Another Stick Resigns Amid Calls for Janek Resignation

Erica Stick, the wife of exiting lead HHSC counsel Jack Stick, has resigned and will be leaving the agency on February 6 from her current paid leave. In the meantime, there have been added calls for Commissioner Kyle Janek to resign his post by some legislators. See for more details.

As the 2015-2016 Texas Legislative Session commences, HHSC has a lot of questions to answer including how the OIG will operate in the midst of scandal and conflicts of interest. How will this affect the performance of HHSC personnel as things such as provider reenrollments continue? Stay tuned for more changes to come in the agency as the Sunset Committee continues to suggest its realignment.

Former Stick Aide and Janek Chief of Staff Received Free $100K MBA Program Tuition Via Taypayers

As if there were not enough problems with the governance of programs at HHSC, it was revealed that at least two HHSC employees working directly with Jack Stick and Kyle Janek received a full tuition ride courtesy of the Texas taxpayer, in direct violation of HHSC rules and possibly of law. See for more details.

Taypapers paid approximately $97,000 to cover full tuition for Janek’s current chief of Staff and Stick’s former aide, Casey Haney. Patricia Vojack, a former Janek State Senator aide, received $37,000 for an executive MBA program. In total HHSC has awarded $525,000 in tuition for HHSC employees since 2002.

The article cites close ties between these two individuals and the Stick family and Janek. Let’s see now, $525,000 is equivalent to how many units of therapy treatments and evaluations for deserving Medicaid children?

TDI Mandates Standardized Prior Authorization Form for All Medicaid MCOs

On 12/12/2014, the Texas Department of Insurance (TDI) published a mandate that all Medicaid MCOs in Texas use a released standardized prior authorization form starting 9/1/2015. This movement should bring about the standardization of information across all Medicaid MCO prior authorizations.

What this means for all Texas therapy providers: Required information will be universalized across all Texas managed Medicaid prior authorizations starting on 9/1/2015. The days of varying and inconsistent information that is needed across the spectrum of all Texas managed Medicaid MCO prior authorizations, are numbered. This should facilitate a standard way of requesting all prior authorizations, regardless of managed Medicaid MCO. Note, however, that an MCO could vary in the amount and types of supporting documents that they may request of the therapy provider.  For example, one MCO may ask for evidence of medical necessity and plans of care included in evaluations, past treatment notes (SOAP notes), etc., while another MCO may ask for fewer clinical notes or a longer stretch of notes in the client’s clinical records with that therapy provider. Supporting documents should support some piece of information that is included in the standardized prior authorization form. MCOs may also vary in their average turnaround time for a disposition on prior authorizations to treat. However, MCOs that enter into a contract with the Texas HHSC must abide by their rules for managed Medicaid administrators. One of the rules is to inform a networked provider within a certain period of time from the date of a request for authorization to treat, of their disposition on that request. See for more details.

Senate Bill 1216 (SB 1216) from the 2013 Legislative session put forth the requirement that all prior authorization information be standardized by 9/1/2015. The form can be found here Instructions for the form can be found here


Texas to be 100% Managed Medicaid by September 1, 2016

The RFP for MCOs to apply to become regional managed care administrators for the new and future Texas Star Kids program for Medicaid-eligible disabled children and adults with cystic fibrosis has closed and the contracts are to be rewarded in 2015 (at least well before 9/1/2015). Some traditional Medicaid eligibles will be moved into the new programs starting on 9/1/2015, with gradual conversion until 9/1/2016 and afterwards. The grace period for this client profile enrollment with a regional MCO will probably be the usual 90 days (after 9/1/2016).

Managed Medicaid organizations will then become a 100% administrator for Texas Medicaid by 9/1/2016. It is imperative that Medicaid therapy-based organizations (and all Texas Medicaid providers) scrutinize their respective managed Medicaid contracts for stipulations that are unfavorable, (i.e., decreased discount rates, more stringent authorization/claims requirements, provider network de-populating, etc). The risk factor with managed Medicaid should include the effective gross profit margins produced by those contracts for that Medicaid population clientele in your census. Refer to our conference talks on gross profit margin calculations for clientele profiles.

One of SynerImages’ mission as a healthcare business consultancy firm specializing in therapy-based organizations is to follow the life-cycle of an organization: from start-up, to compliance, to operational and financial efficiency. The managed Medicaid scenario that Texas therapists face in 2015 dictates that one must present a better product for the client (Medicaid eligibles and others) to these regional MCOs. That facet of therapy care is what will truly distinguish your therapy rehab from others, in addition to the capacity of local access to therapy care – in the minds of MCO provider network analysts.

SynerImages has a two-prong approach to this opportunity. First, we have formed an independent company, Therapy Collaborative Network (TCN), whose sole mission is to build a viable therapy-based provider network for Texas, for therapy organizations to obtain mutually fair and reasonable contracts with MCOs through therapist-capacity (coverage) and competence qualifications (higher standards of therapy quality assurance and utilization management) and the use of a legitimate, neutral, unobstructed, confidential, uninfluenced, unbiased, statistical, and independent individualized alternate messenger-model approach. One of these up-and-coming qualifications that MCOs will start to demand from therapy provider applicants is accreditation/certification status. NORFA was started to fill in this void in the industry. NORFA, as a certification company for therapy-based organizations (and currently in OPT “deeming status” application with CMS), has standards that supersede those of CMS’ requirements for OPTs. In this way, a NORFA certified therapy organization can present to the MCO, a standard of the highest quality in the industry.

For questions about TCN and/or NORFA, call our offices at (956) 618-5300.

Medicaid Revalidation/Re-enrollment (per ACA)

The ACA required states to re-enroll all eligible Medicaid providers by March 24, 2016. TMHP has issued this mandatory request to all Texas Medicaid providers who have enrolled after December 2012 with non-expired Medicaid licenses, to re-enroll per this need. Our experience has shown that because of required screening of these providers (by the OIG), the process is taking up to 6 months to enter the system and receive a new TPI. Hence, it is prudent to start your re-enrollment now so that the 3/24/2016 deadline does not become overwhelming to the system and to the provider applicant (i.e., this system delay may increase and an effective enrollment deadline would be months before 3/24/2016). A part of this re-enrollment/re-validation is a OIG unannounced audit visit before and after enrollment. SynerImages has prepared the known OIG requirements for this process in the form of an OIG-specific policies and procedures binder.

If you have not revalidated your Medicaid TPI number call our office for assistance and we will be happy to correctly and expeditiously complete the application and follow through with the TMHP revalidation process on that application on your behalf.

If you have already received a revalidated TPI with TMHP, but have not yet prepared your new OIG policies and procedures as required by Texas Medicaid, SynerImages offers this policies and procedures compliance binder for your continued participation.

Call us at 956 618-5300 for a quote today!

Thanks and Happy Holidays to everyone!

Things to Anticipate and Prepare for in 2015

The (three-disciplined) therapy-related service organizations in Texas have to be prudent in contemplating the future in 2015 and beyond. Proactive preparation is the most effective way to buffer the effects of fiscal, compliance, and  operational changes brought on by legislative and clinical policies. Here we list some of the more nuanced possibilities to look to in 2015.

  1. Legislative changes affecting the licensing, financing (reimbursement rates),  operational, and compliance landscape for therapists and therapy-related organizations: The 84th Texas Legislation convenes on January 15, 2015. In the last session, the 83rd made dramatic changes that affected the therapy business in Texas. In this session there is a potential for some key political players in the Lege to further change how therapy is rendered, paid, and reimbursed for Medicaid-related services. One of the changes anticipated is a call to require that therapists be certified/accredited separate from their respective state license, in a similar way that therapy organizations are certified to render Medicaid therapy services. Additionally, there is some movement (as was attempted in the last session) to further harmonize the reimbursement schedules across all therapy services delivery models, (i.e., home health, ORF/CORF, general rehabs/individuals). Next, the Texas Sunset Committee during a scathing review of HHSC this past summer, anticipates a reorganization of HHSC, including the manner in which the OIG conducts its business. This coupled with the recent troubles HHSC has had in their contracting processes, may mean some changes are under way in how the OIG will investigate future Medicaid fraud. The Legislation is also due to review the MCO managed Medicaid programs and their respective behavior in collecting and managing reimbursements and profits. This could have far-reaching affects as to how managed Medicaid reimbursement discount rates for therapy services will be implemented during re-enrollment periods in 2015.
  2. Managed Medicaid scenarios: the managed Medicaid organizations that are in place in regions of Texas are slated to start some of their re-enrollment periods. What this means is that they will be reassessing their therapy network coverage and individual provider performance and expertise in contemplating their re-enrollment options. Additionally, their reimbursement discount rates may fluctuate based on regional coverage, network availability, and provider competence in displaying measurable outcomes and results. More of these MCOs will be demanding more stringent requirements for pre-authorizations, claims billing, and client eligibility, as well as more comprehensive therapy-clinical documentation. At some point in this reimbursement scenario, discount rates will increase to the point where, in some cases, the therapy managed Medicaid reimbursement will be on par with or less than the corresponding full Medicare rates. This will be a tipping point for the Medicaid therapy industry in Texas. These MCO discount rates are applied to the current Texas Medicaid Fee Schedule (TMFS) for therapy services and as such, are directly dependent on any legislatively mandated changes to Medicaid therapy services reimbursements to HHSC. Hence, if one expects a x% rate reduction (i.e., [1-x]% discount rate) in the therapy TMFS, and a y% decrease in an MCO’s proposed discount rate from a current discount rate of y1%, then the overall change to your managed-Medicaid schedule will be a [x + y(100 – x) / y1]% rate reduction or a new effective discount rate of {100 – [x + y(100 – x) / y1]}%.  Lastly, the trend, at this point, with MCOs, will be to require some sort of legitimate certification/accreditation for therapy organizations, including individual therapists.
  3. Therapy-based EMRs (in some cases EHRs) will become more prominent as more vendors enter into that part of the provider universe and as CMS and/or HHSC require electronic documentation for timely reimbursement. The national therapy boards (ASHA, AOTA, APTA) have been pushing CMS hard to open up the eligible provider requirement to therapists. This is only a matter of time and if it happens in 2015, then therapists will be eligible for Medicare EHR-incentive bonuses, in addition to the limited PQRS bonuses that they currently qualify for. See our last conference talk on the PQRS program for therapists. Again, this would mark a tipping point for the therapy industry as it would present an alternative clientele for many pediatric-only therapy services organizations wishing to diversify in order to survive an impractical managed Medicaid reimbursement decrease.
  4. ICD-10 is again on a delayed fuse, this time for October 15, 2015. However, many organizations have been preparing for it for a couple of years now through the use of updated therapy EMRs, internal training, and billing updates with their respective billing vendors and staff. If one has not done any preparation for ICD-10, this is your second (or third) chance and it should have started already. ICD-10 changes will be slightly less onerous for therapists than for physicians. Nonetheless, diagnoses schedules must be accommodated for and billing processes changed to accept and interpret those more detailed and distinguished diagnosis codes and descriptions appropriately.
  5. The 2015 CMS Medicare Reimbursement Schedule for therapy CPTs varies from 1% to 5% decreases from 2014 rates. While the reimbursement formulary conversion factor (CF) decreased very slightly, other formulary factors lead to overall low single-digit percent decreases. The annual therapy caps were increased by $20 ($1,940). The PQRS incentive rate stays at 0.5%. However, the number of required PT/OT reported individual measures to avoid a 2% 2017 penalty, will increase from 3 to a maximum of 9. PQRS incentive rates will be phased out at the end of 2015. All these rules will be in effect until March 31, 2015, and will be extended to the rest of the year only if Congress acts to extend them. Otherwise, the reimbursements will decrease dramatically with a formulary CF decrease of 7.58. See and for details.