Home Health & Hospice Week

Watch out for artificial gaps in therapy visit distribution.

You'd better identify and fix any appearance that you're trying to game the new prospective payment system changes--particularly regarding therapy--before the feds do.

Medicare regulators are on high alert for home health agencies trying to unethically maximize reimbursement by changing therapy visit utilization, experts warn. The PPS refinement regulations "are definitely aimed at closing some loopholes and reducing gaming of the reimbursement system," notes attorney Marie Berliner with Lambeth & Berliner in Austin, TX.

HHAs training staff on the PPS changes must focus on goals of good patient care, stresses attorney Deborah Randall with Arent Fox in Washington, DC. Agencies should absolutely "not suggest to their staff that they need to change strategies to achieve therapy levels and trigger reimbursement maximization," Ran-dall tells Eli.

"Government regulators will be looking carefully for that kind of game-playing," Randall warns. "Either over- or under-serving patients could constitute a violation of the Civil Money Penalties provisions of the law," she says.

Bottom line: "Shifts in practice in order to maximize revenue may draw unwanted attention from Medicare and are not recommended," emphasized consultant and physical therapist Cindy Krafft in a recent Eli-sponsored audioconference about the PPS changes.

How therapy reimbursement works: Under the revisions that take effect Jan. 1, PPS will have three new thresholds for therapy at 6, 14 and 20 visits. But there will also be smaller incremental payment increases for many visits between seven and 19.

For agencies that have always had an even distribution of therapy visits, the new system will reward them financially for formerly money-losing episodes with therapy visits in the six to nine range. They will also benefit if they formerly took on those "train wreck rehab patients" with 20 or more visits, pointed out Krafft, with Fazzi Associates in Northampton, MA.

"The agencies that have been the most scrupulous and precise in their coding and recordkeeping practices in the past will come out ahead after Jan. 1," Berliner adds.

But agencies that have had their therapy distribution bunched right at or above the 10-visit mark are likely to see reimbursement declines for therapy in 2008, Krafft cautioned. Avoid These Therapy Red Flags What to do now: Whether you are in the former or latter group, you should focus on dedicating your therapy practice to the patients' needs under the PPS revisions, Krafft advised. Avoid setting artificial target numbers for therapy visits. "Don't start from the numbers and work backwards," she exhorted.

"We don't want to repeat the mistakes of the past," she urged listeners. Don't assign everybody at six visits if nearly all patients used to get 10 or 11. Besides the ethical ramifications, you'll have to answer to regulators looking for just such utilization swings.

If your [...]