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Insurance companies may want to halt therapy for a resident who has reached a Prior Level of Function, but therapists can help by developing relationships with case managers and medical directors. Pro
Insurance companies may want to halt therapy for a resident who has reached a Prior Level of Function, but therapists can help by developing relationships with case managers and medical directors. Pro

Mrs. Johnson is sent to the hospital for renal failure. The woman, whose life before the ambulance ride consisted of a recliner and mobility limited to a walker, is in her third week of approved rehab. 

But then her insurance company stops paying for therapy because Mrs. Johnson has returned to the state she was in before her kidneys failed.

Therapists were beginning to see the woman respond well — so well in fact, she may even gain mobility she hadn't seen in years. 

But the therapy company is forced to walk away. 

“When Mrs. Johnson requests more time because she's actually making gains that she hasn't seen in 10 years, and her son is so pleased with her progress that he's promised to take her to church and out to dinner for the first time in 15 years, [her] insurance has decided it's time to stop,” bemoans Jean Wendland Porter, PT, CCI, regional director of therapy operations at Diversified Health Partners in Ohio, in a recent column for McKnight's. “We comply and stop the therapy. We have become ‘the monster.'”

Such are the difficult, angst-filled decisions therapists face every day with what some see as an outdated, even arcane standard known as “prior level of function” (PLOF). Many are forced to pack up and leave rehab visits for very valid financial reasons. Others have learned to convince some insurers to reconsider after successfully demonstrating progress. 

But for everyone, PLOF is among the rules today that pit costs and quality of life in a constant tug of war.

Gray areas

As are many regulatory and payer rules today, PLOF is riddled with ambiguity and exceptions.

“Our Medicare auditors seem to think it's the level of function prior to the hospitalization. This may be true, but nothing is ever just black and white,” wrote Shelly Mesure, MS, OTR/L, then the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy, in another McKnight's column.

Indeed. As Matthew Mesibov, a clinical physical therapy specialist at Centrex Rehab, observes, PLOF is often a moving target.

“Every therapist conducting an evaluation inquires about PLOF,” he says. “It serves to support reasonable goal setting, which is focused on patients. Clinicians should not automatically accept the ‘most recent' PLOF [from the last two or three months] because, for example, there may be a PLOF that existed six to 12 months ago with a higher functioning level. If clinical judgment is that the PLOF of six to 12 months ago is appropriate and can be achieved within a reasonable time frame, the clinician should base his or her goals on that PLOF.”

And as at least one therapy manager has learned, therapists tend to be more resistant to the rule the older they get. Paul Riccio, vice president of finance and development for Vertis Therapy, says he finds the generational differences “interesting and ironic. A 55-year-old therapist is going to have a much harder time with it than a 25-year-old,” he says. “It's a philosophical mindset difference — what they were taught about the purpose of therapy.” When older therapists were young college students, few spoke about the continuum of care, he observes. The younger therapists today seem to “get it,” however.

Moreover, the PLOF “rule” is often applied differently, depending on where rehab occurs.

“Payers rely on PLOF more heavily when reauthorization comes into play, but it has become less significant for reauthorization per setting,” says Tara Roberts, PT, vice president of rehabilitation and wound care services for Nexion Health. “Payers now are more interested in not how close the client is to PLOF but how close are they to being safely treated in a less expensive ‘restrictive' setting as they move toward PLOF.”

Roberts adds that PLOF guidelines are evolving as new technology, adaptive equipment and general scientific advancements in therapy come into play.

For Riccio and others, there can be good reasons for PLOF because more attention is being focused on the care continuum.

“Our goal of rehab has always been to get people to the highest level of function, which is often their prior,” Riccio adds. “What has changed is the integration of the continuum and the prevalence of managed care.

“It used to be that the therapist's job was to get them to that highest or prior level of function,” he adds. “That rested usually on the shoulders of the skilled nursing facility therapist. Now, that SNF therapist is a step in a chain, from acute to post-acute to home health. And in the cost-efficient, bundled payment, ACO, pick your acronym-of-the-day world we now live in, most people get to their highest level of function later in the continuum.”

PLOF views today reflect how therapists' roles have changed significantly, says Riccio.

“A therapist's job description used to be to get them to the highest level of function,” he says. “Now, a therapist's job is to get them to the next step of the continuum safely. Insurance companies usually determine what the expected level should be, but the ideal should be the interdisciplinary care team, so the case manager from the hospital talks to the admissions person at the SNF, who talks to the case manager at the home health company. In reality, the insurance company draws the line along each step of the way. Which is what makes integration in a bundled payment skilled world in communication so critical.”

When looking at prior level of function, therapists feel responsible for obtaining patients highest possible level of function, says Susan Krall, PT, Customer Relations at Senior Rehab Solutions. But she agrees managed care companies and other entities want therapists to move patients along to less expensive options.

“Financially, I get it,” she says, but there are avenues to allow the patients to receive what they need. “We must make certain that the barriers to safety are identified and ensure patients receive the benefits they need for safe transitions.”

Challenging reviewers

For many therapy companies, PLOF has had minimal impact.

“We are continuing to treat our patients as usual and have not had a change in practice,” says Jeanna Conder, MBA, OTR/L, senior director clinical operations for RehabCare. “Our responsibility is to provide the services that they require to return them to their highest level of function. PLOF is always considered with each evaluation but it does not determine the plan of care for the patient. Prior level continues to be important but may not be achieved in their current setting; but it remains a goal as they continue through the continuum of care.”

PLOF can lead to some painful and difficult decisions for therapists, many of whom become vested in patients' progress.

“As a clinician, if the patient can achieve his or her highest level of independence, I say, let's go for it,” she wrote. “To Medicare reviewers, too often they say, ‘Stop at the prior level of function.' So I often challenge the reviewer to explain this terminology.”

“Part of honoring resident choice is honoring the insurance they chose,” adds Riccio. “If they chose to save $100 a month for 15 years and now that means you have to turn a blind eye to their managed care company that's limiting the frequency, intensity and duration of their therapy, that was the choice they made.”

“Sometimes our job is to hand them off to the next level of the continuum before they've hit that ‘highest level of care' goal. And it hurts,” he continues. “And we don't like it. But that is now the healthcare system we live in. Because when they stop fighting it and work as part of a team, I think we can do better. We have to stop holding on to the autonomy we had 20 years ago. If I know the other person is going to fumble the football, it's still my job to hand it off. I don't get to call the plays.”

Strategies for success

Therapists are most successful in dealing with PLOF issues when proper assessments are made.

“It is incumbent on the therapist to assess based on a therapy evaluation that determines if a patient would be likely to achieve a PLOF within a reasonable amount of time,” says Mesibov. This includes the “demands of the environment. The clinician needs to analyze if the functional demands of the discharge location meet the current abilities of the patient.” 

Krall says therapists can make a case for how discharging a resident can hurt more than help.

“We have to present the data. You can say, ‘If they go home now, their risk factor of going back to the hospital is X,'” she says. “It's all about documentation and presentation of standardized assessment outcomes.”

Roberts agrees thorough documentation leads to a solid plan. 

“PLOF is more of a factor or standard for establishing client baseline pre-incident and determine rehab potential post incident,” she says. “Our philosophy related to PLOF and its impact on our delivery of rehabilitation services is that it is a key to developing an effective, supported and reimbursable plan of care.” 

Conder echoes the significance of this approach. “Prior level of function is a baseline indicator of information just as living in a house with eight steps is a good thing to know,” she says. “It's not the only indicator for when or how we progress our patients.”

It's important to make sure goals are reflected in documentation. If the PLOF is eclipsed, a clinician should continue “as long as skilled care is indicated and the goals are reasonable,” says Mesibov.

“If a patient exceeds their PLOF and it is reasonable to achieve these higher levels given their living environment and activities of participation [assuming the activities are covered in the payer's benefit], then the clinician should continue and make sure clinical documentation supports skilled services.”

Among Roberts' other tips: “Involve the medical director for peer-to-peer reviews and appeals when necessary. Assist client/client representatives in exercising their appeal rights. And continue to remind payers that the therapist's goal is to avoid unnecessary re-hospitalizations, ensure optimal quality of life and highest practical function.”

Riccio asserts three things are needed to navigate PLOF waters. 

 “First, you have to justify the outcome,” he says. “Is it PLOF or a higher level of function that is more likely to prevent the traumatic event later? Second is justifying their unique skillset as a therapist. Is this something that another discipline could do? 

“The [third] one they almost always miss is justifying the care setting. Can this outcome be achieved in outpatient rehab, or do they really need to be in a SNF? One of the hardest things for anyone to do whether they're a therapist or any other professional is to admit that someone else can do as good or better a job. That's a level of humility and maturity we're asking therapists to have when they make that argument with the insurance company.”