Mailly and Inglett Consulting, LLC

Tennessee PT Company Owner Pleads Guilty

In Tennessee, the owner of a physical therapy company pled guilty to violating the anti-kickback statute and was sentenced to 4 months in prison and ordered to pay $173,000 in restitution. The woman paid kickbacks to doctors based on the percentage of her profits for the patients referred to her company for physical therapy services. During the investigation, it was also revealed that the woman employed unlicensed physical therapists, billed for more therapy than was provided, and prepared fraudulent medical records for a Medicare audit.

http://www.oig.hhs.gov/fraud/enforcement/criminal/07/0507.htm

Mailly & Inglett Consulting, LLC

Wayne, NJ

973-692-0033

www.NJPTAid.biz

Bridging the Gap!

Member APTA Practice Management Consulting Network

Note: This information is a communication that is neither privileged, confidential nor otherwise protected from disclosure. The recipient of this information may disclose this information to any other partyso long as this disclaimer is included

National Provider Roundtable-NPI

Medicare Fee-For-Service National Provider Identifier (NPI) Contingency Plan

National Provider Roundtable with Question & Answer Session

The Centers for Medicare & Medicaid Services (CMS) will host a National Roundtable on the recently released Medicare Fee-For-Service (FFS) NPI Contingency Plan. This toll-free call will take place from 2:00 p.m. – 3:30 p.m., EDT, on Thursday, May 10, 2007.

Following the April 2^nd release of CMS’ Contingency Guidance for all covered entities, the Medicare FFS health plan announced its contingency plan for NPI implementation. For more details on the Medicare FFS Contingency Plan, visit the associated Change Request at http://www.cms.hhs.gov/transmittals/downloads/R1227CP.pdf and the related MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS Website.

The call will open with a presentation on the Medicare FFS Contingency Plan announced on April 20^th. Following the presentation, callers will have an opportunity to ask questions of CMS subject matter experts.

The Medicare FFS Contingency Plan does not change the requirement for Medicare FFS health care providers to acquire an NPI. Getting an NPI is easy and free. Go to www.cms.hhs.gov/NationalProvIdentStand for more information.

May 10, 2007 conference call details:

Date: May 10, 2007

Conference Title: NPI Medicare Fee-For-Service Contingency Plan Roundtable

Time: 2:00 – 3:30 p.m. EST

In order to receive the call-in information, you must register for the call. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data. This registration is solely to reserve a phone line, NOT to allow participation. If you cannot attend the call, replay information is available below.

Registration will close at 2:00 p.m. EST on May 9, 2007, or when available space has been filled. No exceptions will be made, so please be sure to register prior to this time.

1. To register for the call participants need to go to:

http://www2.eventsvc.com/palmettogba/051007

2. Fill in all required data.

4. Click "Register".

5. You will be taken to the “Thank you for registering” page and will receive a confirmation email shortly thereafter. (Note: If you do not receive the confirmation email, please check your spam/junk mail filter as they may have gotten caught in that.)

For those of you who will be unable to attend, a replay option will be available shortly following the end of the call. This replay will be accessible from 05/10/2007 until 05/17/2007, 11:59 p.m. EST. The call in data for the replay is (800) 642-1687 and the passcode is 7087149.

For technical difficulties registering, call 1-877-812-4520 and reference call # 7087149.

Mailly & Inglett Consulting, LLC

Wayne, NJ

973-692-0033

www.NJPTAid.biz

Bridging the Gap!

Member APTA Practice Management Consulting Network

Ruling limits chiropractors to spine adjustments

Ruling limits chiropractors to spine adjustments

Ocean County woman sued after being treated for knee problem

Posted by the Asbury Park Press on 04/19/07

TOMS RIVER — A panel of appellate judges ruled Wednesday that state law limits the practice of chiropractic medicine to adjustments of the spinal column, reversing a jury verdict that found in favor of a group of chiropractors sued by an Ocean County woman who received treatment from them on her knee.

http://www.app.com/apps/pbcs.dll/article?AID=2007704190473

Ken Mailly, PT

Barry Inglett, PT, CHT, Cert MDT

Mailly & Inglett Consulting, LLC

Wayne, NJ

973-692-0033

www.NJPTAid.biz

Bridging the Gap!

Member APTA Practice Management Consulting Network

Note: This information is a communication that is privileged, confidential and protected from disclosure. The information contained herein, is intended to be for the addressee only. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled.

If you are not the addressee, any disclosure, copy, distribution or action taken in reliance on the contents of this electronic mail is strictly prohibited. If you have received this electronic mail in error, please notify the sender immediately.

APTA Legislative Action Alert

****APTA LEGISLATIVE ACTION ALERT****

Ensuring that Qualified Physical Therapists

Provide Medicare Physical Therapy Services

Oppose HR 1846 Today!

On Thursday, March 29, Congressman Edolphus “Ed” Towns (D-NY) introduced Medicare Access to Physical Medicine and Rehabilitation Services Improvement Act (HR 1846). This legislationwould overturn the current Medicare “incident-to” rule and recognize athletic trainers and lymphedema therapists as covered providers under Medicare.

APTA strongly opposes this legislation (HR 1846) and supports Medicare’s ability to require qualification standards for therapy services provided “incident to” a physician’s professional services. It is the position of the American Physical Therapy Association (APTA) that physical therapists are the qualified professionals who provide physical therapy examinations, evaluations, diagnoses, prognoses, and interventions. Interventions should be represented and reimbursed as physical therapy only when performed by a physical therapist or by a physical therapist assistant under the direction and supervision of a physical therapist.

Background

In November 2004, the Centers for Medicare and Medicaid Services (CMS) included provisions in the final rule for the 2005 Medicare physician fee schedule that established qualifications and clinical preparation standards for individuals who provide physical therapy services “incident to” a physician’s professional services. These provisions implement requirements adopted by Congress in 1997 to protect patient safety, ensure the appropriate use of Medicare resources, and guarantee the delivery of physical therapy services by qualified physical therapists. Opponents of these regulations were unsuccessful in their attempts to have CMS rescind the rule implemented in May 2005. These organizations also filed a federal lawsuit attempting to force their withdrawal, and a US Court of Appeals upheld a district court decision dismissing the litigation.

Talking Points

Patient Safety - The “incident to” regulations standardize existing Medicare requirements that physical therapy services must be delivered by qualified personnel in all outpatient settings. There is no evidence that these standards have restricted the delivery of physical therapy in physician offices. Without enforcement of appropriate qualification standards, it would be impossible to ensure that Medicare beneficiaries receive and the Medicare program pays for an appropriate level of safe and effective care delivered by an individual qualified to provide physical therapy. HR 1846 jeopardizes the health, safety and welfare of Medicare beneficiaries by allowing non-qualified individuals to provide therapy services.

Cost-effectiveness - In a report issued in May 2006, the Office of Inspector General (OIG) of the Department of Health and Human Services found that 91% of physical therapy services billed by physicians under the old “incident to” rules in the first 6 months of 2002 failed to meet program requirements, resulting in improper Medicare payments of $136 million. The Inspector General found that the total payments for physical therapy claims from physicians skyrocketed from $353 million in 2002 to $509 million in 2004, and that the number of physicians billing the program for more than $1 million in physical therapy more than doubled in that two-year period.

This follows a report done in 1994 by the OIG that estimated that more than $47 million in unnecessary therapy services were delivered in physician offices under the old “incident to” rules. As a result of the 1994 report, Congress passed the Outpatient Physical Therapy Standards Act of 1997 as part of the Balanced Budget Act. This legislation established a standard for physical therapy delivered in a physician’s office consistent with that in all other outpatient settings, and the regulations promulgated by CMS in 2004 implement these standards in keeping with the intent of Congress. HR 1846 is fiscally irresponsible and will cost taxpayers due to inappropriate billing of therapy services by non-qualified individuals.

Quality Care - Medicare beneficiaries deserve a consistent standard of care that ensures that providers who deliver these services have attained the level of education and qualification necessary to provide them safely and effectively. Without appropriate personnel standards for individuals delivering highly skilled and recognized Medicare services such as physical therapy, the standard of quality is jeopardized. HR 1846 dilutes the quality of care for Medicare beneficiaries by allowing non-qualified individuals to deliver therapy services.

What You Can Do

Contact your Senators and ask them to OPPOSE HR 1846 TODAY!

CALL: Contact your House Representative by calling the Capitol switchboard at 202/224-3121. Please ask your House Representative to OPPOSE HR 1846.

EMAIL/WRITE: Utilize APTA’s Legislative Action Center to send an email or letter to your House Representative.

If you have any questions or need additional information regarding HR 1846, contact Mike Matlack at 1/800-999-2782, ext. 3163, michaelmatlack@apta.org. Thanks for your help in getting the message through to Congress!

NJPTAid Listserve Termination

Please be advised that as a result of insufficient demand, Mailly & Inglett Consulting will no longer offer our NJPTAid Listserve as a stand-alone subscription service. This service will continue as a benefit to our clients and Hotline subscribers, and we will honor existing subscriptions through their expiration, but we will no longer accept or renew subscriptions separately. Thank you.

Mailly & Inglett Consulting, LLC

Wayne, NJ

973-692-0033

www.NJPTAid.biz

Bridging the Gap!

Member APTA Practice Management Consulting Network

"Clean Claims" & Medicare

Timeliness Standards for Processing Other-Than-Clean Claims (MM5355)

Note: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material which is copyrighted by the American Medical Association (AMA). You are forbidden to download the files unless you read, agree to and abide by the provisions of the copyright statement. Read the copyright statement now (you will be linked back to here).

MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare carriers and Medicare Administrative Contractors (MAC) for services provided to Medicare beneficiaries

Provider Action Needed
This article is intended as informational only and is based on Change Request (CR) 5355, which provides requirements for all carriers and MACs for timeliness for processing “other-than-clean” claims.

Background
The Social Security Act (Section 1869(a)(2); http://www.ssa.gov/OP_Home/ssact/title18/1869.htm ) mandates that the Centers for Medicare & Medicaid Services (CMS) process all “other-than-clean” claims and notify the individual filing such claims of the determination within 45 days of receiving such claims.

Claims that do not meet the definition of “clean” claims are classified as “other-than-clean” claims, and “other-than-clean” claims require investigation or development external to the contractor’s Medicare operation on a prepayment basis.

“Clean claim” means a claim that does not contain a defect requiring the Medicare contractor to investigate or develop prior to adjudication. Clean claims must be filed within the timely filing period (see the Social Security Act 1842(c)(2)(B); http://www.ssa.gov/OP_Home/ssact/title18/1842.htm ).

“Other Than Clean Claims” Any claim that does not meet the definition of clean claim above. These are complete claims that require manual intervention on the part of the contractor to be adjudicated.

CR 5355 instructs the Medicare contractor (carrier/MAC) to process all “other-than-clean” claims and notify the provider and beneficiary of the determination within 45 calendar days of receipt. See Medicare Claims Processing Manual (Publication 100-4, Chapter 1, Section 80.2.1;

http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf ) for the definition of “receipt date” and for timeliness standards for clean claims.

However, when the Medicare contractor develops the claim by asking the provider/supplier or beneficiary for additional information, the contractor will:

Cease counting the 45-calendar days on the day that the contractor sends the development letter requesting the additional information, and
Resume counting the 45-calendar days upon receiving the materials requested in the development letter from the provider/supplier and/or beneficiary.

EXAMPLE:
The Medicare contractor receives a claim on June 1, but does not send a development letter to the provider/supplier/ and/or beneficiary until June 5. In this situation, five of the 45 allotted calendar days will have already passed before the contractor requested the additional information.

Upon receiving the information back from the provider/supplier and/or beneficiary, the Medicare contractor has 40 calendar days left to:

Process the claim, and
Notify the individual that filed the claim of the payment determination for that claim.

CR 5355 instructs Medicare contractors to follow existing procedures relative to both:

The length of time the provider/supplier and/or beneficiary is afforded to return information requested in the development letters, and
Situations where the provider/supplier and or beneficiary does not respond.

For dates of receipt on and after July 1, 2007, Medicare contractors are instructed to process all “other-than-clean” claims and notify the beneficiary and the provider filing the claim within 45 calendar days of receipt, except when the contractor requests additional information from the provider/supplier or beneficiary, or to another contractor (e.g., the Coordination of Benefits Contractor, another claims processing contractor).

Instructions in CR 5355 do not apply to the following types of claims:

Claims where the Social Security Administration blocks a beneficiary’s Health Insurance Claim Number (HIC),
Claims the contractors are required to hold due to CMS instructions,
Claims rejected by the translator process,
Claims where the Medicare contractor is unable to process due to technical issues with Medicare’s beneficiary record or beneficiary identification issues, and
Claims in development due to processing requirements (e.g., medical review), in Publication 100-8, the Medicare Program Integrity Manual ( http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage ).

Additional Information
For complete details, please see the official instruction issued to your carrier/MAC regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1173CP.pdf on the CMS Web site.

If you have any questions, please contact your Medicare contractor at their toll-free number, which may be found on the CMS Web site at: http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents

MLN Matters Number: MM5355
Pub. 100-4, Transmittal# R1173CP, CR# 5355
Related CR Release Date: February 2, 2007
Effective Date: July 1, 2007

Implementation Date: July 2, 2007

Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.

Posted: 02/09/2007

Mailly & Inglett Consulting, LLC

Wayne, NJ

973-692-0033

www.NJPTAid.biz

Bridging the Gap!

Member APTA Practice Management Consulting Network

APTA Legislative Action Alert

From APTA:

APTA LEGISLATIVE ACTION ALERT

Immediate Attention Requested

Congressmen Xavier Becerra (D-CA), Phil English (R-PA), Mike Ross (D-AR), Charles Pickering (R-MS) and Roy Blunt (R-MO), and Senators John Ensign (R-NV) and Blanche Lincoln (D-AR) introduced "The Medicare Access to Rehabilitation Services Act" January 31, 2007 that would repeal the cap on therapy services for Medicare beneficiaries once and for all (HR 748/S. 450). If Congress does not take action by January 1, 2008, the therapy cap will again be imposed on Medicare-covered physical therapy, occupational therapy, and speech language pathology services. We need to take action NOW to ensure the cap does not go back into place.

Points to Make - Repeal the Cap

· Don’t discriminate against the most vulnerable Medicare beneficiaries – The therapy cap would apply to all Medicare beneficiaries in all Part B health care settings, except hospital outpatient departments. Most Medicare beneficiaries would never exceed the annual cap, but it would force many senior citizens who need physical therapy care the most to choose between forgoing necessary care or paying 100% of the cost out-of-pocket over their Medicare coverage that is capped. Beneficiaries who suffer from a stroke, or have Parkinson’s disease, spinal cord injuries, or osteoporosis are more likely to be the type of patient needing such care.

· Congress has repeatedly recognized the fallacy of the beneficiary cap on therapy services – For the past 7 years Congress has prevented a hard therapy cap from taking place except for 3 months in 2003. Three times Congress imposed a moratorium to keep the beneficiary cap on therapy services from limiting beneficiary coverage (1999-two years, 2000-one year, and 2003-two years). In 2006 and 2007 a therapy cap exceptions process was instituted to prevent a hard cap on therapy services. In addition, a bipartisan majority of Members of Congress in both chambers recognized the problems associated with the beneficiary cap by supporting legislation in previous Congresses to repeal the therapy cap.

· It’s time to solve this problem and not do another short-term fix – Rather than addressing the underlying problem, every year Congress considers a short-term step to prevent the therapy cap from being enacted. Although this results in protecting beneficiaries access to rehabilitation care, this legislation is not passed until very late in the year. This disrupts the continuity of care to Medicare patients because PTs must adjust their plan of care to their patients and creates a high level of uncertainty for beneficiaries regarding their access to physical therapy, occupational therapy, and speech language pathology. It’s time for Congress to eliminate this flawed policy entirely.

What You Can Do

It is important that you send a strong message to your Members of Congress to request that they become cosponsors to repeal the therapy cap once and for all. Please contact your Members of Congress and ask them to cosponsor HR 748/S. 450. You can contact your Members of Congress by calling 202/224-3121 or by utilizing APTA’s Legislative Action Center at http://www.apta.org/AdvocacyLegislative Action Center”. You can write a letter or e-mail to your Members of Congress regarding this important issue. by clicking on “

In your call or letter to your Members of Congress, include specific examples of your patients that will be affected if the therapy cap is imposed again. Also, have your patients contact their legislators. Provide them with a letter they can sign and you can mail or have them access APTA’s Patient Action Center on the therapy cap. If you have any questions please contact APTA at 1/800-999-2782, ext. 8533.

Mailly & Inglett Consulting, LLC

Wayne, NJ

973-692-0033

www.NJPTAid.biz

Bridging the Gap!

Member APTA Practice Management Consulting Network

Note: This information is a communication that is neither privileged, confidential and protected from disclosure. The information contained herein, may be freely disseminated, copied, printed, or otherwise distributed, so long as this disclaimer is included.

HealthSouth Selling Rehab Clinics

http://www.chron.com/disp/story.mpl/ap/fn/4507146.html

BIRMINGHAM, Ala. — Moving ahead with plans to focus solely on post-acute care as it recovers from a massive fraud, HealthSouth Corp. said Monday it will sell about 600 outpatient rehabilitation centers in 35 states to Select Medical Corp. for about $245 million.

Mailly & Inglett Consulting, LLC

Wayne, NJ

973-692-0033

www.NJPTAid.biz

Bridging the Gap!

Member APTA Practice Management Consulting Network

News About 2007 Medicare Fees & Cap

From APTA

BREAKING NEWS!!

Breaking News Alert: US House of Representatives Passes Extension of Therapy Cap Exceptions Process, Fee Schedule Provisions

The US House of Representatives passed legislation by a vote of 367 to 45 to extend the therapy cap exceptions process for 2007 and replace the scheduled 5.1% reduction in the 2007 conversion factor with a freeze at 2006 levels. The provisions were included in the Tax Relief and Health Care Act of 2006 (HR 6111). The bill also provides a 1.5% payment incentive for providers to report on quality measures, and maintains the Geographic Payment Cost Index (GPCI) at 1.0 for the 51 localities that fall below this index for 2007.

This legislation will still need to pass the Senate and be signed by the president to avoid the 5.1% reduction in the conversion factor and the expiration of the therapy cap exceptions on January 1, 2007. APTA's members and grassroots have made a significant impact in voicing the need to address the therapy cap and payment cuts prior to adjournment. Thank you for your continued advocacy!

Watch your inbox for additional breaking news alerts as the bill moves to the Senate.

Ken Mailly, PT

Partner

Mailly & Inglett Consulting, LLC

(973) 692-0033

www.njptaid.biz

Bridging the Gap!

Member, APTA Consulting Service - Practice Management Consultant Network

For more information about the APTA Consulting Service visit www.apta.org/memberservices.

Confidentiality Note: This electronic mail is a communication from M & I Consulting that may be privileged, confidential or otherwise protected from disclosure. This information contained herein, is intended to be for the addressee only. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled.

Stop the Medicare Caps!

All those concerned about patient protection, regardless of whether they belong to APTA, should take action as requested below:

Without action by Congress during the “lame duck” session, physical therapists will be facing payment cuts and patients will be subject to an arbitrary therapy cap, without exceptions, starting January 1, 2007. All physical therapy professionals and their patients are urged to call on Congress to pass legislation to extend the therapy cap exceptions process by using APTA’s toll-free hotline to the Hill from November 13-21 at 1-866-346-9066.

For more information: Click Here

Mailly & Inglett Consulting, LLC

(973) 692-0033

www.njptaid.biz

Bridging the Gap!

Member, APTA Consulting Service - Practice Management Consultant Network

For more information about the APTA Consulting Service visit www.apta.org/memberservices.