I wrote a diary on December 31st, Medicare therapy in Long Term Care--Know the Facts in response to another diary How is this not a Campaign Issue? that was concerned with the diarist’s elderly mother in long term care being told that her physical therapy was being cut and she would only get four weeks of therapy instead of eight. The family was told this was because--
starting Jan. 1, 2020 the budget for Medicare reimbursement for physical therapy has been cut significantly
So my first diary focused on some of the inaccuracies in this and I provided a lot of detail. But—I realized after writing the diary, that there is a lot more information to be provided. Therapy in long term care is not just provided under Part A rules, it is also provided under Part B rules, and I did not provide information about the Physician’s Fee Schedule used in Part B and upcoming cuts in that and what that means.
You can and should read the first diary, which includes my background as a speech-language pathologist working in a variety of settings including long term care, hospital outpatient and some inpatient, and home health. I will add that when I first began doing some contract substitute work in long term care, I felt like I had landed on the moon and was confused by many things that the other therapists there all seemed to know, whereas I was clueless. I had been in Home Health for many years and you just saw the patient for as long a session as they needed each time—it could be 15 minutes (rare) or an hour or anything in between. I was paid the same regardless of session length, and for Medicare patients, the reimbursement to the agency I worked for did not vary by session length and was not actually per session, but instead varied by other factors of therapy utilization. Therapy codes for specific types of therapy are not used in Home Health, so it didn’t matter if I treated swallowing, speech, or cognitive skills. There was no “Medicare Part A vs Medicare Part B” discussion. There were some complications such as needing to know Medicaid patients could be going for outpatient therapy and still receive Home Health services eg. if they needed the physical therapy gym but needed speech at home that was okay. For Medicare, no way. We had to strictly monitor homebound status. One time the WIFE needed physical therapy and was with great difficulty loading the patient in a wheelchair and taking him with her because there was no one to stay at home with him and he lost his homebound status for speech.
Then I started doing contract work for Long Term Care. It paid much better than Home Health! They even offered to pay for my drive time to the facility. And they asked if I knew about therapy codes (no, not really), and there was talk of Part A patients vs Part B patients. Fortunately my professional organization, The American Speech-Language-Hearing Association provides a lot of online resources and I was able to learn what I needed to know about coding right away. I learned things that other therapists didn’t always seem to know— like that Medicare will deny a session if you code for regular comprehensive speech and for a cognitive treatment on the same day, because cognitive is included in the speech code. But OT can provide cognitive the same day that you provide the speech code if a “modifier” (these are typically letters or numbers) is added to the code when it is billed. Yes, it’s complicated and just roll your eyes and move on if this makes your head hurt. But it points up that therapists are professionals that have to have a lot of expertise and knowledge beyond just how to work with patients and all their complexities and how to “do therapy.”
The other thing that happened when I started working in Long Term Care was I saw things that were not ethical in terms of service delivery. The RUG payment system of reimbursement being used drove a lot of decisions about patient care that should not have happened. I discussed that some in the other diary.
So, the first thing to understand is Medical Necessity, which I discussed in the other diary. This is key to knowing your rights, because whether under Part A or Part B, you or your loved one have a right to therapy if the following criteria are met:
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.
Note that this applies ONLY to therapy services, not long term care placement or home health eligibility etc. It only refers to therapy in those settings. If the person becomes ineligible for long term care but still needs therapy they are entitled to get that therapy in another setting such as outpatient. Also note that this definition involves judgment by the THERAPIST and the supervising physician who certifies the plan of care as being medically necessary. It does not mean the family gets to decide what is “medically necessary”. Therapists are supposed to understand the practical ramifications of the rule including Medicare’s policy that if a therapeutic intervention is routine, repetitive and can be done without the skill and expertise of the therapist, it is NOT “medically necessary.” Therapists are supposed to plan to shift responsibility to the patient and/or their caregivers in a maintenance program, and can plan for a tapering schedule of follow-up visits to be sure the plan is appropriate and does not need to be modified. Lots of physical therapy exercises and OT activities fall into this “maintenance plan” category. Speech therapy less often, because usually what we are doing is more cognitively complex and rarely is it simple physical motor exercises, but for problems like unclear speech (dysarthria) or swallowing, therapy tends to be shorter and move to maintenance plans also. I pointed out in the other diary that I understand the reality that home programs often are not realistic and many individuals and caregivers have many challenges implementing them on their own.
As I noted in the other diary, 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. I also noted:
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.
So—whether the individual is receiving therapy services under Part A in a hospital or long term care facility, under Part B in a long term care facility or outpatient rehab setting, or in home health, the number of visits and length of treatment must be based on patient need and never on reimbursement by Medicare.
And now let’s get to Part A vs Part B. I myself was very confused about this for a long time. My other diary talked about changes to the reimbursement system for therapies under Part A, a new system called PDPM that started October 1st, 2019. So patients who have been in the hospital and are discharged to long term care for Medicare-covered services are under Part A, and the PDPM reimbursement applies. It should having NOTHING to do with how much therapy someone gets, and Medicare is watching you, facilities and rehab providers, to see if you cut therapy under this new system. Bottom line is they can take the money and provide no therapy at all but that isn’t going to fly for very long with anyone, the least of which being the patients needing therapy.
If someone is in long term care over the long haul and is not being funded under Part A, they are typically there with Medicaid paying for long term care and Medicare Part B paying for therapy. I did not discuss that payment system. Part B pays for therapy also in a hospital stay some times when the patient has been in the hospital a certain number of days and does what our hospital called going to a “swing bed” and the rules and payments start following Part B guidelines. Part B also pays for outpatient therapy in a rehab department you take the patient to.
For Part B therapies, each session is coded as to what services are provided and Medicare uses a Physician’s Fee Schedule to reimburse for each code. This Physician’s Fee Schedule is published each year and typically has changes every year. Changes are “budget neutral” so that if one code’s fee is cut, another code is increased. The 2020 Fee Schedule does have an 8% cut in physical therapy code services (while increasing other medical-related codes), but this doesn’t even go into effect until Jan 21, 2021.
But does this mean therapy services should be cut by 8% or any amount? NO! The amount the provider is reimbursed is to have NOTHING to do with the plan of care that is determined to be medically necessary. Providers get all kinds of different rates from different payers—private insurance plans typically pay a much higher rate, Medicaid pays a much lower rate. Here’s an example from speech therapy. Kentucky Medicaid currently reimburses the comprehensive code we use the most, 92507, at $48.30 per session Under Medicare, it is $80.37! Therapists don’t base the therapy plan on this reimbursement rate. We don’t provide 60% less therapy because it is a Medicaid patient! In fact, if you have a lot of Medicaid patients, the best thing you can do is provide more volume of therapy in as fast a time as possible (productivity) which means MORE therapy not less. I loved having my Medicaid kids that I would see long term over many years that were the core of my caseload. The hospital just had to figure the low rate in their plans. They loved it if the kids had private insurance in addition to Medicaid because they could bill that at very high rates (maybe $150, I don’t know, but that’s seems plausible) and Medicaid picked up any co-pays, 20% not covered, or anything beyond a limit in number of visits, so if private insurance only covered 30 visits per year, Medicaid covered the rest (at Medicaid rates).
The long term care facilities that are providing some Part B therapy under those rules, in addition to Part A therapy under the PDPM have to do the same thing, figure out the rate cut into their business plans. It makes NO sense that they would cut someone’s therapy to four weeks from eight weeks and not only does it not make sense, it is unethical.
I want to add something on monitoring the services you or your loved one gets from any therapist. They have many pressures on them to focus on things other than patient care—productivity requirements and reimbursement issues. There was rampant corruption and abuse under the old reimbursement rules for therapy under part A in Long Term Care (the RUG system) and millions of dollars of fraud/abuse claims paid by rehab contractors/companies. They are going to try to game the new system (including the new Home Health reimbursement system). They may try to maximize number of codes billed. For example, in speech someone might be picked up for a swallowing problem in the hospital. They may likely also have some cognitive problems if they are elderly or otherwise impaired. They may or may not actually need cognitive therapy for those problems—just because someone has impaired memory doesn’t mean therapy is “necessary”. If they need help remembering their swallowing guidelines and strategies that is supposed to be part of the swallowing therapy, not a separately coded service. But a therapist may add on that service and code to help their productivity or if they are seeing them under Part B to increase reimbursement. Someone on tube feedings may be seen by speech past the time that they need to be because their supervisor told them to keep seeing them “until discharge” to another care level or setting. This stuff happens ALL the time.
I know it is difficult and often impossible for patients and caregivers to monitor all this, but being forewarned is being prepared. Some patients HATE having to do cognitive therapy because someone is coming in telling them their brain isn’t working right, which is very upsetting. Sometimes they may be in denial, but sometimes they may really not need that therapy. Patients ALWAYS have the right to refuse therapies. And this must always be respected. If you think you or a loved one is receiving unnecessary services, you have a right to refuse those services.
One last thing—Medicare Advantage is a whole different critter. These are private insurance plans and the rules may be very different. There may be limitations on the number of therapy visits. There is often a requirement to get the services approved as “medically necessary” by a reviewer (prior authorization). Medicare Advantage plans may or may not follow the new PDPM reimbursement system, each one can do whatever they want. Private insurance operates very differently than traditional Medicare.
Personally, I opted for traditional Medicare with a supplement. Most people I worked with in the hospital recommend the same thing. Often you don’t know what you get with Advantage until you need it. I know some employer plans use these Advantage plans and you may have no choice in your retirement, but if you have a choice, be careful when looking at Advantage plans as they may often sound good but end up not meeting your needs as well as traditional Medicare.
I hope this information can be useful to some, and apologize for the length and complicated nature. And I think one of the takeaways is that greed and corruption are going to be parts of ANY system, whether Medicare or private insurance funding. I am watching the series For All Mankind and have just reached the part where that is one of the themes—all systems are corrupt, all bureaucracies have corruption. . . .we have to have regulation and oversight to minimize this. And be informed.