Jaclyn Warshauer spent a good chunk of her career as a contract physical therapist, traveling to different skilled nursing facilities to fill in for therapists who were on maternity leave or sick leave.
Boy, did she get an unexpected education.
She recalls that she would go to one location, where she would be told, “Medicare says you do this, but you can’t do that,” she says. “And then I’d go to the next facility and they’d tell me something completely different.”
In other words, there are many different interpretations of the Medicare rules and along with them many myths, explains Warshauer, who is now national director of medical review and quality services for Aegis Therapies. Despite efforts by the Centers for Medicare & Medicaid Services to clarify Medicare rules via its coverage manuals and local coverage determinations, some rules are just too broad to interpret specifically, she notes. And so myths persist.
This conundrum could explain why when the National Association for the Support of Long Term Care (NASL) created a resource for its members to clarify many of the myths around rehab therapy, it became a popular resource.
“We had been hearing our members talk about therapy in terms of its misconceptions,” says Cynthia Morton, NASL executive vice president. “It was, ‘I hear “X” all the time and it’s not right.’”
When the organization set out to create the document, Morton says, it wanted to be careful about not redoing the Medicare Policy Manual.
“Instead, we wanted to debunk the lore that is inaccurate and taken as gospel when it shouldn’t be,” she explains.
With that, NASL created “The Top 100 Medicare Therapy Myths in Skilled Nursing and Home Health.” Warshauer served on the NASL committee responsible for its development. Rather than recite all 100 items here, she offered her top three:
1. As long as the patient is improving, Medicare will pay for therapy. If the patient does not improve, Medicare coverage stops. The reality is that improvement alone does not meet coverage guidelines.
“The patient must require the skills of a therapist,” the document says. “And, likewise, the fact that a patient is improving does not mean the coverage stops. Coverage is not based on an improvement standard. Rather, coverage decisions are based on the need for skilled services that are determined to be specifically necessary to the care of the patient.”
2. If you don’t have any denials, you are doing a good job managing your Medicare patients. According to NASL and CMS, fewer than 1% of claims under- go manual reviews in which the Medicare records are reviewed to determine whether coverage, coding and documentation guidelines have been met and the claim submitted is appropriately supported.
“Without medical review, there is not external feedback as to how well a facility is managing their patients from a Medicare perspective. The facility should have their own internal quality review program to ensure compliance with Medicare requirements,” according to NASL.
3. It is OK to keep a patient on therapy caseload because the therapist believes there will not be acceptable follow through by the patient/CNAs/nursing/ caregiver. “The treatment must require skills of a therapist in order to be billed as skilled therapy. If the follow through is a challenge because the program is so complex, then, if the skills of a therapist are required, the therapist can treat under a skilled maintenance program,” NASL says.
“However, if the program does not meet the skilled maintenance requirements, it would not be appropriate to continue. Medicare does not cover therapy services due to the unavailability of a competent person to provide a non-skilled service,” NASL adds.
For NovaLeigh Dodge-Krupa, vice president of Strategic Care Innovations at Genesis Rehab Services, dispelling myths around rehab therapy is a crucial aspect of transitioning the delivery of physical, occupational and speech therapy to the new world of alternative payment models (APMs) and to meet the “Triple Aim” of better care, better outcomes and lower costs touted by CMS.
“Post-acute care providers are faced with meeting the requirements of APMs, and ultimately the goals of ‘Triple Aim,’” says Dodge-Krupa. “But how do we do this while maintaining a patient-centered model of care?”
The answer, she explains, lies in a three-pronged approach that includes creating clinical options for therapists to integrate in their comprehensive treatment plans, supporting the core transitional elements within a rehab department’s evolving practice from a traditional volume-based to a value-based care model. It also includes dispelling some myths regarding rehab care delivery in a SNF to support therapists as they actively participate in the transition.
Paving the way to APMs
There are a number of myths in need of clarification in order to smooth the way for therapists to effectively transition from volume-based to value-based care and at the same time maintain a patient-centered care environment, according to Dodge-Krupa.
The following are two that she finds most pressing:
1. A patient who is referred to home health services from a SNF will have better health outcomes. The reality is that in order for home health to accept a patient and provide services, the patient must meet the requirements of homebound as established by Medicare, says Dodge-Krupa.
“Oftentimes, they don’t meet those requirements, and what we have experienced in our centers is that, in some cases, up to about 40 percent of patients referred to home health services end up not receiving home health services at all, or not at the level therapists recommend for continued services, she explains. This is because they don’t meet the requirement of homebound, or they refuse the services because they don’t want several different individuals coming into their homes.”
2. The integration of rehab technicians to support care delivery is not allowed in a SNF. It’s true, says Dodge-Krupa, that reimbursement of rehab techs for providing patient care is not allowed under Medicare. “But in a SNF there is no rule against a rehab tech being integrated into the supportive care of our patients,” she explains.
“Under some APMs and the different reimbursement models with capitation or episodic payment, we can integrate rehab techs, as allowed by specific state therapy practice acts, to maximize benefits and outcomes of the therapy programs.”
Illustrate the skill
When it comes to reimbursement and documentation, there is a pervasive myth that skilled therapy is accurately and precisely documented in the patient record, says Paul Riccio, vice president of finance and development at Vertis Therapy.
“Skilled therapy requires a skill set that is unique to a therapist,” he says. “But it is not unheard of for an excellent therapist to get denied for payment, not because he didn’t provide the right service, but because he did not demonstrate his skill set in the documentation.”
Riccio notes that these types of denials from Medicare happen when the therapist fails to document the science behind the service. For example, when a therapist has a patient lift a 10-pound weight for five repetitions but then does not show why she chose those particular weights and those particular repetitions, Medicare is likely to deny the service because it did not meet the skilled criteria.
“What makes a treatment skilled is what the therapist uniquely brings to the table, and that is not always reflected in what the patient is doing,” Riccio explains.
Education fights folklore
“With CMS guidelines and clear direction on practice acts and billing practices, therapists need not be practicing under myths or ambiguous practices,” according to Greystone Healthcare Management Vice President of Specialty Services Mark Miller.
“We have a corporate director of rehab in place who meets with all facility directors on a quarterly basis to review regulatory/practice updates. Billing, ethics, and best practices are a consistent theme in the quarterly meetings.”
Greystone also has a compliance hotline that provides any employee the opportunity to express concern or to report any practice that goes against company policies or CMS guidelines.
Despite all efforts to ward off confusion, the complexity of Medicare rules and regulations likely will always serve as fodder for persistent misconceptions around what is allowed and what is not.
To that end, Miller and Warshauer seem to agree: one of the best ways to avoid and prevent a myth from creeping into your practice is consistent education.
Professional organizations, government agencies and the vendor community all have a stake in seeing that therapy is administered in a proper way.
Accordingly, each offers tutorials or lessons in their respective areas of expertise.
That’s the kind of education a therapist should hope for.
MAKING FUN AND GAMES WORK
It may be stating the obvious to say that the rise of therapeutic games in skilled therapy has spurred a number of myths. But Jintronix cofounder and CEO Mark Evin is sanguine about his ability to dispel and dismantle such myths.
With Jintronix systems in 170 SNFs in the United States, Evin says he has uncovered a number of myths that therapists encounter.
“You can have two facilities five miles from each other, owned by the same company, and have nothing very different from each other,” says Evin. “One facility reports that the patients love the system and can’t get enough of it, while a group five miles away reports that their patients don’t like video games.”
What’s the difference? Much of it comes down to how you introduce the system to the therapists and then how the therapists introduce the systems to their patients, Evin explains.
“Sometimes it has to do with patients who are used to seeing weights and equipment when they enter a rehab gym — and are not used to seeing games and videos,” he says.
Experts agree that the success of any therapy often lies with the therapist’s own enthusiasm or ability to “sell” the course of action chosen.
Similarly, if a therapist is unsure about using a therapeutic gaming system, she might inadvertently communicate this apprehension to the patient, Evin adds.
Both therapists and patients sometimes have a notion that rehab is serious and that video gaming should be “zany and fun” while rehab should be serious, he adds.
This is something he tackles with a better story “and, of course, we always bring it back to the clinical validity,” he says.