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  • SNF Billing Practices Targeted in HHS Inspector General Report

    The Office of Inspector General (OIG) of the US Department of Health and Human Services (HHS) has turned its attention to skilled nursing facilities (SNFs), where it alleges that Medicare payments have "greatly exceeded SNF costs for therapy for a decade." Those increases in SNF billing resulted in $1.1 billion in Medicare payments during 2012 and 2013 alone, with about 80% of that increase attributable to the use of "ultrahigh" therapy, the OIG claims.

    According to a report released September 30, the payment system for therapy in SNFs provides a "strong financial incentive" for facilities to bill for higher levels of therapies, even when those therapies may not be needed by certain patients. In particular, they write, the differences between the cost of therapy and Medicare payments for that therapy skew heavily toward providing ultrahigh levels of therapy—720 minutes or more a week per patient--for which facilities receive an average of $66 a day over costs, compared with $11 over costs for low therapy, according to CMS estimates.

    Some of the OIG findings were reported in advance by the New York Times, which quoted Daniel R. Levinsion, HHS inspector general, as saying that the data collected for the report show that some nursing homes were attempting to "optimize revenues" by taking advantage of the payment system.

    The OIG report asserts that between 2011 and 2013, the percentage of SNF resource utilization groups (RUGs) that received ultrahigh therapy increased from 21% to 34%, and RUGs receiving very high therapy rose from 12% to 22%. Meanwhile the percentage of RUGS receiving low therapy dropped from 14% to 12%.

    The increasing use of higher therapy levels, coupled with annual increases to base payment rates based on the market-basket index, resulted in steady increases in SNF cost/payment margins from 2002—where the margin was 25%--to 2010, when the margin peaked at 42%. Since that time, the estimated margin has dropped and is estimated to have been 29% in 2012, the most recent year evaluated.

    The OIG findings are consistent with results of an analysis conducted earlier this year by the Wall Street Journal, which found that the use of ultrahigh therapy has increased from 7% of patient days in 2002 to 54% of patient days in 2013.

    The news stories and OIG report point to an even larger issue: the relationship between volume and value-based health care.

    In a letter to the editor published in WSJ, APTA President Sharon L. Dunn, PT, PhD, OCS, writes that the challenges of delivering appropriate patient care in systems that incentivize volume "are, unfortunately, well known to those in the rehabilitation profession."

    "Patient care decisions should be made by clinicians in accordance with their clinical judgment and ultimate professional responsibility to their patients," Dunn writes. "Value—the outcome of care relative to the cost or resources needed to provide that care—should be the primary indicator of performance."

    The OIG report makes several recommendations to the Centers for Medicare and Medicaid Services (CMS), ranging from changing payment methodology and rates to strengthening oversight. CMS accepted the recommendations and agreed that the payment system needs to be reassessed for potential reductions that would improve payment accuracy. CMS is conducting a study to explore alternative therapy payment models.

    The issue of productivity pressures is at the heart of a collaborative effort by APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA), which collaborated to produce a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)." For more on productivity: check out the APTA Center for Integrity in Practice as well as "Measuring by Value, Not Volume," a recent feature article in PT in Motion magazine that takes a closer look at how some PTs are responding to the challenge.  


    • Being an entry level PTA working presently PRN for several facilities, it is as some of the articles report frustrating at the least to conform to productivity guidelines that are set by facilities. There needs to be an overhaul that refactors and includes other aspects when considering productivity. As much as a facility may promote quality patient care, productivity has a negative impact regardless of how much a clinician tries to put forth their best effort in patient care. If each "department" sets their own standards, those standards are bound to conflict. A bridge must be built for the benefit of the pt. This can only be done in a collaborative effort among the disciplines and the facility governments, most likely in changing and passing of law. Working PRN and being sent to various facilities, there is no factoring in place for working a facility that is unknown, with a caseload of unfamiliar patients, staff or timing for patient care communication. Nor is there consideration of actual time spent commuting from therapy room to resident rooms especially in a large facility or the frustration and time spent in sharing of computers. All of these things go against productivity and create stresses that inadvertently affect actual patient care which should be the priority. Unless action is taken to bridge the governments on this issue in a legal manner, the problems will remain.

      Posted by Tammy Marks, PTA on 10/13/2015 11:07 AM

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