identify services for medical review, using such factors as the Secretary determines appropriate, which may include the following: Services furnished by a therapy provider (as defined in paragraph (10)) whose pattern of billing is aberrant compared to peers. Services furnished by a therapy provider who, in a prior period, has a high claims denial percentage or is less compliant with other applicable requirements under this title. Services furnished by a therapy provider that is newly enrolled under this title. Services furnished by a therapy provider who has questionable billing practices, such as billing medically unlikely units of services in a day. Services furnished to treat a type of medical condition. Services identified by use of the standardized data elements required to be reported under section 1834(p). Services furnished by a single therapy provider or a group that includes a therapy provider identified by factors described in this subparagraph. Other services as determined appropriate by the Secretary. Subject to the succeeding provisions of this subparagraph, the Secretary shall use prior authorization medical review for outpatient therapy services furnished to an individual above one or more thresholds established by the Secretary, such as a dollar threshold or a threshold based on other factors. The Secretary shall end the application of prior authorization medical review to outpatient therapy services furnished by a therapy provider if the Secretary determines that the provider has a low denial rate under such prior authorization. The Secretary may subsequently reapply prior authorization medical review to such therapy provider if the Secretary determines it to be appropriate. The Secretary shall, where practicable, provide for prior authorization medical review for multiple services at a single time, such as services in a therapy plan of care described in section 1861(p)(2). The Secretary may use pre-payment review or post-payment review for services identified under paragraph (1)(B) that are not subject to prior authorization medical review under subparagraph (A). The Secretary may determine that medical review under this subsection does not apply in the case where potential fraud may be involved. The Secretary shall conduct prior authorization medical review of outpatient therapy services under this subsection using medicare administrative contractors (as described in section 1874A) or other review contractors (other than contractors under section 1893(h) or contractors paid on a contingent basis). With respect to an outpatient therapy service for which prior authorization medical review under this subsection applies, the following shall apply: The Secretary shall make a determination, prior to the service being furnished, of whether the service would or would not meet the applicable requirements of section 1862(a)(1)(A). Subject to paragraph (6), no payment shall be made under this part for the service unless the Secretary determines pursuant to subparagraph
(A)that the service would meet the applicable requirements of such section. A therapy provider may submit the information necessary for medical review by fax, by mail, or by electronic means. The Secretary shall make available the electronic means described in the preceding sentence as soon as practicable, but not later than 24 months after the date of enactment of this subsection. If the Secretary does not make a prior authorization determination under paragraph (4)(A) within 10 business days of the date of the Secretary’s receipt of medical documentation needed to make such determination, paragraph (4)(B) shall not apply. With respect to an outpatient therapy service that has been affirmed by medical review under this subsection, nothing in this subsection shall be construed to preclude the subsequent denial of a claim for such service that does not meet other applicable requirements under this Act. With respect to services furnished on or after January 1, 2015, where payment may not be made as a result of application of medical review under this subsection, section 1879 shall apply in the same manner as such section applies to a denial that is made by reason of section 1862(a)(1). The Secretary may implement the provisions of this subsection by interim final rule with comment period. Chapter 35 of title 44, United States Code, shall not apply to medical review under this subsection. There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the identification of services for medical review or the process for medical review under this subsection. For purposes of this subsection: The term outpatient therapy services means the following services for which payment is made under section 1848, 1834(g), or 1834(k): Physical therapy services of the type described in section 1861(p). Speech-language pathology services of the type described in such section though the application of section 1861(ll)(2). Occupational therapy services of the type described in section 1861(p) through the operation of section 1861(g). The term therapy provider means a provider of services (as defined in section 1861(u)) or a supplier (as defined in section 1861(d)) who submits a claim for outpatient therapy services. For purposes of implementing this subsection, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $35,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each fiscal year (beginning with fiscal year 2014). Amounts transferred under this paragraph shall remain available until expended. Beginning with 2017, and every two years thereafter, the Secretary shall— make a determination of the improper payment rate for outpatient therapy services for a 12-month period; and make such determination publicly available. If the improper payment rate for outpatient therapy services determined for a 12-month period under subparagraph
(A)is 50 percent or less of the Medicare fee-for-service improper payment rate for such period, the Secretary shall— reduce the amount and extent of medical review conducted for a prospective year under the process established in this subsection; and return an appropriate portion of the funding provided for such year under paragraph (11). . The Comptroller General of the United States shall conduct a study on the effectiveness of medical review of outpatient therapy services under section 1833(aa) of the Social Security Act, as added by paragraph (1). Such study shall include an analysis of— aggregate data on— the number of individuals, therapy providers, and claims subject to such review; and the number of reviews conducted under such section; and the outcomes of such reviews. Not later than 3 years after the date of enactment of this Act, the Comptroller General shall submit to Congress a report containing the results of the study under subparagraph (A), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate. Section 1834 of the Social Security Act ( 42 U.S.C. 1395m ) is amended by adding at the end the following new subsection: Not later than 6 months after the date of enactment of this subsection, the Secretary shall post on the Internet website of the Centers for Medicare & Medicaid Services a draft list of standardized data elements for individuals receiving outpatient therapy services. Such standardized data elements shall include information with respect to the following domains, as determined appropriate by the Secretary: Demographic information. Diagnosis. Severity. Affected body structures and functions. Limitations with activities of daily living and participation. Functional status. Other domains determined to be appropriate by the Secretary. The Secretary shall accept comments from stakeholders through the date that is 60 days after the date the Secretary posts the draft list of standardized data elements pursuant to subparagraph (A). In seeking such comments, the Secretary shall use one or more mechanisms to solicit input from stakeholders that may include use of open door forums, town hall meetings, requests for information, or other mechanisms determined appropriate by the Secretary. Not later than 120 days after the end of the comment period described in subparagraph (C), the Secretary, taking into account such comments, shall post on the Internet website of the Centers for Medicare & Medicaid Services an operational list of standardized data elements. Subsequent revisions to the operational list of standardized data elements shall be made through rulemaking. Such revisions may be based on experience and input from stakeholders. Not later than 18 months after the date the Secretary posts the operational list of standardized data elements pursuant to paragraph (1)(D), the Secretary shall develop and implement an electronic system (which may be a web portal) for therapy providers to report the standardized data elements for individuals with respect to outpatient therapy services. The Secretary shall seek comments from stakeholders regarding the best way to report the standardized data elements. The Secretary shall specify the frequency of reporting standardized data elements. The Secretary shall seek comments from stakeholders regarding the frequency of the reporting of such data elements. Beginning on the date the system to report standardized data elements under this subsection is operational, no payment shall be made under this part for outpatient therapy services furnished to an individual unless a therapy provider reports the standardized data elements for such individual. Not later than 24 months after the date described in paragraph (3)(B), the Secretary shall submit to Congress a report on the design of a new payment system for outpatient therapy services. The report shall include an analysis of the standardized data elements collected and other appropriate data and information. Such report shall consider— appropriate adjustments to payment (such as case mix and outliers); payments on an episode of care basis; and reduced payment for multiple episodes. The Secretary shall consult with stakeholders regarding the design of such a new payment system. For purposes of implementing this subsection, the Secretary shall provide for the transfer, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, of $7,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for each of fiscal years 2014 through 2018. Amounts transferred under this subparagraph shall remain available until expended. Chapter 35 of title 44, United States Code, shall not apply to specification of the standardized data elements and implementation of the system to report such standardized data elements under this subsection. There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the specification of standardized data elements required under this subsection or the system to report such standardized data elements. In this subsection, the terms outpatient therapy services and therapy provider have the meaning given those term in section 1833(aa). . Section 3005(g)(1) of the Middle Class Tax Extension and Job Creation Act of 2012 (42 U.S.C. 1395l note) is amended, in the first sentence, by inserting and ending on the date the system to report standardized data elements under section 1834(p) of the Social Security Act ( after 42 U.S.C. 1395m(p) ) is implemented, January 1, 2013, . Section 1842(t) of the Social Security Act ( 42 U.S.C. 1395u(t) ) is amended by adding at the end the following new paragraph: Each request for payment, or bill submitted, by a therapy provider (as defined in section 1833(aa)(10)) for an outpatient therapy service (as defined in such section) furnished by a therapy assistant on or after January 1, 2015, shall include (in a form and manner specified by the Secretary) an indication that the service was furnished by a therapy assistant. .
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