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  • SNF Use of Ultrahigh Therapy in the News Again

    The issue of some skilled nursing facilities (SNFs) gaming the Medicare system by excessive use of "ultrahigh" care continues to make headlines—this time in California, where an Orange County Register article claims that SNFs in the state use ultrahigh therapy at rates exceeding the already-high national average.

    In "Big money in nursing home therapy, but is all the treatment necessary?" reporters Deborah Schoch and Ron Campbell take a close look at billing practices among SNFs in the Orange County area of California, near Los Angeles. Orange County is the sixth largest county in the country.

    According to the Register, 72% of Medicare rehabilitation patients in the county's SNFs received treatment at the ultrahigh rate—an average well above the state's overall 66% rate, which itself is higher than the 58% rate across the US. The article goes on to describe therapists' claims of being pressured to increase hours inappropriately, and outlines some of the steps being taken to address concerns about misuse of the therapy rates.

    Along the way, the report quotes Roshunda Drummond-Dye, APTA's director of regulatory affairs, who confirms that APTA regularly receives calls from physical therapists (PTs) "who are being pressured to do practices that are unnecessary or illegal." The Register story also cites a Physical Therapy-published study that, while acknowledging certain benefits of receiving an extra hour of therapy a week for patients recovering from hip fractures, also found that therapy above the ultrahigh threshold of 720 minutes a week "was less effective than lower intensity therapy in returning patients home," according to the Register.

    The article adds to the growing media focus on SNF billing practices. Late last summer, the Wall Street Journal published a report outlining the findings of its study of the use of ultrahigh therapy hours, and the issue resurfaced in October when the Office of the Inspector General of the US Department of Health and Human Services (HHS) issued a report highly critical of SNFs. That report was in turn the subject of a New York Times article on the issue, an article that prompted a letter to the editor from APTA President Sharon L. Dunn, PT, PhD, OCS.

    More recently, the US Department of Justice (DOJ) announced that the nation's largest nursing home therapy provider had agreed to pay $125 million to settle a DOJ lawsuit that alleged the company engaged in a "systematic and broad-ranging scheme" to increase Medicare reimbursements by submitting false claims for rehabilitation therapy. The RehabCare settlement was the result of a whistleblower lawsuit brought to the DOJ by APTA member Janet Mahoney, PT, DPT, and Shawn Fahey, an occupational therapist. Both worked for RehabCare.

    The Register article includes some therapists' accounts of the pressure they faced to increase therapy hours among patients—pressures that forced providers such as Melissa Lathon to quit.

    Lathon, a former social series director at 6 nursing homes, is quoted in the Register article as saying that management "would pretty much twist the therapists' arms and say, we need another week at the ultrahigh level."

    According to the Register, Lathon left her position "after a supervisor ordered her to fill out a document saying a patient needed assistance in walking when he had clearly shown he was walking independently."

    Helping physical therapists and physical therapist assistants understand their obligation to eliminate fraud, abuse, and waste is the central idea behind APTA's online Center for Integrity in Practice—a suite of resources to support care based on patient need and clinical judgment.


    • What a tragedy it is to go into a career where you want to help others but are instead forced to use and even harrass the elderly so that our employers can steal from the US Government...The game is to make the elderly, even people that are near death, exercise so we can make money!!! Are you in Heart Failure, COPD, Advanced age, Alzheimers, Advanced Disease, etc? According to Rehab Providers you need 12 hours of exercise per week....yep, that is the answer....the only answer, because that will make them the most money of course...Think about that for a moment, a young person in the prime of their life, in top shape goes to the gym for an hour a day, 3-4 days a week and tolerates 4 hours total per week and that is a lot...We expect a 94 year old with dementia, COPD and CHF to tolerate 12 hours of exercise per week because it is good for them...no actually we do it because it is good for us (the company)...

      Posted by Walter White on 3/1/2016 7:45 PM

    • Glad to see some accountability for the misuse of pressuring therapy staff for ridiculous numbers/practice.

      Posted by Crystal Watson, PTA on 3/1/2016 9:42 PM

    • I retired because I was being asked to do things that were in a "gray" area i.e. not exactly legal. Even when I questioned the director, they admitted it was a gray area. I said it's my license on the line - so I quit. Also, legal documentation and productivity expectations are unrealistic - I feel sorry for those just entering the field - like stepping onto a treadmill going full speed.

      Posted by Laurel on 3/2/2016 2:35 PM

    • I left S in at work several years ago when I could not stomach the fraud any longer. I took a $30,000 plus pay cut -but at least I could sleep at night. it is definitely one of the most blatant and disgusting practices in healthcare .

      Posted by Ellen on 3/2/2016 10:26 PM

    • This is the reason why I am exploring a different career after 23 years as a therapist. Not only are we being forced to push out these RUG levels, we are also being forced to do concurrent therapy with the managed care patient's whether they are appropriate or not

      Posted by Charmin McCoy on 3/2/2016 11:31 PM

    • I cannot understand why rehab companies are allowed to do this. Why is RehabCare still in business after all they have done and all the litigations against them and or facilities they provide rehab for? I spent a horrid 9 months as one of their employees. In 20 years of working as a OTA, I have never been treated so badly or disrespectfully. I am appalled at what has happened to the healthcare industry.

      Posted by Laura Thompson on 3/2/2016 11:57 PM

    • There are ethical, reasonable subacute SNFs getting great clinical outcomes from in house rehab teams and they are not pushing RUGs inappropriately- I work for one in Oregon! Very short lengths of stay, focus on safe discharges and we still to home visits! PTs and PTAs need to demand ethical and safe work environments and these practices like RehabCare would stop. Don't take a job with a productivity bonus if you don't believe in being treated like a commodity!

      Posted by Carol Ramsey on 3/4/2016 1:40 PM

    • Not only are SNF therapists pressured to unnecessarily advance RUG levels but they are required to produce ridiculous productivity numbers. Additionally, in my experience, there is little to no clinical accountability. I believe that Medicare should scrutinize PT evaluations and PT/PTA treatments to a greater degree as well as apply performance based measures as well as make performance transparent to the public. I believe we can all agree that SNFs are NOT created equal and these days it may not be easy to locate one you would feel comfortable sending your grandmother to.

      Posted by Konrad on 3/4/2016 5:19 PM

    • I went on record in PT magazine a few years ago reporting this trend amongst SNFs (see archives). This trend has been occurring for years. Cant believe its taking this long for light to be shown on the issue, and hopefully something to be done. I imagine the enormously high amounts of money SNFs have sought as they increase the rehab hours for each patient (I believe the term used to be "RUG 'em up"). If you consider ALL the companies out there who own SNFs, its got to be in the tens of millions of dollars.

      Posted by Dave on 3/8/2016 9:45 PM

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