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  • APTA, AOTA, ASHA Alert Patients, Physicians to Misuse of SNF and HHA Payment Systems

    In addition to providing CMS with reports of inappropriate practices by HHAs and SNFs, the organizations are now taking concerns about PDPM and PDGM misapplication directly to physician and consumer groups.

    From the moment new payment rules governing skilled nursing facilities and home health agencies were rolled out, APTA, and the professional associations representing occupational therapists and OTAs and speech-language pathologists have been battling some employers' willful misapplication of the rules. Now the organizations are taking that mythbusting effort directly to physicians and consumers.

    This week, APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association released two joint letters and a consumer "fact sheet" that exposes how some SNFs and HHAs inappropriately use the new systems — known as PDPM for SNFs and PDGM for HHAs — to reduce patient care, cut therapist hours, and sometimes eliminate entire jobs. "PDPM" stands for "Patient-Driven Payment Model"; "PDGM" stands for "Patient-Driven Groupings Model."

    In a joint statement announcing release of the letters, the organizations write that "Preserving access to therapy services is critical, particularly as postacute care organizations prepare for the expected surge in patients recovering from COVID-19."

    The consumer-focused letter, sent to numerous patient and consumer advocacy groups, cites examples of HHAs and SNFs reducing therapist hours, requiring therapists to perform services outside their scopes of practice, ignoring or modifying physician orders and plans of care, misinforming therapists about which treatments are allowed under the payment systems, and failing to provide maintenance therapy, among other practices.

    "Our associations stand committed to ensuring all patients retain access to medically necessary therapy services and ensuring all stakeholders understand the impact these business-driven decisions can have on patient outcomes," the organizations write, adding that "Medicare beneficiaries and their caregivers deserve to know the facts about Medicare coverage in SNFs and HHAs to address the inappropriate practices."

    To that end, APTA, AOTA, and ASHA created an accompanying fact sheet that explains, in easy-to-understand language, the most common mistruths patients and caregivers are being told. Among the messages that the organizations point out as false:

    • Medicare limits the amount of therapy that can be received.
    • Medicare dictates what forms of therapy a therapist can deliver.
    • A portion of SNF therapy treatment must be provided in a group setting.
    • Medicare only pays for therapy services that improve a patient's condition.
    • Medicare does not pay for certain diagnoses.
    • Medicare does not cover home health services unless the patient is discharged from the hospital or institutional setting.
    • Medicare won't reimburse for any home health care services that exceed a total of 30 days of service.

    "Many SNFs and HHAs are using these payment systems in ways that support patient access to necessary care, but some are purposefully providing misinformation," said Kara Gainer, APTA's director of regulatory affairs. "We believe the facilities and agencies misusing the systems are outliers, but it's still important that all patients are aware of their rights."

    The fact sheet includes steps patients can take if they believe a SNF or HHA has inappropriately restricted access to therapy services, including links to consumer advocacy groups that can help pursue the issue.

    The letter directed at physician groups is aimed primarily at home health and warns that "some HHAs are making care choices for patients based on the perceived financial incentives … rather than the actual needs of patients of patients or the plan of care."

    "We recognize that CMS only implemented PDGM on January 1, 2020," the letter continues. "However, we anticipate that as patients raise concerns with their physicians and outcomes data becomes available, the failure of some HHAs to provide the care that has been ordered as medically necessary for the patient will require your attention."

    APTA, AOTA, and ASHA have been supplying CMS with a steady stream of examples of inappropriate practices by SNFs and HHAs since the new payment plans were introduced. For its part, CMS says it has been tracking SNF and HHA utilization and outcomes data, but has yet to release any findings, describing any release as "premature" at this stage.

    APTA's webpage devoted to PDPM and PDGM includes resources to better understand the rules, as well as links to materials that can help PTs and PTAs advocate for proper application of the systems.


    • Yes this is happening at TXHH. They have significantly reduced therapy and is becoming nurse driven. I’m not only a PTA but a certified lymphedema therapist. I was told Medicare does not pay for physical therapy to treat these patients and nursing can. This is substandard care unless the nurse is certified. A lot of substandard care is going on in home health.

      Posted by Larissa Mears on 5/15/2020 9:51 PM

    • If there are specific companies or providers providing inappropriate clinical care, then address them individually. Please quit painting the entire industry in this manner. As a 25+ year member of the APTA and leader in the SNF industry I find it offensive. The vast majority of us are working tirelessly to apply clinically appropriate treatments in a very challenging environment. I believe many of the reporters of issues do not understand the new payment system and are not taking responsibility to understand the regulations or how to use their clinical skills in a manner that balances clinical appropriateness with the Triple Aim. We have been tasked with REDUCING THE COST OF HEALTH CARE while balancing patient satisfaction and outcomes. We need to accept this change in thinking and be innovative rather than labeling every attempt as negative and inappropriate. The letter to consumers is not helpful and even has inaccurate information. For example, cognitive therapy is limited by national and local coverage determinations and there are many situations where it would NOT be covered by Medicare even though it is "allowed" via a state practice act. This is very confusing for a consumer. It's already difficult for us to wade through the vast requirements and this is not helpful. More and more often I'm disappointed in how my APTA dues dollars are being used.

      Posted by Tracy Fritts on 5/16/2020 2:18 AM

    • The company I worked for all of sudden started implementing PDPM stating that concurrent and groups were mandatory an many of us including me were laid off. People went from 45-75 minutes of individual therapy to 30-45 minutes. Then of course concurrents. Then groups of 3-4 people. Groups were not appropriate but if they were not done and productivity where it should me the therapist and the DOR would get written up and threatened to be fired. I have been laid off since October. I have been a LPTA for 35 years. I can not find a job because pay scale has plummeted and it cheaper to pay a new grad. My years and knowledge are not appreciated. Who can afford to lose 10 dollars an hour if I finally am able to work. This system and the Rugs system were crazy. No matter what, companies interpret the way they want and take to the extreme so the money increases the company. There is no pats on the back or appreciation for therapusts anymore. Used to have continuing education paid for and maybe a small company party. Since RUGS nothing. What happened to our purpose of being able to do what is best and appropriate for our patients?

      Posted by Denise Shepherd on 5/16/2020 9:08 AM

    • Thank you to our professional organizations for providing these facts and standing up for the level of care all of our patients deserve.

      Posted by Renee K on 5/16/2020 11:13 AM

    • "We believe the facilities and agencies misusing the systems are outliers, but it's still important that all patients are aware of their rights." This is probably the sentence that should begin this entire article. And it should be in BOLD letters. And, this should have been shared in the letter that was sent to the Consumer Advocacy groups.There is no reason to add any other misperception. The fact is the VAST MAJORITY are really working to PROVIDE GREAT CARE. The second sentence might share that any potential scenario described was essentially obliterated with COVID-19 related issues. And the third sentence, should consider addressing the problems of providing maintenance OR restorative care (at all) when a PT is not allowed to go into the SNF and is also not allowed to use Telehealth to provide an initial evaluation or ongoing treatment. Finally, as I read the two letters, I see an interesting twist. The "Consumer advocacy" letter is the only one that talks of PDPM. In the "Physician" letter, there is no mention of PDPM at all. Further, the Consumer advocacy letter sounds so much more negative. This is odd when we all want a positive image of Physical Therapy--and I think these Consumer Advocacy groups is one place we want to share this positive image. With nothing at all written in the Physician letter about PDPM, why are we even mentioning SNFs in the above article? Please understand, I am all for stopping inappropriate activities. In this case however, I think the inappropriate activity was a very poorly written article and, potentially, a poorly written letter to Consumer advocacy groups. There is no reason to cause our profession to be perceived incorrectly, based on outliers. At the very least, we should be VERY SURE to let these groups know we are ONLY talking about Outliers in these scenario's. We could have, at the very least, added this sentence in the very first paragraph of 'that' letter: "We believe the facilities and agencies misusing the systems are outliers". We did not. For this reason, maybe we should have a follow up letter and make sure these groups understand these are the outliers...AND ask for their help getting Telehealth reimbursed in these settings so we CAN provide the care needed.

      Posted by Robert Latz -> ?JPb> on 5/17/2020 9:02 PM

    • Once again, here we have APTA showcasing their private practice bias and trying to throw shade on the SNF and HHA communities. I feel for all of the members that pay their dues to this sham of an organization to have them completely misrepresent the majority of these settings. The writer of this article and the president of the APTA should be ashamed to associate themselves with this kind of negative literature. Try and advocate for our elderly communities, not have them fear that what we are trying to do is just for reimbursement purposes. You people are savages. All you have to do is look how much the APTA pushed for telehealth on the private practice playing field and how very little they advocated for it to be implemented anywhere else and you get a clear picture of where their values all lie. Please try and advocate positively for your profession as a whole. Again, you should all be ashamed of yourselves thinking that you’ve done anyone in these practice settings justice. This is in part why I’ve neglected to continue to pay for these membership dues. You all are not worth a dime of the money spent on this organization

      Posted by Bob M on 5/18/2020 10:22 PM

    • Great job APTA. What brave thought leaders you are for kicking nursing home providers while they are down and already being unfairly characterized during this pandemic. I cringe to think that even a penny of my dues funded this irresponsible, cowardly and immaterial OPINION paper. There must be better ways that you can find to support your members who work in nursing homes than this.....

      Posted by Glenn H., Las Vegas on 5/20/2020 6:32 PM

    • Actually, the problem is more MEDICARE and the insurance companies, as opposed to the home health agency. Their bureaucratic payment policies and rules hinder delivery of patient care

      Posted by Dave R on 5/22/2020 8:23 PM

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