Home Health & Hospice Week

Here's what to do now about the proposed therapy changes.

Come Jan. 1, you'll say goodbye to the 10-visit therapy threshold and hello to a much more complex reimbursement mechanism for therapy visits.

Watch out: And if you're not careful, you could also be saying hello to fraud and abuse charges for therapy utilization changes, experts caution.

The Centers for Medicare & Medicaid Services has proposed a major change to the therapy threshold as part of its prospective payment system refinements rule issued April 27 and published in the May 4 Federal Register. CMS wants to do away with the 10-visit therapy threshold and use a staggered 6-, 14- and 20-visit threshold instead (see Eli's HCW, Vol. XVI, No. 16).

And CMS proposes even further payment differences for individual therapy visits within the six-to-13 and 14-to-19 visit case mix categories, explained consultant Mark Sharp in a May 17 audioconference on the PPS changes sponsored by Eli Research. That means agencies will receive more payment for every visit from six to 19, said Sharp, with BKD in Spring-field, MO.

Clarification: "Unlike the existing model, the proposed new case mix adjustment model does not lend itself to a simple explanation of the 'bonus' payment for reaching the therapy thresholds," the National Association for Home Care & Hospice explains in a rule summary for members. Therefore, "it is not feasible to compare the difference between today's increase in payment at 10 therapy visits with the proposed increase at 14 visits," NAHC advises. Are You At Risk? Agencies that currently have a wide distribution of therapy visits will have less financial and compliance risk under the revised PPS, predicts consultant and therapist Cindy Krafft with UHSA in Atlanta. Those with a concentration of episodes in the 10-to-12 therapy visit range and very few in the seven-to-nine visit range are more likely to face financial hardships under the PPS revisions, Krafft expects.

Gaming: CMS made the change because it thinks HHAs responded to current PPS reimbursement incentives--namely, the extra $2,000 or so received when a patient requires 10 or more therapy visits.

Many HHAs will find themselves in financial or compliance trouble because of this behavior, Krafft agrees. "Agencies could have avoided the problem from the very beginning by not trying to manipulate practice to increase reimbursement," she tells Eli.

But utilization changes aren't solely due to "agencies following the dollars," Sharp insisted. New initiatives such as outcomes-based quality improvement (OBQI) and Home Health Compare public reporting encourage increased therapy utilization. "All these things actually created a reason to get more therapy involved in our home health services," he said. Fraud & Abuse Charges Threaten HHAs The HHS Office of Inspector General has been targeting HHA therapy utilization for scrutiny under current PPS, [...]