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

This past year has been pretty crazy with all of the pending and new regulations for Medicare. There are many discussions circulating about healthcare reform, how to fix our current system, what changes need to be made.

Part of this discussion is being fueled by the Office of the Inspector General report that was issued last November and targeted skilled nursing facilities. Per the recommendations from the report, OIG stated it should use the Fraud Prevention System to target facilities that bill at a higher percentage range of Ultra and Very High reimbursement categories.

In response, facilities have started becoming very nervous about their reimbursement distributions and re-assessing budgets based on RUG categories.

This worries me because I wonder: Will this create an atmosphere of fear-based rehab services vs. clinical decision-making based rehab services? While I fully realize that fraud occurs and must be handled immediately, to create a generic statement of, “Let’s target companies who bill at these higher rates” poses many dangers to patient care.

As a consultant, I have been working with all of my clients to revisit their policy and procedure handbooks for determining RUG categories, therapy schedules, and operational management. These providers also have conducted group and/or individual staff meetings focusing on quality and compliance of services.

We developed a simple five-question survey that each client had to ask every therapy employee.  Most surveys were collected anonymously, analyzed, and training provided with updated policies.

If you can develop strong policies and procedures based on these questions, you will have a good offensive game plan in place.

1.   How do you determine if a patient requires therapy? (Or are you at risk of employees feeling like the “must pick-up” regardless of clinical reasoning)

2.   How do you determine which RUG category to plan for new patients?

3.   How do you assign the therapy schedules and patient caseload?

4. What communication policies are followed when a patient refuses or misses planned treatment sessions?

5.   What communication policies are followed when patients are unable to tolerate the projected planned treatment sessions?

It’s time to make sure you’re ready. Are you?


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.