One Therapy Rule – Part 1

MSL has done some research on a change coming our way. You may have heard of it – the “One Therapy Rule,” formally known as the EIDT Program. Watch this video and stay tuned for your opportunity to take action.

Are you thankful for Medicaid?

Author: Lainey Morrow, Medicaid Saves Lives’ Founder

It’s customary this time of year to count our blessings, and there’s one in particular that millions of Americans shouldn’t forget: Medicaid. 

If you’re a recipient (or know a recipient), think for a second what your life would be like without Medicaid.

My little girl qualifies for TEFRA because of her diagnosis, and she’s thriving because Medicaid gives her treatments like therapy and medicines that we simply can’t afford. Medicaid not only helps her day-to-day, but it’s also giving her a future where she may someday be able to live on her own and provide for herself. Because of Medicaid, she can climb stairs, say that she wants a drink, draw a line, feed herself with a spoon, and sit quietly with other students around a table. When I think of life without Medicaid, I see many who would be crushed under personal debt and suffering without hope.

If you’re thankful for Medicaid, please tell those who make our state and national policies, especially if you need to continue receiving it.

This is the perfect time of year to let our lawmakers know that we’re thankful for Medicaid. Why? Because it’s improving and even saving lives! I ask you to take a moment, and write your elected officials a note. Even better, include a photo. Tell them why Medicaid is important to you. If writing several is overwhelming, just start with one. 

You can also post on social media about why Medicaid is important to you using the hashtag #thankful4Medicaid to help others see why Medicaid is so important.

We need to tell everyone the great things that Medicaid does and who it helps. People need to hear this positive message. By sending notes, calling, and posting on social media, we are clearly communicating that we still need Medicaid, and we’re directly asking the people in charge to continue funding Medicaid for us.

Let’s flood our government with letters and calls this holiday season!

Arkansas Only

Contact any elected official in the US!

Therapy Cap PA Requests: Q & A 


The PT, OT, and SH Association Presidents regularly meet with DHS and AFMC to discuss issues that providers have when requesting Prior Authorizations (PAs) for children who need therapy over the 90-minute cap. These are the results of their latest meeting.

Keep track of your questions and email them to be discussed at the next meeting.


The Recap of ArkSHA, ArPTA, and AROTA meeting with AFMC and DDS on 08-25-17:

The following are issues raised by members of ArkSHA, ArPTA and AROTA, and responses from AFMC and DDS.

Issue: Shifting of Units Between Therapist and Assistant

There are still questions regarding the length of time it is taking to shift units from PT/OT/ST to PTA/COTA/SLPA and vice versa. AFMC reports that following completion of the large number of DMS-640 form validations AFMC received many change requests to prior authorizations. AFMC encouraged their staff to continue to process initial DMS-640 validations and that all changes would need to be checked before processing. Currently, AFMC states that they are about 10 days out on corrections and Jarrod McClain, AFMC Director for Clinical Review, indicated that their staff are working diligently to get the updates made as quickly as possible. The updates to the PA’s flow to DXC each night and providers can start billing immediately upon receipt of the changes.

In addition, Jarrod stated that AFMC is working to decrease the timeframe for corrections but they have to ensure that they are getting the correct request ID modified. According to Jarrod, it takes a few days to check and update the claims data extract file. If providers continue to see a delay, please contact Jarrod McClain at AFMC. He will personally see that his staff checks on the status of their request and get it processed.

Issue: Use of evaluations from preschool programs to kindergarten

There was concern from many members as to how long their evaluations will be valid in a schools setting. The consensus is that if the evaluation utilized is an evaluation conducted by a non-educational agency, or by a provider who is not contracted by an educational agency, then the evaluation is good for one year. If an educational agency or a contractor of the educational agency conducted the evaluation, then the evaluation falls under the school-based evaluation criteria of every 3 years.

Issue: Some prior authorizations were only approved after sending in a cover sheet restating information included in the evaluation.

AFMC was aware of this issue and is working to improve their processes for approval. In the meantime, providers are encouraged to highlight justification for medical necessity in the evaluative reports, including statements about how the services recommended are under accepted standards of practice to treat the patient’s condition, how services are complex and will require the skilled services of a qualified therapist, and a statement about therapy prognosis (See Medicaid Manual Section II). Though a cover letter outlining these justifications is not required, providers are encouraged to consider using a cover letter attached to the evaluation to make these medical necessity statements more salient for reviewers.

Issue: Are reviewers actually reading the evaluations or just looking for technical language?

AFMC assured us that they are reading all evaluations. They perform both technical and administrative reviews in order to ensure that all requirements of the evaluative reports are included, as well as a medical necessity review to ensure that justification for medically based services is included.

Issue: I heard that AFMC was using nurse reviewers and not experienced pediatric therapists in each discipline. Is this true?

AFMC utilizes registered nurses to perform the initial reviews of all PA requests. If a request is denied than the request is assessed by an experienced licensed therapists specific to the discipline. If the therapist agrees with the denial it is then sent to a board certified pediatric physician for final review. If a provider does not agree with the denial or would like to request reconsideration they may do so by resubmitting the request.

Issue: What about beneficiaries who receive services from multiple providers for the same service?

AFMC and DDS continue to emphasize the need for care coordination for beneficiaries with multiple providers of the same modality (physical, occupational or speech therapy). Dr. Chad Rodgers, AFMC Medical Director, attended our meeting and reported that the pediatricians and PCPs he has been in contact with are interested in understanding what situations justify the appropriate signing off on multiple prescriptions. He asserts that although he can’t speak for all physicians he personally looks at every request for therapy services before signing them. He recognized that it is difficult to for most physicians to understand why a child needs multiple services. He and assistant director of DDS Elizabeth Pittman stated that it would be beneficial to state on the DMS-640 the specific need for a particular service and that the beneficiary will need the services of multiple therapists. AFMC and DDS are considering a change to the DMS-640 forms in the future to accommodate the different services provided within one discipline. Elizabeth Pittman reported that the new MMIS system (which has an anticipated implementation of summer of 2018) will be less burdensome on providers and will have the ability to disclose is the beneficiary is receiving services from other providers. Until then, providers need to ask during the intake process if the recipient is receiving therapy services from any other provider, and then coordinate as needed. According to Jarrod McClain, only 10 providers have bumped into challenges with the multiple provider issues thus far.

Issue: For short term scripts (i.e. ortho docs who write for 2-6 weeks) that then need an extension once the patient has had a follow-up recheck. What is the most efficient way to keep PA’s from having to be unnecessarily done?

Providers can simply go into Review Point, and click the extend button. The codes will be transferred over and the new prescription can be uploaded. Information about the progress of the patient and continued medical necessity should be included with the extension.

Issue: It has come to the attention of AFMC and DDS that some facilities are sending notices to parents that they should not allow services for their child in the school due to the need for a PA if the school and independent facility are both treating the beneficiary.

Although Medicaid is a “medical” assistance program, it recognizes the importance of school-based services. The federal Medicaid program actually encourages states to use funds from their Medicaid program to help pay for certain healthcare services that are delivered in the schools, providing that federal regulations are followed. The associations stand with AFMC and DDS that sending notices to parents regarding billing for services between schools and independent clinics is not recommended. IDEA laws require schools to provide services to beneficiaries if needed for educational purposes. Schools also must provide therapy that is medically necessary. Therapy services outside of the school setting should not replicate services provided by therapists contracted or working with the school.

Issue: A representative at DHS has stated that physical therapy re-eval codes are no longer a valid code as of July 1st. Has anything changed in the recent rule change?

Reevaluation codes are not currently and haven’t been a reimbursable code. The two billable codes for physical therapy services are 97001 and 97110.

Take Action: Graphic to Share

The news changes like the wind. Are they voting or aren’t they? Repeal and replace or repeal without replace? No matter what’s happening with them, we need to continue to make our needs and wants abundantly clear.

Many are saying that they can’t get through to Senators via phone calls. Don’t stop calling because they are counting the calls. 866-426-2631

However, social media is a great way to publicly contact your Senators, especially since they won’t post their direct email addresses.

Share this graphic with them and tag them in your posts. Use hash tags like #BCRA or #ProtectOurCare to help others see your posts!

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Revised Senate health care bill: Where are we now?

A revision of the BCRA Senate Health Care   bill has been released, but what’s different? We have the one-stop-shop for understanding the bill for yourself.

Some reports say that they want to vote as early as Tuesday. Get to reading and then get to calling!

Every call matters. Here’s the number for Senators across the nation: 866-426-2631

Find your states US Representative & contact his/her office

Find your state’s US Senator & contact his/her office

Read the new revised bill to make sure you discover everything for yourself.
Check out these resources to guide you:
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What was the original bill?

Full text of the original bill. Click on the image below, and  use the resources above to help you.
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How the BCRA will affect you, even if you don’t receive Medicaid

The topic of health care is not only in some ways oppressive on our minds but also overwhelming these days. Months ago, the House wrote the American Health Care Act (AHCA) in an effort to repeal and replace the Affordable Care Act (ACA), and they passed it on to the Senate. Then, the Senate must have found fault with the AHCA because they wrote their own version of the bill called the Better Care Reconciliation Act (BCRA). If the Senate passes their bill, it will have to go to the House for their approval. We have seen months (years!) of coverage on the subject of health care, and it’s downright confusing at this point.

Let’s try to clarify some of the confusion by pulling a few articles together to show what will change with the Senate health care bill, the BCRA. (The AHCA doesn’t matter if the House approves the BCRA.) This research will show that nearly everyone who isn’t extremely wealthy will be affected negatively by the bill as it stands proposed today. If you care about, or are affected by, any of the following categories, you can expect changes to come to you and your family if this bill were to pass.

1. Medicaid Funding

“[T]he Senate bill would radically restructure all parts of Medicaid—not just the expansion provided under the Affordable Care Act.” 1

“The cumulative impact: a $772 billion spending cut over 10 years, versus current law, and 15 million fewer people enrolled in Medicaid in 2026.” 2

2. Essential Health Benefits

“But another change might have more far-reaching effects: eliminating the Affordable Care Act’s ‘essential health benefits,’ or EHBs. That shift could affect almost everybody, including the 156 million Americans who receive health coverage through their employers.” 5

Here’s a rundown of what they are: 4, 5, 6

  • Outpatient care — scheduled doctor visits, (outpatient care you get without being admitted to a hospital)
  • Emergency room trips — ER visits and ambulance trips.
  • In-hospital care — All care people get as hospital patients, such as surgery.
  • Pregnancy, maternity and newborn care — before and after birth
  • Mental health and substance abuse disorder services — (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative services and habilitative services – help recovering from an injury or illness, but also treatment (therapy) for kids with autism or cerebral palsy.
  • Lab tests
  • Preventive services — vaccines, cancer screenings, etc.
  • Pediatric services — including dental and vision care for children.

3. Pre-existing Conditions Protections

“The BCRA retains the popular ACA provision that people with pre-existing conditions cannot be charged more for insurance because of their health status. However, weakened essential health benefits would hurt people with pre-existing conditions.” 1

“The Senate bill would retain some limits. It wouldn’t, for example, allow states to waive the prohibition on discriminating on the basis of preexisting conditions. But it would allow states to remove caps on out-of-pocket spending for exchange plans.” 3

4. Subsidies & Taxes

“One major difference is that the Senate bill provides subsides only up to 350% of the federal poverty level starting in 2020; the ACA currently provides subsidies up to 400%. In other words, while individuals earning up to $47,550 qualify for help under the ACA, only those earning up to $41,580 would qualify under the Senate plan. This means far fewer people will qualify for aid.” 1

Sources:

1 4 Things to Know About the Senate’s Health Care Bill

4 ways you probably didn’t know the Republican bill changes Medicaid

3  Crazy Waivers

4 What Are ‘Essential Benefits’ in GOP Health Care Bill Debate?

5 The 10 ‘essential’ benefits that could be eliminated under the GOP health care plan

6 What Marketplace health insurance plans cover

Facts & Faces of Medicaid

Share the facts and faces of Arkansas Medicaid.

Show people who Medicaid cuts would hurt. Don’t give up. Keep calling and sharing.

Data source is credited. We have gathered several of KFF’s posts here to save you some time.

Senate Healthcare Bill Released

Updated: 7/9/17 4:08 pm

By now, you’ve probably seen more than 10 different news stories about the Senate healthcare bill. Maybe 10 per day! But what’s the truth? Will it really cut Medicaid? Will it really affect everyone? Well, the only way for you to know is for you to read it yourself. And we can help you.

You need to read, but also, don’t stop responding. The Senate wants to vote on this bill as soon as they can come to an agreement. They’re having many negotiations behind closed doors. Let your voice be heard through those doors! These are the Arkansas Senators to contact:
Sen. John Boozman (202) 224-4843
Sen. Tom Cotton (202) 224-2353

If you’re not from Arkansas, this info pertains to you as well. Every call matters. Here’s the number for Senators across the nation:  866-426-2631

Find your states US Representative & contact his/her office

Find your state’s US Senator & contact his/her office

Contact information for all of AR Congressmen.

What’s truly in the bill?

Make sure to read the bill to form your own educated opinions. Click on the image below to access the full text, and  use the resources above to help you.
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