It appears that Medicare/CMS is planning to start a game with our skilled therapy services. What does this mean? Basically it means that you as a person or resident will not be important, but rather you as a diagnosis will drive the care Medicare will pay for.
If you're familiar with DRGs, you will recall the uproar that happened when a patient’s diagnosis was the only driver of hospitalization, care, and payment. This is similar to that payment model.
Implications of a New CMS Payment Model
So, what does it mean to us? Honestly, we can only speculate—however, in a recent article in McKnight’s, Dan Ciolek, associate vice president for therapy advocacy at the American Health Care Association, was quoted as saying that “massive” changes appear on the horizon as the Centers for Medicare & Medicaid Services adopts more alternative payment models, and groups such as the Office of Inspector General and the press place more scrutiny on therapy billing. Ciolek went on to say that the perception is that therapies are being provided at ultra-high levels when it isn’t necessary.
Well, the OIG has been investigating therapy services for several years and yes, there have been some issues uncovered and several organizations have been penalized for their billing practices. This is a concern for all of us as our Medicare dollars may have been misused. However, at what cost?
Is Medicare going to become the watchdog for all therapies provided in our communities and outpatient clinics? Will Medicare dictate what care we are allowed to provide based solely on diagnoses?
That appears to be the plan.
Long-term care providers have been labeled as money mongers by the press, plaintiff attorneys, and CMS over the years. There have been accusations of profits over care for years if an organization makes attempts to remain solvent. So, what are we to do as providers if the care we know needs to be provided is curtailed by new guidelines prohibiting it? It is definitely a debacle!
What Should Providers Do Now?
Since the final guidance has not been published to date, and it may take several years before we can evaluate what it means to us, there are a few things you as the provider can do.
- Remember therapy caps? Remember when we really feel a resident needs more therapy, but they've exhausted their benefits? If the proposed process is initiated as planned, it will be similar to what we are doing now. Bottom line, use therapies judiciously!
- Remember Restorative Nursing? Sadly, many communities didn’t have a formalized Restorative program until the MDS 3.0 identified it as an opportunity to improve care AND get reimbursed for the services. Maybe it's time for you to tighten up your program, engage caregivers who understand the restorative model, and live it every day! This will assist your residents in the transition from skilled services to independence with ADLs, ambulation, etc.—and possibly avoid decline post discharge from therapies.
- When was the last time you evaluated your therapy billing practices? It may be a good time for you to contract a consultant for an outside, fresh-eye therapy audit. You may be surprised at what you find, and this is a great opportunity for you to identify where you could be doing things better while avoiding OIG scrutiny!
- Take a look at your resident population and identify those residents who may be at risk for negative outcomes related to a lack of therapy services. Of most importance are those residents with repeat falls, falls with injuries, and overall decline. Are you tracking and trending these events and identifying those at risk? Not sure? Check it out! Remember, regulatory surveyors won’t care that your therapy services have been limited by CMS—they will only care if a resident has a negative outcome!
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Start using a cloud-based event dashboard that does all the leg work for your team. With QA Reader, there's no more sitting at a desk for hours at a time doing data entry. No more data entry errors and omissions. The average community will spend about 500 nursing hours per year just tracking and trending incidents. This doesn’t include care plan development, validation of care plans, fall team meetings, etc. It is strictly the hours spent documenting the events. Why would we waste 500 hours a year when these nursing hours may be better used out on the units preventing the incidents instead of tracking them?
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