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Therapy:

Warning From MAC May Signal Big Drop In Therapy Utilization

Published on Fri Jul 10, 2020

The pandemic isn’t distracting Medicare from your therapy utilization.

You’d better be checking your pre- and post-PDGM therapy stats, because the feds are.

So indicates a new message from HHH Medicare Ad­ministrative Contractor National Government Services. In a July 7 email to providers, NGS refers agencies to its “Role of Therapy Under PDGM” web post.

Even though therapy thresholds were eliminated for case-mix adjustment under the Patient-Driven Groupings Model that took effect Jan. 1, “the need for therapy services under the PDGM remains unchanged,” NGS says in the post. “Therapy provision should be determined by the individual needs of the patient without restriction on the types of disciplines provided or the frequency or duration of visits,” the MAC notes, quoting from a February MLN Matters article the Centers for Medicare & Medicaid Services issued on the topic.

The February article, which NGS links to in its post, served as a “shot across the bow,” Washington, D.C.-based healthcare attorney Elizabeth Hogue cautioned at the time. Home health agencies were “officially warned that utilization of therapy services will be scrutinized” (see Eli’s HCW, Vol. XXIX, No. 6).

CMS clearly stated in its PDGM rulemaking, partic­ularly the 2020 rules, that it would be scrutinizing therapy utilization changes under the new payment system, notes Phil Goldsmith, physical therapist with Bristol, Pennsylvania-based Southeastern Health Care at Home. And CMS’ February MLN Matters article drove the point home, says Goldsmith, who serves as the American Physical Therapy Association Home Health Section Treasurer.

Watch out: “Changes in therapy utilization could easily be prompting such a reminder” from NGS now, cautions consultant and occupational therapist Karen Vance with BKD in Springfield, Missouri. CMS hasn’t released any PDGM statistics yet, but plenty of anecdotal information points toward a steep drop in therapy utilization under the new payment system, Vance maintains.

“The timing for redistribution of this article is certainly of interest,” observes PT Chris Chimenti, senior director of clinical innovation with HCR Home Care in Rochester, New York.

COVID-19 Has Skewed Data

However, getting a handle on PDGM data may be harder than it would first appear, thanks to COVID-19’s emergence in March. Utilization for all disciplines, not just therapy, fell under the pandemic, Goldsmith notes.

Factors including reduced referrals, especially from hospitals, and patient refusal of visits contributed to declining utilization overall, and of therapy in particular, experts agree.

Any data from 2020 should be taken with a grain of salt, Goldsmith urges. CMS pointed out in the 2021 home health proposed payment rule that it didn’t have enough reliable data to make behavioral cuts to payment rates, he adds.

However: COVID-19’s impact didn’t hit squarely until mid to late March, points out attorney Robert Markette Jr. with Hall Render in Indianapolis. “Agencies that took radical action in January and February ... may very well be open to government scrutiny,” Markette warns. But “changes in late February, March, April, etc. will likely be lost in the overall decline in utilization from COVID,” Markette tells Eli.

Home health agencies that show big utilization drops may get scrutinized by “MACs, RACs, ZPICs, and everyone else,” Goldsmith says. CMS has announced contractors are resuming regular review Aug. 3 (see story, p. 226).

And “UPICs and other auditors are allowed to investigate fraud during the pandemic,” Markette highlights. “This means that I would expect agencies that NGS, Palmetto GBA or CGS think have engaged in therapy fire sales would, potentially, be audited/investigated,” he cautions.

Another risk: In addition to direct scrutiny for utilization swings, HHAs may also see drops in publicly reported outcomes due to “less therapy involvement in the plans of care,” Vance predicts.

“Therapy is a key driver behind many, if not all, of the metrics used to calculate” Medicare’s patient outcomes and resulting star ratings, stresses Chimenti, who serves as the APTA Home Health Section Vice President. “Skilled therapy interventions directly impact patients’ abilities with ambulation, transfers, bathing, as well as impact pain interfering with activity and dyspnea on exertion,” he explains. “The ability to deliver improvements in quality of life and functional independence will optimize quality ratings, and in turn, positively influence the experience of care.”

And don’t forget: Increased patient contacts and therapy interventions help reduce hospital readmissions, Goldsmith points out.

Between outcomes and rehospitalizations, HHAs should ask themselves what is the cost of not doing rehab — or enough rehab — rather than asking what is the cost of rehab, Goldsmith urges. “As we move into value-based purchasing … that will matter more as time goes on,” he says.

Long range, there’s no denying the direct reimbursement risk of cutting therapy services. “Medicare home health case mixes under the PDGM were created considering past trends of therapy usage,” NGS explains in its post. “If therapy thresholds unexpectedly change, CMS will revise case mixes that may potentially result in decreased reimbursement,” the MAC stresses.

Bottom line: “Home health agencies should not turn away patient referrals or limit therapy services based on reimbursement,” NGS instructs. “This is not a responsible patient care option. As long as the individual meets the criteria for home health services as described in the regulations at 42 CFR 409.42, the individual can receive Medicare home health services, including therapy services.”

Note: CMS’s MLN Matters article is at www.cms.gov/files/document/se20005.pdf.

 

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