The rule that rankles

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The rule that rankles
The rule that rankles

For months, long-term care operators and therapy providers have been wringing their hands and gritting their teeth about the impact the Multiple Procedure Payment Reduction rule will have on their therapy programs—and on the Medicare beneficiaries whose wellness hinges on access to therapy services.

Now that the rule is in effect, those concerns haven't lessened. In fact, for some, they've become even more magnified as providers attempt to navigate their way through the fallout of a policy that many consider to be seriously flawed and irresponsible.

Indeed, the challenges are plenty, and they're not solely reimbursement-related. The 25% cut to the Medicare practice expense for second and subsequent therapy services is, of course, a major blow to providers (as is the combination of other therapy reductions that will take a bite out of their bottom line). But  it's the changes to the way therapy will be delivered that presents the biggest problem in both the short- and long-term, experts say.

“The entire policy is unfair and arbitrary, but most problematic is the application of the MPPR policy without separating or distinguishing between the unique disciplines of occupational therapy, physical therapy and speech-language pathology services,” notes Tim Nanof, MSW, federal affairs manager for the American Occupational Therapy Association Inc., Bethesda, MD. “The payment incentives created by MPPR support less integrated and more distinctly segmented care.”

Key omission

The fact that the MPPR policy excludes data from the institutional setting, which is where roughly 65% of outpatient therapy occurs, is particularly irksome for skilled nursing operators. Even more troubling, though, is the impact it could have on the level of therapy service provided to residents.

“MPPR does not take into account that patients may receive different therapies during a day and may undergo multiple therapy sessions multiple times a day, with little or no duplication,” reasons Greg Crist, vice president of public affairs for the American Health Care Association. A possible result, he explains, could be a cut in speech therapy for millions of individuals who may desperately need it.

“Due to the existing Medicare payment policy, payments may be cut for services for speech therapy because that same patient receives physical or occupational therapy services on that same day,” Crist explains. “This policy that arbitrarily cuts one therapy from a patient's care plan is not in [that individual's] best interest.”

Pay cut

Of course, it's not in providers' best interests, either. Under the MPPR policy, the government commits to pay the practice expense component in full for one therapy service, while reducing the others. It's a strategy that seems to conflict with Medicare law, which has all three therapies listed as separate and distinct entities, AOTA points out, and it also apparently runs counter to the Centers for Medicare & Medicaid Services' quest to improve nursing home quality.

Although it's too soon to accurately predict just how far the negative effects of MPPR will go, some say it's not far-fetched to assume that the policy could impact the number of therapists entering the profession. And it could even drive existing therapists out of certain specialties. Whatever the case, one thing is certain: When the availability of therapists and therapy programs is limited, providers and Medicare beneficiaries become even more vulnerable.

“At this point, we are unsure how claims will be processed. For example, the final rule states that the subsequent therapy service practice expense will be reduced by 25 percent. Is there an order to filing therapy claims and, if so, will one therapy be reduced more than another?” wonders Cynthia Morton, executive vice president, National Association for the Support of Long Term Care, Alexandria, VA.

She noted that just before Christmas, a refinement to the rule reduced the payment cut to 20% for some providers. But exactly who would be affected by the change, and by how much, was still being sorted out by policy makers and long-term care advocates as of press time.

No quick fix

As the industry still waits for some of these key MPPR-related questions to be answered—and seeks strategic ways to survive the cuts—it appears some so-called solutions could actually create bigger problems down the line.

“If PT, OT and SLP continue to remain combined, these providers have already discussed reducing care or alternating therapy days to maximize reimbursement,” says Shelly Mesure, MS, ORT/L, rehabilitation management consultant and owner of consultancy A Mesured Solution Inc., Philadelphia. “Unfortunately, this puts the patient in a precarious situation where clinical practice may not be the guiding factor for the amount and methods of therapy services needed.”

Although Mesure was hopeful that lobbying efforts would ultimately pay off and result in physical, occupational and speech therapy services being considered separately for determining MPPR, providers are developing a contingency plan to weather the storm, just in case.

“If things remain as indicated in the final ruling, some skilled nursing facilities and outpatient providers are considering decreasing frequencies to three times a week if [a resident is] receiving multiple therapies,” she says. “Or, if they're only receiving one type of therapy, [they're considering] possibly shortening therapy sessions per day, and adding additional days of therapy to maximize the day-to-day utilization.”

Hurting residents

Such an approach could offset some of the reimbursement issues, but it won't likely benefit the resident, notes AHCA's Crist.

“Clinical outcomes must remain a top priority, but the severity of the payment cuts will incentivize changing service delivery to minimize payment cuts. The changes are likely to inconvenience patients because of having to receive less therapy more frequently and for longer episodes,” he says.

That's assuming they receive certain therapies at all. In some cases, beneficial therapy programs may fall by the wayside altogether because facilities may not put forth the effort in Medicare Part B billing due to the volume of operational and denial management resources it requires, according to Mesure.

“MPPR creates many operational issues in regard to tracking the Part B caps,” she notes. “Coding KX modifiers are applied at the time of billing once cap allowances have been exceeded. Many companies are not equipped with fancy software packages to calculate this billing; therefore, I have concerns that Medicare Part B recipients may not receive their full Part B benefits due to delays in billing.”

Complicating matters further, she says that very few of the leading software vendors—at least as of press  time—had provided their clients with potential changes or “fixes” to accommodate this new tracking system.

Beyond Part B

In the weeks and months ahead, providers will gain a clearer picture of what to expect under MPPR and, as a result, will likely develop some strategies that will help them rise above the policy's limitations and challenges, without reducing or eliminating therapy services that their residents deserve and require.

“We are concerned about therapy,” Morton says. “We need to spend our energy and expertise on developing permanent solutions to this therapy issue so that patients can appropriately get the care they need and deserve.”

Until then, it would be wise for providers to think beyond Part B, Crist says.

“Providers should not focus solely on Part B therapy services, but should rather take a more holistic approach to evaluate the provision of Part B therapy services as part of a review of goals and opportunities for the delivery of therapy services overall.”

Diligent assessments and documentation also will prove vital, adds AOTA's Nanoff: “Any    changes to clinical outcomes will have to be monitored.”

Despite MPPR's deleterious effect on some providers and beneficiaries, there's still room for optimism, some believe.

“We are confident that our members will survive this,” assures Crist, pointing to the fact that a significant win for the institutional setting was having the practice expense component of the fee reduced from 50% to 25%. “No financial cut is welcomed, but this is survivable.”

Still, there is a much larger therapy payment issue that continues to plague the skilled nursing environment—and it reaches far beyond MPPR.

“The bigger issue is the overall attack on therapy payments,” Crist notes. “When you add up the therapy cap and the concurrent therapy issue and you realize that CMS is just getting started on MPPR, it's pretty daunting.”