Home Health & Hospice Week

You aren’t stuck with your therapy utilization.

A new warning against cutting therapy visits under PDGM is scary, but that doesn’t mean you can’t make any changes to your agency’s therapy provision at all.

In a new MLN Matters article, the Centers for Medicare & Medicaid Services warns that home health agencies must take individual care needs into account when care planning and should not alter therapy visits based on reimbursement concerns (see related story, p. 44).

Some providers feel they are damned if they do make therapy utilization changes because that will invite scrutiny and possible consequences, and damned if they don’t because they won’t be able to afford to operate under the Patient-Driven Groupings Model with their pre-PDGM therapy visit levels.

There’s good news: HHAs can find a compromise between arbitrarily slashing therapy visits and going bankrupt.

Follow this expert advice to manage your therapy provision under the new payment model:

• Know where you stand. Be sure to know where your pre-PDGM therapy utilization stats fall, so you can judge how they change going forward.
• Provide the history. If a patient or employee cries foul when you won’t furnish therapy, you can rebut with good stats. “Agencies that are able to show consistent utilization of therapy services pre- and post-PDGM will be in a good position to defend their use of therapy services,” says attorney Elizabeth Hogue. For example, “we have some clients who can show consistent utilization of therapy services under cost per visit, the interim payment system (IPS), PPS, and PDGM,” Hogue reports.
• Get ready to defend. But if you make any changes in therapy provision under PDGM, you can expect to land in the hot seat. You should be ready to support changes with solid documentation — that is not related to reimbursement, advises attorney Robert Markette Jr. with Hall Render.

“CMS is not going to give you the benefit of the doubt,” Markette warns. You’ll need to have evidence that shows any changes were made for justified clinical reasons.

• Follow the QAPI model. CMS is against changing utilization for reimbursement reasons, but it has proven to be enthusiastic about providers becoming more efficient while maintaining or even improving quality of care.

For example: CMS encourages all providers — including HHAs — involved in the Compre­hensive Care for Joint Replacement (CJR) model, which bundles payments for joint replacement patients and rewards Medicare savings, to find efficiencies in furnishing care, Markette points out.

If you take a page from the Quality Assurance & Performance Improvement handbook and focus on improving — or at least maintaining — patient outcomes, you can clinically justify changes to your utilization, he suggests.

• Target the right kind of data. Key to convincing authorities that change is OK will be using data based on objective, measurable criteria, Markette advises.
• Avoid knee-jerk reactions. Providers that automatically slice their therapy utilization in half on PDGM’s start date or after the first billing cycle will be asking for trouble. Testing ways to create efficiencies while maintaining or improving care will take time, so resulting changes will be gradual, Markette offers. While year-over-year data might differ significantly, month-over-month data should not.
• Craft a therapy policy. “To show consistent appropriate utilization, agencies must implement a policy on therapy utilization,” Hogue counsels. “The policy must require current as well as retrospective monitoring of utilization.” Adjust as needed.

The policy can incorporate your strategies for creating efficiencies, such as using new technologies.

• Work with therapists. Some HHAs have had difficulty getting therapists to perform basic duties like turning in paperwork on time, individualizing care plans, and completing OASIS assessments in therapy-only cases. The time for that is over.

Agencies should be “working with therapists and trying to help them understand the patient-specific philosophy when completing their frequency,” recommends Kyle Johnson with Home Health Coding Solutions in Brigham City, Utah. “Many therapists are still doing the same old 2wk8 on every patient, regardless of what the home health need is,” Johnson continues. CMS itself emphasizes that care planning, including for therapy, should be tailored to the patient.

For example: “Some patients might need 2wk4 for a COPD exacerbation, others might need 3wk2 for a joint replacement,” Johnson offers. Work “with the therapists so they look at the patient individually,” he urges. Often, that will naturally lead to shortening intended frequencies.

In its MLN Matters article, CMS also points out that therapists should be “assessing and documenting patients’ functional impairments” as “captured through responses to OASIS items.” They should also be “developing an individualized home health therapy plan of care in collaboration with the certifying physician” and conducting “a comprehensive assessment … [to] help to ensure that patient needs are identified, an individualized therapy plan of care is established, therapy services are provided, and goals of care are met.”

• Achieve therapy cost savings in another way. In many markets, therapists have been in short supply and could command top dollar. Now with the Skilled Nursing Facility Patient-Driven Payment Model and PDGM creating incentives to get much more efficient about therapy provision, there should be a “glut” of therapists available, expects Tom Boyd with Simione Healthcare Consultants in Rohnert Park, California.

That means it’s a good time for cost savings like renegotiating pay, particularly for contract therapists. “Most HHAs should not be paying the therapists the same rates they did under PPS,” Boyd advises. “Keep the service, but cut the payments to therapies.”