Major Medicare Initiative Frequently Asked Questions

March 4, 2008

UPDATE: Bills have been introduced in Congress. HR 3968 is the House bill; S 2704 is the Senate bill.

February 14, 2006

The AARC’s Respiratory Therapy (RT) Initiative Under Medicare Part B

What is Medicare Part B?
The Medicare program is divided into Parts A-D. Part A includes hospital inpatient services, Part C deals with managed care, and Part D is the new prescription drug benefit. Part B includes medical services generally delivered in the outpatient setting by physicians’, physician assistants, nurse practitioners, clinical nurse specialists, and physical therapists, to name a few. Although Medicare Part B recognizes a number of non-physician practitioners and the services they provide, it does not include respiratory therapists and the services they furnish.

To fully understand this complex subject, we suggest you review the AARC’s Reimbursement College.

What is the AARC’s Medicare RT Initiative?
We are asking Congress to recognize qualified respiratory therapists and the services they furnish by amending the statute to include a separate benefit under the Medicare Part B “medical and other health services” provision.

How would this be done?
Congress has to pass legislation in order to revise any portion of the Medicare statute. Since we want to add something new, we will have to work closely with Congressional staff to get Congress to introduce and pass our changes into law. Therefore this Initiative will be a key element of our legislative agenda.

How does this relate to the other issues AARC has pushed in its legislative agenda?
We are not abandoning our previous Congressional legislative agenda by any means. This is a more expansive and comprehensive strategy than our previous efforts.

We will continue our work on other key health issues, including advocating for a national coverage policy for outpatient pulmonary rehabilitation, pursuing legislation that would prevent any further changes in Medicare home oxygen patient ownership of their oxygen equipment, working with our Tobacco Prevention Partners on pushing for legislation to exert greater regulation over tobacco products, and other as yet undetermined issues that will no doubt come up.

The AARC advocated for years on Medicare coverage of RTs as part of the home health benefit. Why are we giving up on that after all the time and effort?
We are changing our tactics but not giving up on pursuing the ability of RTs to furnish services in the home setting. Visits to a patient's home by the qualified RT will be part of this new initiative, but the services will not be carried out under Medicare's Home Health benefit.

Previously we have focused on amending the Medicare Home Health benefit to include respiratory therapists. However, the home health benefit is highly restrictive and only available to Medicare beneficiaries who can rarely leave their homes. They are a small percentage of patients who could benefit from our services outside of the hospital. Yet, tactically, it was and continues to be important to us to provide access to medically fragile patients.

If the RT Initiative is enacted as outlined in our plan, qualified RTs will be able to furnish services to Medicare patients in their homes as though they were physicians' services. This new access to the home setting is accomplished by removing the current "direct" physician supervision requirement that RTs operate under currently.

This will allow us to collect data and positive outcomes on the value of respiratory therapists outside the hospital setting. This type of outcome data will enhance the entire profession of respiratory therapy and all respiratory therapists.

Recognizing Qualified Respiratory Therapists Under Medicare Part B

What exactly is the AARC proposing to do?
In a nutshell, we are proposing to revise the Medicare statute to permit qualified respiratory therapists to provide respiratory therapy services under the general supervision of a physician.

Can’t RTs do that now?
No. Outside of the institutional setting, the law requires that RTs must work under the direct supervision of a physician. “Direct supervision” means that the physician must be physically present in the office suite and be immediately available to provide assistance to the RT performing the services. In Medicare terms, this is known as services furnished “incident to a physician’s professional service.” Under general supervision, our change would allow the physician to see patients outside of the office setting because the qualified RT would be able to furnish RT services without the physician being there, although the physician would still need to be available for consultation by phone.

So, for example, the physician could be doing rounds at a hospital and the RT could be back in the physician’s office providing asthma education or smoking cessation services to a patient. Another example is the physician could be in his/her office and determines it is medically necessary to do a ventilator check on his/her patient who is being cared for in the home. The physician could send the RT to the home to do that check. Under the current law, the RT wouldn’t be able to do this.

In simple terms, when the qualified RT furnishes the service without the physician being present, it would be as though the physician provided that respiratory therapy service.

Why is that such a big issue?
By changing the law, physicians will have a lot more flexibility to treat their patients with qualified personnel so they don’t have to be in the office for extended periods of time.
And, this new benefit category will provide an avenue for qualified respiratory therapists to provide RT services in ways they couldn’t before.

The delivery of health care services has changed a lot over the years since the Medicare statute was first enacted. This is especially true for pulmonary medicine and the delivery of respiratory therapy services. Medical evidence supports the efficacy of services such as disease management, smoking cessation, proper education on aerosol device delivery systems, and office-based spirometry, etc. Services that once could only be provided in an acute hospital setting are being delivered in alternate care sites. So, using the example above, you will find patients at home on ventilators that 25 years ago would not have been possible.

You keep referring to “qualified respiratory therapists.” What do you mean?
In order for an RT to furnish services under the change we are proposing to Congress, the RT would not only have to be credentialed and legally authorized to perform RT services in the State in which the service is furnished, but they would also have to be a “registered” respiratory therapist and hold a bachelor’s degree. This is an important distinction because it will effectively give respiratory therapists recognition under Medicare Part B's program similar to other non-physician practitioners such as nurse practitioners, physician assistants, and clinical nurse specialists, all of whom have a minimum of a bachelor’s degree or master's degree and advanced professional credentials.

Why are you limiting the benefit to only Registered RTs with a bachelor’s degree?
We want to make sure that any request we make to Congress to change the Medicare law is credible. In order to do that, we need to make sure that the credentials of the RT are comparable to the credentials of these other professionals who can provide services under Medicare Part B. For example, clinical nurse practitioners and clinical nurse specialists are the only types of nurses recognized as a separate Medicare Part B benefit and to qualify they have to have advanced degrees. Therefore, we feel that at a minimum the RT must have the title of “registered” and hold a bachelor’s degree in order to qualify for this new benefit.

Can the qualified RT open up his or her own independent practice?
No. Current Medicare law doesn’t permit it and neither will our proposed legislative change. The qualified RT still has to work for a physician and be under some type of physician supervision.

So, under the proposed change, can the qualified RT bill Medicare directly?
No. The services of the qualified RT still have to be billed by the physician. What would change is that the RT would have to have a provider number or some type of identifier so that when the physician submits the bill, Medicare has some way of knowing that the RT furnished the service instead of the physician. The difference between what happens now and what would happen if new legislation were enacted revolves around the level of physician supervision and payment to the physician.

For example, under current law, if the physician provided an RT service directly or had an RT furnish the service as “incident to the physician’s professional service”, Medicare would pay the physician based on 100% of the physician fee schedule amount for that service. Under the new legislation, if the qualified RT furnishes an RT service and the physician is not in the office when the service is performed, the physician would still be paid as though he or she furnished the service, but the payment amount would be based on 85% of the allowable amount under the physician fee schedule because the physician wasn’t directly involved when the service was provided.

If the physician would get less money when a qualified RT performed an RT service, what is the incentive to hire the qualified RT in the first place?
Under our Initiative, the big incentive for the physician is that it allows more flexibility and frees up his/her time to see other patients outside of the office setting. And, the qualified RT would now be recognized by Medicare as a non-physician practitioner who can furnish services without the need for the physician to be physically present when the service is being furnished. Using the example mentioned above, the physician could be doing rounds outside of the office and the RT could be providing the RT services the physician might otherwise be providing. And that makes a huge difference.

Can the qualified RT be an independent contractor and work for more then one physician?
Yes, the qualified RT could be an independent contractor to the physician. In other words the RT wouldn’t have to be a full-time employee of one physician’s office. The RT could work for several physicians. For example, the RT could contract with one doctor’s office to provide asthma education to a physician practice on Tuesdays and Thursdays and work with another practice on Friday to provide smoking cessation services.

I already work in a physician’s office. How does this affect me?
If you work in a physician’s office now under Medicare’s “incident to a physician’s professional service” benefit, our legislative initiative will not affect your current status. In other words, CRTs or RRTs without a bachelor’s degree who currently work in a physician’s office in which the physician is required to provide “direct” supervision would continue to so. This benefit does not change with our Initiative.

If I work in a physician office practice and don’t’ meet the criteria for a qualified RT, will I lose my job?
You will not lose your job because you don’t have the credentials we are proposing in our Initiative. Nothing in our Initiative mandates that the physician employ an RT who is registered with a bachelor’s degree to work under his/her general supervision. We are simply advocating it is an option for the physician. The physician office practice could conceivably hire both the RRT/Bachelor RT and RTs who do not meet both criteria. The RRT/Bachelor RT could (not must) work under the general supervision provision this Initiative is creating, and the RT who doesn’t meet both criteria could work under the “incident to the physician services” provision, or direct supervision rules. It is up to the physician to decide who works under which benefit.

If Congress enacts this Medicare RT Initiative, what services do you see the qualified respiratory therapist providing?
Respiratory therapists are rapidly moving into areas such as disease management, patient education on the selection of appropriate aerosol devices, education on the devices and use of medications and patient compliance with the aerosol meds, office spirometry, smoking cessation, asthma management, and ventilator management for non- hospitalized patients.

I’m a respiratory therapist who doesn’t meet the criteria. Why should I work and lobby for this since you are leaving me out of the provisions?
It is important for you to support this Initiative, because Medicare recognition of RT services under Part B enhances both the profession and the respiratory therapist. It expands what the profession can do and it gives visibility to the respiratory therapist that does not exist under the current law.

The change could also enable us to track and collect data on the services that qualified RTs may provide, because Medicare will be able to identify such services for the first time. One of the challenges the respiratory profession has had over the years is having hard data on how the profession has clinically impacted patients’ health, their quality of care and their clinical outcomes. The new benefit could help us collect data that will provide further irrefutable evidence of the efficacy of respiratory therapy services and the benefits that result from such services being provided by all respiratory therapists.

I’m a respiratory therapist who works in the hospital. This Initiative impacts respiratory therapists who work primarily in a physician office practice. Why should I care and work for this?
We see the Initiative as opening up new employment opportunities and career advancement for the respiratory therapist. It enhances the profession and raises the stature of the respiratory therapist. And, that will benefit you. You may one day want to work outside the hospital and as a qualified RT a new door would be opened. Even if you always choose to be employed in the hospital, your colleagues might want to move on and be employed in a physician office practice with greater independence. If enacted, this Initiative will do just that.

The Medicare Durable Medical Equipment (DME) benefit is a Part B benefit. Will home care equipment companies be required to hire the qualified RT if they are employing RTs right now?
No. The DME benefit is a separate benefit with its own rules and regulations and our Initiative has no impact on it. The DME benefit primarily covers medically necessary equipment, such as oxygen and ventilators, and the services and supplies needed to make the equipment work. DME companies can choose, as they do now, whether to employ personnel such as respiratory therapists to assist with the set up, training and maintenance of the equipment, but clinical services are not covered under this benefit, regardless of whether they are provided by an RT, nurse or other clinical professional.

Our Initiative could, however, open the door for a qualified RT to make a home visit to a Medicare patient who happens to be receiving DME services, if the physician that RT works for decides the visit is medically necessary and the physician does not have the time to furnish the service directly. But the visit would not be part of the DME benefit; it would be covered under the changes we are proposing to the “medical and other health services” benefit. .

I already am employed by a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, etc. How is this Initiative going to impact my job?
It’s not. Services provided by RTs in these settings now will continue unchanged because they are covered by rules and regulations that govern those sites of care. It is up to those agencies or facilities to determine the types of professionals they want to hire and the qualifications of those personnel. Our Initiative does not impact those choices in any way.

I am a Registered RT with a Bachelor’s Degree. If the law changes, and I can provide services in lieu of the physician providing them without the physician being present, just what services can I provide?
You will able to provide only those respiratory therapy services that are defined under your state practice act or those in which you are legally authorized to perform by the state.

OK, what can I do to help?
There is a lot you can do and a lot we need every respiratory therapist to help in order to achieve success. As stated above, Congress must enact this Initiative. And we must get their attention and let them know this is an important issue not only to the profession but to the patients we serve. The more members of Congress hear from their constituents the better the chances to enact the Initiative

• Contact your member of Congress and both your Senators. You can log on to the AARC’s website at our Capitol Connection. The page will walk you through how to find your member and there is a brief explanation of the Medicare Respiratory Therapy Initiative and a draft email you can send to your members of Congress.
• Enlist your patients or clients to write. The Medicare Respiratory Therapy Initiative isn’t only a professional benefit, but will increase patient access to respiratory therapy services.
• Work with your physician community to gather their support, and have them send emails to Congress. Physician voices have a great impact on legislators.
• Don’t forget your family and relatives are voters too. Don’t be hesitant to ask them to support this effort through their emails.
• Contact you state respiratory society (most state societies have website and contact numbers—go to: http://www.aarc.org/links/links_affiliates.asp) and volunteer to be part of the 435 Plan. What is the 435 Plan? There are 435 members of the US House of Representatives. The goal of the AARC is to have at least one respiratory therapist and one consumer/patient in each Congressional district. Coordinated by the State Society, RTs who are part of the 435 Plan can be activated to respond to key issues and legislation and work at the local and district level to advocate for our legislation.

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