I read a diary on the Community Spotlight list yesterday titled How Is This Not A Campaign Issue? that described what is an all-too common occurrence under the new Medicare payment rules. The diarist wrote that their elderly mother was being denied care:
I was just told by the physical therapist that, starting Jan. 1, 2020 the budget for Medicare reimbursement for physical therapy has been cut significantly. In practical terms, this means that instead of eight weeks of therapy she will only get four weeks.
What the diarist and possibly the therapist do not know, is that this information is grossly incorrect. So let’s get to the facts.
First, my background. I am a (mostly) retired speech-language pathologist. I was able to retire November 1st when I found out my employer would continue health insurance for the entire month if I worked even only one day! I then was eligible for Medicare on Dec 1st and have been happily at home since, still seeing one young person with autism privately now, as I had worked with him for the past 11 years and the family wanted me to continue. So I learned how to become a Medicaid provider (lots of research to do that accurately!) just to keep seeing him.
I worked 20 years in Home Health, doing some substitute work for a few years in Skilled Nursing Facilities, then worked in a hospital outpatient therapy department. I first began to see some abuse of payment systems in Home Health on a small scale, then was confused and concerned about what I saw and was told to do when I subbed in Long Term Care for two different companies, and I began reading about whistle-blower cases brought against rehab companies including one of the companies I had worked for, and then began seeing some abuses in the hospital where I worked----although I was on the periphery of that as they were occurring in the hospital bed section and I did almost exclusively outpatient work. During this time I realized I needed to become informed on all these issues and began reading my professional publications. The American-Speech-Language-Hearing Association is very concerned about these issues. Our state licensing has begun requiring 2 hours of continuing education in ethics every two year renewal period mostly due to reports of unethical behavior, most of it in long term care.
FACT: Therapy under Medicare—whether in Long Term Care, outpatient therapy, or Home Health, is ALWAYS to be based on patient need, not reimbursement formulas. Furthermore, the AOTA, APTA, and ASHA professional therapy organizations inform their members of the ethical rules surrounding service delivery in a joint statement:
Ethical Service Delivery
Decisions regarding patient/client care should be made by clinicians in accordance with their clinical judgment. Clinicians are ethically obligated to deliver services that they believe are medically necessary and in the patient’s/client’s best interest, based upon their independent clinical reasoning and judgment as well as objective data.
FACT: The Medicare rules for reimbursement in Long Term Care facilities changed October 1st, 2019 (not January 1st 2020 as the diarist was told). Note it says “changed”, NOT “reduced”. This is critical. The new system is called Patient Driven Payment Model, hereafter known as PDPM.
Here is some history on this change.
Under the previous system (RUG IV), payment was driven by the minutes of therapy provided. Under that system, there was rampant manipulation of treatment time to maximize reimbursement. I had no notion of this until I did some sub work. The first facility had no therapist and I was filling in temporarily on a very limited basis and at first there was no “rehab manager” to tell me anything, but once that person was in place, I was told there would be a list of the patients each day with a “recommended number of minutes”. I was supposed to follow that but was told I could deviate from it according to patient need. These minutes guidelines were designed to maximize reimbursement rates. Once I was assigned a patient and they were not in their room. I asked staff where they were and they said the patient was dying and was in a different room. Needless to say I did not see the patient, but I later read in whistle-blower cases that therapists were made to see patients such as this, along with other abuses. The company I worked for had to pay out millions of dollars to Medicare over their abuse of the RUG payment system. The therapists that blew the whistle got a substantial payment also.
Now, the reimbursement system has been changed to try to reduce such abuses. But Skilled Nursing Facilities that required therapy beyond a patient’s need to maximize reimbursement may struggle to maintain staffing because their capacity was disproportionately inflated. Additionally,such Skilled Nursing Facilities may establish administrative mandates to provide as little therapy as possible to maximize profit under PDPM.
I talked with a COTA (occupational therapy assistant) just after the October 1st change and she said ¼ of the COTA’s had been laid off by the rehab company at her facility. The facility is known locally as the “high quality” one the more wealthy people use and the owners were reportedly “upset” at what the rehab company contracting with them was doing, but the COTA I spoke with did not know what would come next.
FACT: All of the professional therapy organizations tell their members something along these lines:
SLPs should always reinforce the ethical and legal obligation to provide therapy based upon the clinical need of the patient as opposed to administrative mandates for the purpose of maximizing reimbursement.
REALITY MEETS FACTS:
The reality is that most therapists “do what they’re told” and don’t spend time reading their professional magazines or attending ethics seminars. They are told “reimbursement has been cut” when it really hasn’t been. And because all of us are very conditioned by private insurance managed care practices that limit therapy, everyone just assumes that Medicare operates the same way. It doesn’t. Not in long term care, not in home health, and not in outpatient therapy. Therapy should ALWAYS be based on patient need, not reimbursement formulas. It is true that if therapy is provided that is not deemed “medically necessary”, Medicare can come back in and demand reimbursement for the payments for services that were made-- and the patient could be liable. It seems “easier” to just not provide the service and “not take a chance” so therapists or managers often say to tell patients “Medicare won’t pay for it”. But that is not the case. Any denial can be appealed. Therapists and patients do need to understand the legal criteria for “medical necessity” and provide the appropriate documentation. But bottom line is that any “medically necessary services” needed to improve or even maintain function must be reimbursed by Medicare.
FACT: The new PDPM system puts patients into diagnostic categories based on their diagnosis and co-morbidities. The facility receives more money for patients with problems in more areas such as dementia, swallowing, etc. and less for patients with fewer problems. The reimbursement rate for patients in the PT/OT comorbidity categories tapers off over time—because traditionally PT and OT start out intensely and taper off. The rate for speech-language-swallowing therapy co-morbidities does not taper off. But it is not supposed to matter to patient care—if one patient needs to taper off but another one does not, the therapist is still supposed to provide the care. The facility is getting a “pot of money” equivalent to what Medicare thinks they should have been getting based on past history of patient care and some patients will use more of that money than needed and some will use less. The bad thing is that the facility can just take the money and NOT PROVIDE ANY THERAPY at all—since they no longer report therapy minutes.
Medicare is aware of this and announced plans to monitor therapy under this new system.
FACT: PDPM, which is essentially a payer policy change, should not change clinical practice. CMS (Center for Medicaid Services) will monitor provider practice during the implementation of PDPM, with audits largely focused on the clinical presentation of patients, including:
- Changes in payment that result from changes in the coding or classification of SNF patients versus actual changes in case mix.
- Changes in the volume and intensity of therapy services provided to SNF residents under PDPM, as compared with the current system.
- Compliance with the group and concurrent therapy limit (a maximum of 25 percent of a patient’s total therapy per discipline).
- Increases in the use of mechanically altered diet that may suggest that patients are being prescribed the diet based on facility financial considerations rather than for a clinical need.
- Overuse of cognitive impairment as a payment classifier in the speech-language component.
- Patient populations that experience inappropriate early discharge or provision of fewer services, perhaps due to the variable daily adjustment in reimbursement (although the per-diem rate for speech-language services remains consistent, payment for physical and occupational therapy services taper off over time).
- Trends in patients with stroke, trauma and chronic conditions to identify any adverse trends from application of the variable per-diem adjustment.
- Misuse of the interrupted-stay policy, particularly facilities where readmissions occur just outside the three-day window used as part of the interrupted stay. (After three days an admission is considered new—with new assessment schedules and per-diem rates—rather than as a continuation of a single stay.)
FACT: Whether it is in a SNF, Home Health, or outpatient therapy setting--Medicare does not impose limits or deadlines on number of sessions, length of time, or amount of coverage. A patient’s discharge from services should be based solely on the clinician’s judgment of the patient’s need for services that meet these criteria. The criteria for medical necessity that need to be met are:
· Services must be designed to treat an illness or injury (medically necessary).
· Services must require expertise as a speech-language pathologist, physical therapist, or occupational therapist
—that is, they can be safely provided only by someone with the education, training, and experience of these professionals.
· The services must be designed to improve or maintain function for the patient.
FACT: Sometimes patients or their caregivers do want to continue therapy that is not really medically necessary. It is inappropriate to use the financial thresholds in outpatient therapy or reimbursement formulas in long term care or home health as the reason for discharge. Therapists must explain to the patient that they no longer meet Medicare coverage requirements—either the patient has met their goals or continued improvement or maintenance of function is not possible. Therapists are obliged to move patients doing routine exercises that the patient has been taught to perform to a home-education program. The reality is that many patients and caregivers are not very good at continuing these programs --but therapists cannot continue providing care if the activity is simple and routine, and the patient or their caregiver can do it without professional guidance; so the therapist must move patients to such a home program or Medicare payments can legally be recovered in an audit. BUT—a home program must never be used to substitute for skilled therapy care that is medically necessary. The therapists are violating their code of ethics, and this behavior by a rehab facility can and should be reported to Medicare using the Medicare Fraud and Abuse Hotline. CMS is actively seeking feedback due to this new payment system and they are expecting abuses.
Summary—If your loved one is being denied therapy, it is not because Medicare is denying the services, it is due to the corporate greed of the rehabilitation providers and long term care facilities. And the Home Health reimbursement formulas were also recently changed, so expect abuses in that sector also.
Update: Thank you for putting this on the Recommended List! Hope this helps someone get the care they need!
Update: I wrote another diary to clarify some things that came up in the comments here and to cover Medicare Part B therapy services and issues related to this. You can find it here: Medicare therapy in Long Term Care—Know the Facts Part 2