Bottom line on therapy
Therapy billing is highly complex and closely monitored.
The announcements came rolling in one after another last fall, federal officials detailing significant cash settlements with healthcare companies investigated for making false claims, encouraging kickbacks and perpetrating outright Medicare fraud.
When the Justice Department reached a $38 million agreement with Extendicare Health Services and a subsidiary — some services deemed “effectively worthless” by the government, others medically unreasonable and unnecessary — therapy providers and long-term care administrators couldn't help but take note. The resolution was the largest failure-of-care settlement with a chain of skilled nursing facilities in Department of Justice history.
In the current environment of auditing and risk mitigation, compliance experts say a hands-off approach to billing is asinine. Nursing home managers are as responsible as their rehab providers for ensuring healthcare is delivered according to both patient need and government standards.
“They're holding the therapy companies responsible, but they're also looking at facility responses,” says Alissa Miltenberg-Vertes, vice president of corporate compliance for HealthPRO Rehabilitation. “For the first time ever, administrators can't just say, ‘The therapy company was doing it, and I didn't know.'”
Facilities need to work with reputable therapists and corporations with a well-oiled system of checks and balances intended to correct human errors and spot patterns likely to draw the attention of auditors.
Communication, education and routine evaluations are critical factors to ensuring that bills are submitted as intended — and that patients continue to receive treatments they actually need.
That, says Ellen Strunk, PT, MS, GCS, CEEAA, a federal affairs liaison to the Academy of Geriatric Physical Therapy, is the best defense against an investigation, financial judgments or complex restructuring and corporate integrity programs.
“There's been a potpourri of problems with skilled nursing facility documentation, MDS submittals and therapy documentation,” says Strunk, who performs third-party reviews through her company, Rehab Resources and Consulting. “Regulations are burdensome, difficult to keep up with. You might have missed something. That's where people struggle.”
Malfeasance or mistakes?
In 2012, the Office of Inspector General found that nearly a quarter of claims from skilled nursing facilities were billed in error. Still, in most of the recent OIG and DOJ cases, nursing homes and therapy providers didn't admit to wrongdoing on entering into a settlement.
A $30 million settlement with contract therapy providers RehabCare Group Inc., RehabCare Group East Inc. and Rehab Systems of Missouri and management company Health Systems Inc., however, did reveal a kickback scheme related to the referral of nursing home business.
Industry insiders say most therapy providers aren't out to bilk the system.
In fact, Liz Almeida-Sanborn, MS, PT, says the company she founded 10 years ago didn't make any process-related changes in response to the spate of settlements. Connecticut-based Preferred Therapy Solutions has always invested heavily in compliance, she said. They're just talking about their procedures with more clients now.
Almeida-Sanborn concedes that layers of paperwork and increased scrutiny have combined to complicate work for individual therapists — employees who are already working with nursing home residents who present with complex medical needs and co-morbidities.
Uncertainty about how treatment translates to coding can lead to mistakes. Those who are accidentally upcoding — say, billing for individual therapy when the patient is part of a group, or billing for blocks of time when the therapist leaves the room — don't necessarily know what they're doing incorrectly until someone else compares their therapy documentation with a resident's codes.
“There are definitely places that [deliberately] upcode. There are definitely places that push the envelope on length of stay. But 85 percent of problems walking out the door are human error,” Miltenberg-Vertes says. “There's a big difference between intentional fraud and abuse, and sloppiness that might look like fraud and abuse.”
Careful attention and end-of-month triple checks can catch sloppy work before it's submitted for reimbursement. But there are other issues that make long-term care vulnerable to billing errors.
Therapy caps and manual review triggers put added pressures on providers and their contracted therapists. Providers who indemnify therapy they determine is medically necessary can offer some reassurance.
Facilities with high percentages of Ultra High therapy patients are also often flagged for review, says P.J. Rhoades, PT, DPT, MS, CHC, for Creative Health Solutions. Nursing homes with dedicated stroke units or other intensive-care wings should assess how they compare to peers in annual PEPPER reports. They don't necessarily need to reduce levels of care; proper documentation should stand up to intense auditing.
But Rhoades cautions that facilities shouldn't aim for Ultra High clients just to secure reimbursements. Chain managers who cling to a numbers-first mentality may find themselves under the auditor's watchful eye.
Therapy providers interviewed by McKnight's say most administrators were traditionally driven by admission numbers and outcome data in the past. They rarely considered compliance issues, and few rolled up their sleeves to manually review paperwork or check up on the billing practices of contracted therapy units.
That's changed following a tumultuous couple of years in which auditing opportunities increased, compliance programs became mandatory, and several big-name companies were forced to send money back to the federal and state governments.
“We've had to work to make administrators, managers and operators understand we're in this together,” says Almeida-Sanborn. “We're partners in care all the way from the bedside to payment submission.”
Creating a culture that encourages questions and open communication may be key to heading off long-term problems.
Several federal investigations were launched as a result of whistleblower accusations. Rhoades says it's critical to listen to concerns and kick them up the line so that departments can respond and institutionalize changes.
Some solutions might be easy. For instance, a therapist treating a secondary problem might feel compelled to code to a primary diagnosis because the admission sheet doesn't offer enough options. A conversation with the medical or admissions staff might make the paperwork more accurate. But if the therapist is afraid to ask for clarification, the bills might look as if the treatment was unnecessary.
“Sometimes as therapists, we just do what we're told,” says Rhoades, who recommends offering all employees multiple reporting lines or the ability to contact regional compliance representatives for coding guidance. “We need to develop a culture of trust.”
Expense or investment?
Rhoades says all facilities should also have someone on their team who is dedicated to reviewing regulations. Many therapy companies provide their own compliance units, with regional representatives who occasionally attend morning meetings or monthly triple checks with MDS, administrative and medical staff.
“Unless you have somebody like myself who stays in the regs day in, day out, you're at risk,” says Rhoades. “We don't expect our therapists to know all the rules, because it's impossible. It's our job to make sure they do it the right way.”
Cash-strapped independent SNFs and small chains have a major disadvantage, says Strunk, because they don't have the luxury of hiring outside therapy companies or dedicating a single employee to quality assessments.
But those facilities are subject to the same rules, and some have had to make paybacks that might be even harder to absorb than the multimillion-dollar settlements levied against chains.
Maryland-based Episcopal Ministries to the Aging, for example, was hit with a $1.3 million payback agreement to resolve allegations that it submitted false claims at a single skilled nursing facility. The U.S. Attorney specifically called out the company's failure to prevent its therapy provider from “engaging in a pattern and practice of providing high levels of therapy that were not reasonable or necessary.”
Strunk and Kristy Brown, president and CEO of Centrex Rehab, say smaller companies need to join professional groups that offer listservs, newsletters and continuing education on compliance issues. And they may need to re-evaluate third-party reviews, learning to see them as investments rather than expenses.
“You employ a consultant to regularly audit and make sure they are compliant with all regulations, from billing to number of therapists to assistants,” says Brown, MS, CCC-SLP. “This will cost you more. This will decrease revenue. However, it will provide you with a strong sense of doing what is right and that you are going to keep the money that you earned from Medicare.” ν