Entitlement or over utilization?

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Shelly Mesure, MS, OTR/L
Shelly Mesure, MS, OTR/L

What is a patient entitled to from his or her Medicare Part A benefits? Currently, the environment of determining the most appropriate payment category (RUG level) has come under fire by accusations from the Office of Inspector General, Medicare and various other sources.

There have been a lot of lawsuits, fraud allegations, convictions, plea bargains and so on. In my recent blog, β€œIt's Complicated,” I discuss the need for better and improved communication between the rehab departments and the facility as a whole.

Now it's time to discuss the actual process of determining the most appropriate resource utilization group (RUG) level. This should be the collaboration of the evaluating therapy team (physical, occupational, and/or speech therapy), the rehab manager, and the MDS coordinator. The therapy team should report to the manager the patient's initial plan of care while discussing goals, precautions and barriers to rehab. If the barriers to rehab are low, it can be assumed that the patient will respond well to treatment and make a great recovery, returning to prior level of function.

The rehab manager then receives the feedback from all of the applicable evaluating therapists and determines the therapy schedule in accordance with the different RUG levels available.

How does a patient get chosen to follow the Ultra High RUG level? Is it over utilization if we provide this for a large majority of our patients? Or should this be an entitlement to every patient, so that they should be provided with the maximum level of treatment they may tolerate from a medical point-of-view? Claims payers have their own ideas, and they might conflict with clinicians.

If I were the patient, I would want to receive as much therapy as possible to help return to my prior level of function as quickly as possible. This, however, is the best-case scenario.

The truth is, many of our patients are medically complex and we, unfortunately, are not able to predict the future, as it sometimes seems that regulators want us to do. As a therapist, I can only hope that all of my patients will continue to demonstrate progress, get better and live happily ever after.

Shelly Mesure ("measure"), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a veteran speaker and writer on therapy and reimbursement issues.

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Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.

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