A federal proposal to cut a key factor used to calculate physician pay is especially troubling to some professionals who support skilled nursing facilities because they’re left out of key pay incentives.
That was among the many concerns expressed by long-term care leaders as the Centers for Medicare & Medicaid Services closed the formal comment period on its proposed 2025 Physician Fee Schedule this week.
The proposal lowers the conversion factor by 2.8% over a year’s time — to $32.35 — for calendar 2025. The cut will occur because a Congressional act that increased the rate this year is set to expire in January. That means physicians, therapists and others who bill for care in nursing homes are expected to receive no raise.
Cynthia Morton, executive vice president of ADVION, formerly the National Association for the Support of Long-Term Care, joined major physician and medical associations in warning CMS that the pay “is not reflective of the increased costs providers face, and the PFS lacks the payment update mechanisms that other Medicare payment systems have.”
CMS cannot increase overall provider pay — or avoid so-called sequestration cuts that will cost providers an additional 4% in Medicare rates next year. It needs Congressional intervention.
But, Morton argued, the agency could more carefully craft its attempts at bonus payments, which currently exclude key provider types.
“ADVION’s members, specifically rehab therapists and portable X-ray suppliers, which operate in an institutional setting like a nursing facility, are excluded from MIPS [the Merit-Based Incentive Payment System],” Morton wrote. “As a result, they continue to have no means of achieving or earning a payment increase under the current Quality Payment Program to mitigate the zero percent update. This continued exclusion puts these providers at a disadvantage to other providers and is unfair to the patients they serve.”
The American Health Care Association/National Center for Assisted Living echoed those comments in its letter to CMS.
“This is particularly challenging to our SNF provider members that CMS has excluded from participating in [MIPS] for outpatient physical and occupational therapy services as well as speech-language pathology services, despite the statute clearly indicating that outpatient therapy services are included as MIPS-eligible services,” wrote Daniel E. Ciolek, PT, associate vice president of therapy advocacy for AHCA. “Such incentive payments could help offset some of these cuts for high-quality outpatient therapy providers.”
Both organizations also encouraged CMS to work with Congress on a permanent physician pay solution that takes into account inflation and other factors, but not to shy away from short-term fixes in the meantime.
“ADVION urges CMS to find a viable solution for these providers who operate in nursing facilities under consolidated billing to have a way to demonstrate their performance and achieve a payment update,” Morton added.
Non-physician providers including therapists, she said, have “continually borne the brunt of budget neutrality cuts under the PFS.” She also noted they are unable to provide certain services that CMS has allowed additional billing for, such as Evaluation and Management services.
Caregiver training needs
ADVION joined LeadingAge and others in embracing the establishment of new payment codes for Caregiver Training Services. These codes facilitate payment for an informal caregiver who will be tasked with caring for a patient being discharged, even when that patient is not present.
ADVION asked CMS to confirm that therapy providers are eligible to provide those services, while LeadingAge asked the agency to allow delegation of training to nurses, certified nurse assistants, home health aides, medical assistants, and community health workers when they’re supervised by a physician or other practitioner who can bill for it
LeadingAge also asked CMS to add similar codes to the Medicare Telehealth Services List to accommodate a scenario in which the practitioner completes the caregiver training service remotely.
“Creation of these codes appropriately reflects that informal, unpaid caregivers are critical members of the interdisciplinary team for older adults and play an increasingly important role in supporting older adults who choose to age at home,” wrote Jonathan Lips, LeadingAge’s vice president of legal affairs. “In addition to reducing complications related to ongoing conditions or illnesses, we also believe CMS has opportunities to support caregivers who are providing functional assistance that serves to prevent further deterioration, or adverse events like falls, and we encourage CMS to explore those needs and opportunities further.”
Other fee schedule requests
AHCA also endorsed a 3.6% increase in the telehealth facility fee nursing homes can charge, and asked CMS to consider an add-on code when providers must spend more time than “typical” with beneficiaries during a session.
“In the nursing facility environment, residents with complex conditions, multiple comorbidities, and physical and cognitive impairments may require the originating site clinician to spend significant time with the beneficiary during the telehealth encounter,” Ciolek wrote. “The proposed $31.04 originating site facility fee is inadequate to cover the nursing facility’s costs of the telehealth technology and the clinician’s personnel time and may disincentivize appropriate use of this care option for such beneficiaries.”
Other elements addressed by respective LTC-oriented organizations included support for telehealth in the use of substance use disorder treatment; a push for better, more-transparent rate-setting for mobile X-ray providers; and an extension of clinicians’ ability to use telehealth to prescribe controlled substances into 2028.
