The red glare
Providers are being held more accountable than ever before for therapy documentation and billing processes.
In the wake of several high-profile False Claims Act lawsuits against rehab therapy companies and skilled nursing facilities, and ongoing federal government criticism of therapy billing methods in long-term care, providers are feeling the pressure to get therapy assessments and billing right more than ever.
“We're seeing a lot more scrutiny toward therapy documentation, and the No. 1 concern has been related to ‘reasonable and necessary' services,” acknowledges Stacy Darling, MBA, MPT, AT, RAC-CT, vice president of operations at Post Acute Consulting. She's also often asked how to deal with claim denials due to a therapy plan of care being well-established and not in need of the skills of a professional therapist.
“What I'm finding overall is that therapists really are providing good treatment. However, they're not doing a good enough job documenting the need for that treatment and the specific skills they're providing their residents,” she says. Today's climate of suspicion isn't all that surprising given that, for years, SNFs have been held accountable for their residents' overall care, Darling says.
“It only makes sense that they're now going to be held accountable for what their contract therapy companies are doing,” she says.
So how can SNFs and therapy providers avert future misunderstandings and keep themselves clear of accusations of wrongdoing?
One of the first steps to better therapy practices and billing is ensuring that front-line therapists have all the tools they need to successfully perform their jobs, says Gina Tomcsik, director of compliance at Functional Pathways.
“Not only are good clinical outcomes necessary, but in today's arena of denial, success is measured by clean submissions, paid claims and a bulletproof clinical record that will effectively support the minutes of therapy billed,” she says.
That starts with providing excellent orientation to all new employees, along with continuous clinical and operational support, says Kristy Brown, CEO of Centrex Rehab.
“Through welcoming, comprehensive introductions to the company and ongoing relationships, therapists will gain the knowledge and exposure they need to understand the right and wrong approaches to any situation.”
While it may seem basic, it's also important that therapy companies ensure their therapists know the rules related to Medicare Part A coverage, compliance and timelines, says Leah Klusch, RN, BSN, FACHCA, executive director of The Alliance Training Center.
“I have found that many therapists are eager to learn, but some have been treating patients for years without knowing the compliance rules,” she says, adding that every therapy department should have a copy of the most updated Medicare Benefit Policy Manual and MDS Manual on hand and refer to it often. Klusch also recommends that SNFs consult with their contract therapy providers about how many PRN, or, as-needed, therapists they use, and whether they are trained in the specific Medicare guidelines for skilled nursing.
“Many therapists who work most often in hospitals think they can come into SNFs and do things and document the same way they do in hospitals, but the rules are very different,” she says.
One way the industry works to ensure the most updated reimbursement information is getting down to front-line therapists is through the professional therapy organizations — such as the American Physical Therapy Association, American Occupational Therapy Association and American Speech-Language-Hearing Association — says Cynthia Morton, executive vice president of the National Association for the Support of Long Term Care.
“To the therapist, a patient
isn't labeled Medicare Part A or Medicare Part B when they are working together, so it can be difficult for the front-line caregiver to always know what is and isn't covered. Plus, it changes often,” Morton says. “We produce one-page informational pieces, and our members speak at the conferences of the professional societies about the latest specifics in how Medicare is covering therapy for people in long-term care.”
Sara Lord, an attorney at Arnall Golden Gregory LLP who has represented companies involved in False Claims Act litigation, agrees that the onus is on employers to make sure staff are properly trained. She notes that one of the best ways for SNFs and therapy providers to stay out of trouble is by keeping an eye on what the government is doing — by monitoring the annual Office of the Inspector General workplans, for example.
“If the OIG workplan indicates that over the next year, the agency is going to be completing a study of certain practices, a prudent provider is going to look to its compliance program to ensure that doesn't become a problem for them,” Lord says. Another resource for companies trying to stay on top of things are corporate integrity agreements, which the OIG posts on its website when they're entered into, she says.
“These agreements give a pretty good idea of how the government thinks a company ought to be policing itself internally.”
Putting heads together
At its core, the contracting relationship between a SNF and therapy provider must be a partnership, Morton says.
“Nursing facilities use contract rehab providers because they don't have the expertise in-house to get a therapy program up and running, and the teams need to have a tight bond because often it's the therapy being provided to the patient that's getting them well faster in order to be discharged home, which is really everybody's goal,” she says.
John Calcavecchia, vice president of business development at Preferred Therapy Solutions, agrees, noting that one of the most important things a rehab director must do is communicate well.
“It needs to happen every day at your morning report — sharing what's going on with every patient,” he says. “The rehab director also has to be involved in reporting and making sure we're providing the facility with outcome measures of here's where we at and here's where we're looking to go, for every patient. In today's healthcare climate, we all need to work together to make sure the whole building is running successfully.”
Klusch says it's also crucial for therapists to work with the facility's MDS coordinator to make sure the status of the resident and the therapy treatment plan are congenial.
“That's often where the negative audit results come from, when you have, for example, a resident being treated for a swallowing problem but there's no diagnosis on the MDS for swallowing problems,” she says. “The therapist has to be aware of what the facility's assessment of the resident is, because that's going into an official data bank.”
Unfortunately, in today's climate, providers need to operate as if they could be accused of wrongdoing at any time, says Leigh Ann Frick, PT, MBA, chief clinical officer at Heritage Healthcare.
“It is no longer about ‘if' your charts will be reviewed but ‘when',” she says. To help conduct business ethically and in compliance with federal, state and other applicable laws and regulations, many rehab companies and SNFs are now dedicating significant resources to compliance programs.
“We believe this is vital in knowing that the service being delivered is adequately documented and billed,” Brown says. “If there are areas where therapists need tune-ups, we use these occasions as tools for identifying and providing educational opportunities for professional growth.”
Tomcsik also encourages companies to enforce a triple-check and interdisciplinary system designed to internally audit claims prior to submission, to help decrease a facility's chance of being audited.
“People roll their eyes when you say ‘triple check' but it's an important piece in making sure your claims are clean, that they get paid, and that records support what you're billing,” she says. “Triple check and interdisciplinary teams review the codes being used, make sure they are active and really dive into each resident case and make sure that it's bulletproof.”
Robust compliance programs also include an open-door policy — an easy, and often anonymous way for employees to report any perception of wrongdoing, Morton says. This may be through a toll-free hotline or compliance officer set up aside from regular business, to ensure concerns are dealt with appropriately.
“There are legal ways for self-reporting this information, and companies would rather go that path and get it out in the open and stop it,” she says.
New technology also may soon be available to help support therapists when it comes to documentation and compliance, says It's Never 2 Late Director of Therapy Chris Krause. He says the company is actively working to update its patient engagement software to capture improvements in a patient's balance, range of motion and other clinical data collected during a therapy session and have it seamlessly integrated into a patient's electronic medical record.
“The computer would do much of the technical and clinical analysis, so it's not subjective, and it's being captured in real time,” Krause says. “The efficacy of the intervention goes up, compliance goes up because I've captured the things that CMS cares about, and a claim's risk for denial goes down. That's the solution providers have been searching for: the ability to treat more patients, treat them faster and better, and document everything so we bill right and get paid right the first time.”