Home Health & Hospice Week

Increased PPS complexity may reduce gaming, experts hope.

Get ready to defend your therapy visits under the proposed prospective payment system changes.

The Centers for Medicare & Medicaid Services aimed to cut gaming of therapy use under PPS in its April 27 proposed rule on system refinements.

CMS saw a "marked shift" in therapy delivery pre- and post-PPS, from a concentration under 10 visits to a concentration over 10 visits, the agency says in the rule. Current PPS clearly provides "undesirable incentives" with the single 10-visit trigger for a significant payment increase.

So under the PPS refinements, CMS set out a complex reimbursement methodology for therapy that will be resistant to simple gaming by providers, believes Abilene, TX-based financial consultant Bobby Dusek.

CMS proposes to base payment on three thresholds at 6, 14 and 20 visits, as well as on which episode the patient is in and the number of individual therapy visits between 7 and 19 (see chart, this page).

The complexity of the four-equation model formula will make it "difficult for most clinicians to quickly determine the therapy dollar add-on," points out therapist David Perry with Perry Therapeutics in Grosse Pointe Woods, MI. That's markedly different from the current single add-on at 10 visits.

The smoothing payments between visits 7 and 19 are important, noted consultant Mark Sharp in an Eli-sponsored audioconference on the PPS revisions. Under the proposed system, "you don't have these major thresholds that would encourage, in CMS' eyes, increasing therapy utilization," said Sharp, with BKD in Springfield, MO.

Welcome change: Perry hopes the reimbursement refinement will take the pressure off therapists to hit certain targets, such as the current 10-visit threshold. "Hopefully the focus will return to providing what is clinically relevant and appropriate, and steer away from playing the numbers game as much," Perry tells Eli.

In determining the medically necessary number of therapy visits, agencies need to pay less attention to the financial model in place and more attention to the patient's clinical needs, urges Betty Gordon with Simione Consultants in Westborough, MA.

Train Staff Or Risk Compliance Problems

That may be easier said than done with the new PPS system still rewarding providers for furnishing therapy visits. Even though the single threshold will be gone, "therapy patients are still winners" under the PPS refinements, observes reimbursement consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN.

For example: The base payment for a patient with a Home Health Resource Group (HHRG) of C1F1S1 under a first or second episode with 13 or fewer visits is $1,276.60, while the same HHRG with 14 more visits is $3,467.92, according to Table 5 in the rule (for a selection of therapy HHRG payment rates at each threshold, see chart, this page).

With that continued incentive for gaming, providers can expect CMS to get serious about scrutiny of therapy visits, experts agree. "Significant changes in your past patterns of therapy visits will be evident and may lead to increased audits," Perry warns.

Agencies that try to manipulate their therapy utilization will be "in a world of hurt," Gaboury predicts. CMS says in the rule that it will be much easier to deny therapy visits as not medically necessary over the 14-visit threshold instead of the 10-visit one.

Strategy: "Enhance your therapy documentation to support the skilled nature of the services delivered," Perry advises. "This will be your best protection of increased scrutiny, audits or denials."

When training clinicians on PPS refinements, you must emphasize that many fewer patients will hit the 14-visit threshold than the 10-visit one, Gaboury counsels. Focus clinicians on visits' medical necessity and documenting that need.

Note: The PPS proposed rule is at www.cms.hhs.gov/HomeHealthPPS/downloads/CMS-1541-P.pdf.