The No Surprises Act and Good Faith Estimate
A Good Faith Estimate (GFE) is an estimate of expected charges for a healthcare service provided to any patient with either no insurance or choosing not to bill insurance for their therapy visit or when requested by any patient even without an appointment scheduled.
- If insurance is billed, the GFE requirement does not apply
- NOTE: the GFE does not apply to Medicare patients & the ABN process would continue to apply when services are not payable by the Medicare program
- A notice must be posted in your office and online stating that a GFE is available
- The GFE must be in written form, either on paper or electronically
- The GFE must be issued no later than 3 business days after an appointment scheduled more than 10 days in advance.
- If scheduled with less notice, the GFE must be given no later than 1 business day after an appointment is scheduled.
- If changes occur to services requested, a new GFE should be given no later than 1 business day before services are rendered
The GFE must include:
- Patient name and DOB
- Description of service and date scheduled
- List of items and services from all providers (even those with separate scheduling)
- CPT, diagnosis code, and charge per item
- Name, NPI, and TIN of all service provider and the state of services provided
- Disclaimer that separate GFEs will be issued for separate providers and items
- Disclaimer that other services may be required that must be scheduled separately that are not included in the GFE
- Disclaimer that this is only an estimate and actual services, and charges may differ
- Disclaimer informing the patient of their rights to patient-provider dispute resolution process if actual billed charges are substantially above estimate, as well as where to find information on starting the dispute process
- Disclaimer that GFE is not a contract, and patient is not required to obtain services from provider
Patient provider resolution process:
- Can apply in the event that billed charges exceed GFE by $400
- The dispute process can be initiated up to 120 days from receipt of bill with the Department of Health and Human Services
- Dispute will be reviewed, and provider will be allowed to provide documentation to establish medical necessity and/or unforeseen circumstances that could not have been included in the GFE
- Parties can settle the dispute at any time. However, if they do not settle the final decision will be based on information submitted
Vaccine Requirement 2022 Update
(January 20, 2022)
The SCOTUS made a decision that blocked the OSHA vaccine mandate, but still upholds the CMS mandate. There will still be appeals court rulings on the horizon, but most likely this ruling will hold as CMS has an obligation to protect beneficiaries and an authority to require those who bill the Medicare program to have this infection control measure in place.
- Phase 1: due January 27th requires facilities show developed and implemented policies and procedures that ensure all staff are vaccinated for COVID-19 and that all staff have at least 1 dose of the vaccine, pending request for qualifying exemption, or granted exemption.
- Phase 2: due February 28th requires facilities show developed and implemented policies and procedures to ensure all staff are vaccinated for COVID-19 and that all staff have received necessary doses to complete the vaccine series or granted exemption.
- Phase 3 due March 28th, facilities must be 100% compliant with standard.
Information on 2021-2022 Vaccine Requirements
(November 17, 2021)
ASHT has put together information on the CMS and OSHA vaccine requirements. There is some speculation about if these requirements will be mandated ultimately as there have been lawsuits and appeals in place, however, in the interest of being prepared for this, here is what we know.
Call on Congress to Stop Payment Reductions for Therapy Services for Medicare Beneficiaries
(August 5, 2020)
On August 3, 2020, the Centers for Medicare and Medicaid Services (CMS) released its proposed 2021 Medicare Physician Fee Schedule. The rule recommends significant payment reductions to more than three dozen healthcare professions, including occupational and physical therapy.
CMS is using the revenue from these cuts to offset an increase in payments for physicians. These cuts are the result of a Medicare statutory requirement known as "budget neutrality," which requires that any increase in costs to the Medicare program must result in decreased spending elsewhere in the Medicare program. The CMS proposal would cut reimbursement for Medicare Part B therapy codes (including 97165, 97110 and 97161 for example) by an estimated 9 percent.
ASHT, the American Occupational Therapy Association and the American Physical Therapy Association have been actively raising concerns with Congress and CMS about the impact these cuts have on providers and patients in need of care, particularly amidst the COVID-19 pandemic.
Fortunately, bipartisan legislation has been introduced in the House of Representatives (H.R. 7154, the Outpatient Therapy Modernization and Stabilization Act) by Reps. Boyle (D-PA) and Buchanan (R-FL) that would prevent these proposed reimbursement cuts by waiving the statutory budget neutrality requirements.
ASHT will continue to advocate against these cuts with CMS, but we need you to take action now by asking your members of Congress to intervene to stop these payment reductions.
Telehealth Implementation Checklist
(July 10, 2020)
ASHT has compiled the following checklist to help guide the implementation of telehealth into your organization of practice. Before you begin providing services via telehealth or using telecommunications modalities, we encourage you to consider federal and state legislation and regulations that govern practice, billing and coding issues, as well as hardware and software requirements.
Telehealth and COVID-19
(May 14, 2020)
ASHT is providing the following list of resources to assist members with implementing telehealth services. Resources include webinars, FAQs, coding and billing guidelines and reimbursement information.
American Occupational Therapy Association
American Physical Therapy Association
Centers for Medicare and Medicaid Services
- CMS Fact Sheet
- CMS Physician and Practitioner Guidance
- Medicaid State Plan Fee-For-Service Payments
- COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers
American Medical Association
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS): CMS Flexibilities to Fight COVID-19 Update
(April 7, 2020)
Submitted by: Angela M. Stephens, DHS, OTR/L, CHT
In response to the COVID-19 pandemic, there are several temporary changes across the entire U.S. healthcare system. These changes will be immediate and will be in place during the emergency declaration time period. In summary, the goals for this action are:
- Ensure local hospitals and health systems have the capacity to handle the patient volume due to COVID-19, temporary expansion sites.
- Remove barriers for physicians, nurses, and other clinicians to be readily hired to meet the healthcare demand
- Increase access to telehealth in Medicare
- Expand in-place testing
- Patients Over Paperwork, to allow focus on patient care for Medicare and Medicaid beneficiaries that may be affected by COVID-19
Patients Over Paperwork
Patients Over Paperwork will allow DME Medicare Administrative Contractors the flexibility to waive replacement requirements for DMEPOS. However, the claim must include a narrative description from the DMEPOS supplier as to why a replacement was warranted. The DMEPOS Medicare Prior Authorization program has been paused for certain items. CMS is not requiring accreditation for newly enrolled DMEPOS providers, and the expiring supplier accreditation is extended for 90-days. The “proof of delivery” signature requirement has been waived by CMS for both Part B drugs and DME. Documentation should be placed in the medical record stating date of delivery and that the signature could not be obtained. In addition, CMS has expanded the Accelerated and Advance Payment Program. Medicare providers should submit the request to the appropriate Medicare Administrative Contractor (MAC). Each MAC will then review the request and issue payments within 7 calendar days of receipt dependent upon the provider has met the required qualifications. A fact sheet has been developed by CMS and can be viewed on this link: https://www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf
Medicare Appeals in Fee For Service (FFS), Medicare Advantage (MA), and Part D
CMS is allowing MACs and Qualified Independent Contractors in certain FFS programs, MA, and Part D plans to allow extensions to file appeals and to process appeals with the flexibilities that are available if good cause requirements are met. In addition, some FFS programs are permitted to waive requirements for timeline requests of additional information to adjudicate appeals. Medicare Advantage plans may extend time frames by 14 calendar days to adjudicate determinations and reconsiderations for medical items and services based upon certain requirements. For more detailed information please review this link: https://www.cms.gov/files/document/covid-dme.pdf