Provisions included in the H.R. 3630:Middle Class Tax Relief and Job Creation Act of 2012  expect that beginning Oct. 1, 2012, hospitals will be subject to the same Medicare therapy caps and regulations as the rest of the outpatient therapy provider sector.

Given all the site neutral considerations of payment reform underway, this seems like a reasonable correction to our broken payment system. But for hospitals who have not been subject to the same rules as other outpatient therapy providers, this may present a logistical host of problems not anticipated.

For starters:

• Concurrent tracking of the cost of care (Medicare payments) for each patient receiving outpatient therapy services will be an important exercise for hospital accounting and billing systems. They must communicate to caregivers to make certain the $3700 cap is enforced.
• Next, each request for payment must include the national provider identifier of the physician who currently periodically reviews the plan of care.
• Hospitals must initiate procedures using the “KX” modifier on claims above the cap.
• Audits of billing procedures must consider the CMS developed National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.
• The Coding Policy Manual should be utilized by carriers and FIs as a general reference tool that explains the rationale for NCCI edits. ref.(https://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp) This will require increasing the dialogue with intermediaries for their interpretation of the regulations, (we all know how that works).
• A manual medical review process for high-cost beneficiaries (those with more than $3700 in therapy services) will be initiated by intermediaries requiring after the fact justification of claims and retrospective defense procedures.

The House Middle Class Tax Relief & Job Creation Act of 2011 extends the therapy caps and at some point the system will get replaced by an alternative outpatient therapy payment methodology. In the meantime The Congressional Budget Office estimates including the hospital outpatient  component into the current cap methodology would result in a net reduction in Medicare spending by $1.7 billion over 10 years.  That wrings a lot of payment out of the outpatient therapy watershed.  So “how ya doin?”

Health practitioners and technical occupations dropped by 18,800 in March to 578,100, resulting mostly from fewer advertisements in registered nursing, occupational therapy, speech pathology and physical therapy. However, jobs continue to outnumber practitioners looking for jobs, as the ratio of advertised vacancies to job seekers stands at 2.41 to 1.

The Bureau of Labor Statistics predicted last year that healthcare jobs will grow the fastest of all industries by 2020, with healthcare practitioners and technical occupations rising 25.9 percent between 2010 and 2020. Conference Board announcement and now there are signs the sector is moving the other way.

The behavior of heath care providers cutting back on job advertisements in wake of an increasing demand is a very curious observation. It may possibly be a symptom related to the market basket freeze referenced by my colleague, Darlene, in her recent blog. Is it possible healthcare is cutting back on the investment in practitioner resources as a going lean strategy? Salary and related employee costs known as the employee burden rate is the single largest component of a provider’s expense and historically was an easy target for cutting expenses. Nevertheless, when demand for what practitioners do is increasingly cutting back and freezing market basket values, it can only mean fewer people will receive the care they require; the social issue contributing to the recent change in CMS leadership.

Face it, business as usual is no longer affordable in healthcare. Moreover, it is up to each of us to be more innovative in figuring out where to reduce cost and improve quality of the service we provide; it does not appear to be happening with policy makers or those charged with our healthcare budget management.  Managing healthcare costs and value will require more of a team effort than currently applied and success will depend upon enterprise strategies rather than silo focused tactics.

This is good, right?

We must ask, “what has changed over the history of rehab outcomes reporting?” And while we take personal pride in looking back upon what we have learned, providers are hard-pressed to offer evidence to support the fact that quality or cost has been favorably influenced by these efforts. Many changes have occurred during the 25 years but most have been a result of payment or regulatory change. The pursuit of quality has never been a financial objective so there was no incentive to do anything different. If financial benefit (or consequences) did not result from better-worse-the same rankings, it seems these outcome reports may have less that meaningful use. Of greater concern is the question, “why are rehabilitation hospitals missing from the current incentive programs promising recognition and rewards for exceptions performance?” Could it be the rehab sector has been measuring and managing the wrong outcomes for the past 25 years?

The answer could exist somewhere in the shifting expectations that providing care is no longer justified unless it is done with consideration of cost and effectiveness. Being a well respected provider is not a guarantee for success in the new world of healthcare payment. Demonstration of value will be required and its quantification will add new granularity and meaning to better-worse-equal to.

The Medicare Hospital Value-based Purchasing Program will feature:

Throughout history practitioners have performed and delivered care based upon what the payment system has paid for; there is no reason to expect this fact to change. Providers don’t create the economic reality they function within, they react and adapt to it. The economic incentives associated with the Value-based Purchasing Program will shift our focus from traditional outcomes to value metrics and we will succeed on new levels of performance.

We should anticipate a fundamental shift in the way we are reimbursed for the services we deliver and the amounts allocated for those services. Provider behavior will follow in the way the post-acute rehab provider treats and manages the highest-cost, chronically ill patients and where payers and patient seek treatment for those conditions. The use of advanced analytical and data tools to enhance efficiency and recommend the course of treatment with the highest likelihood of quality care and low cost will be the standard methodology to capture and report outcomes and value.

Social media and the Internet afford instantaneous communication across a broad constituency of interested parties for rapid reply to questions or concerns.  These same media afford the exposure of faults and shortcomings.  Questions asked target the state of a provider’s rehabilitation practices.  These media are the information super highways driven by novice and expert alike.

This is an incredible resource. In order to take full advantage of this intelligence, users need to learn how to ask better questions and resist the urge to find the quick solution to their need to know. Users will need to learn how to discriminate data quality. There must be a perception that the right elements are being measured in the right ways, and that apples and oranges are not being confused with each other. There needs to be trust in the quality of the information required.

The challenge of implementing clinical intelligence systems will be daunting and learning is required by the provider and the patient for effective use. Asking questions along the way will provide evidence that learning is occurring and the transformation is sustainable.

I am wondering how these practices will play out in the future of accountable care. Transparency of cost information is a significant driver in the effort to lower care costs and improve efficiencies of care delivery. Understanding the relationships between cost and payment would seem to be a rationale step to making better decisions about effectiveness and efficiency for everyone involved in the process.

Electronic clinical records and data systems are providing sources of information about the care delivery process previously unavailable.  There is a growing awareness that access to provider information may actually increase the knowledge base to all, including patients.

In a recent study appearing in the Annals of Internal Medicine, Patient Interest in Sharing Personal Health Record Information, the practice of holding clinical notes beyond patient access was challenged and offered a conclusion that “existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their healthcare.”

“Patients want to look into their doctor’s black box, and many doctors are a bit nervous about what they’ll find,” said one of the researchers from Beth Israel Deaconess said in a news release. The researcher continued, “but I expect that over time everyone will benefit enormously from such transparency.”

As the electronic record of patient care releases more insight into the cost and effectiveness of the care delivery process, all involved will need to adjust their historical perspectives of who should see what; the new accountability will demand it.

Take the staff awareness survey at MediServe.com.

The CMS Innovation Center will release multiple opportunities to demonstrate better care, lower costs and managing health outside of traditional brick and mortar establishments.  Just recently they released “Independence at Home Demonstration”, a model program that will surely affect outpatient services and new wave ‘home health’.

On Dec. 21, 2011, CMS released a call for applications for this new project and encouraged medical practices to test effectiveness of delivering primary care services in the home for Medicare beneficiaries with multiple chronic conditions. These comprehensive services are to focus on timely, appropriate care that improves quality of life while lowering costs; preferably by decreasing the need for care at institutional settings.

This project will also test ”whether home-based care can reduce the need for hospitalization, improve patient and caregiver satisfaction and lead to better health and lower costs to Medicare,” per the CMS announcement.

If you look at the number of beneficiaries that referred to ‘home health’ or ‘outpatient services’ upon leaving rehabilitation, you begin to understand the need for coordinated care management beyond discharge.

So who are the candidates for this type of program? Beneficiaries with multiple chronic conditions who require someone’s assistance with two or more activities of daily living; and who have had a hospital admission within the last 12 months that included rehabilitation services. The potential for growth beyond initial participants is quite remarkable.

Will these types of programs be sustainable and how much will they affect services presently provided by outpatient therapy settings and home health services? Will these programs help fill the gaps perceived to occur in the near future with an explosion in covered Medicare lives (whereas multiple caregivers and increased physician visits with increased co-morbidities is not a rare occurrence for people with chronic conditions)?  (The Silver Book: Chronic Disease and Medical Innovations in an Aging Nation; Partnership for Solutions. Chronic Conditions Making the case for ongoing care – September 2004 update.  Baltimore, MD: Johns Hopkins University, 2004.)  Small populations with chronic conditions may be responsible for more than 80 percent of health care cost dollars.

Medicare is asking that the Independence at Home Demonstration include primary care practices and associated multidisciplinary teams of which can include pharmacists, social workers and other ‘supporting staff’.  They must serve no less than 200 beneficiaries with multiple chronic conditions each year of the demonstration. Overall, the demonstration may include up to 10,000 beneficiaries and up to 50 such practices. The application process and instructions for how payments will be made during this 3 year demonstration are included HERE.

Payments will be tied to success in meeting six quality measures compared to a threshold equal to or less than the average utilization in an unmanaged, clinically similar population with case mix and geographic adjustments.

So the question remains, are the complexities for innovation within the capabilities of  standard payment models?  Medicare states providers ”will continue to bill and be paid standard Medicare FFS reimbursement, subject to beneficiary deductibles and coinsurance and balance billing rules.” Additional incentive payments will then be derived from targeted payment levels and the number of quality measures met.  Will providers take those risks?  To what level can ‘supportive staff’ be utilized within a home? Does this create a level of care dependent on extenders of a multidisciplinary team not yet recognized within ‘standard payment’ methodologies? Only time and creativity will tell.

We have been told post-acute care services may look very different from what we have today. Health care reform will take on many faces.  For up to 10,000 beneficiaries, this new face of health care will begin shortly after the deadline for applications in just a couple of months.

Find MediServe on Facebook.

Five years ago Sister Mary Jean Ryan, CEO of SSM Healthcare, set the standard for healthcare organization quality and was recognized by having been awarded the Malcolm Baldridge National Quality Award for performance excellence in health care.  Since then healthcare leaders have looked to the Baldridge process as a means to increase organizational effectiveness rather than organization recognition.  These best practices underscore the four key areas that organizations focus upon to manage their business and achieve organizational goals returning high value for all stakeholders. They are leadership, people, measurement and processes.  Organizations facing the challenge of improving the effectiveness and efficiency of patient care service delivery can look to the winners of the Baldridge competition for comparison to organizations known to be the best.

Value in patient care has come to represent the idea and activities associated with getting the best care at the best price. The evolving healthcare economy and Accountable Care initiatives impose greater demands upon delivery organizations to demonstrate the value of services provided.  To do so providers must assess their effectiveness in the key areas, use the essential best practices and plan to significantly improve results. Taken in context and applied to healthcare, optimizing value translates to improving performance in patient care delivery.

Performance improvement in healthcare is a disruptive technology and faces resistive inertia of the institutional status quo and human behaviors.  Traditional approaches of listening to the “voice of the customer” and providing them what they want will only partially fill the paradigm for the transformational change to value-based care delivery. Performance improvement, innovation and leadership will be accelerated by the evidence provided by the success of others when advancing disruptive technologies to optimize value of patient care.

The disruptive technology comes in the form of evidence-based management which relies upon monitoring and measuring key areas of systems and clinical process to provide insight to variance from the expected. The cultural impact of metric driven management affects organizations at all levels.  Five years of Baldridge winners have been analyzed to identify what distinguished them from others, common to this elite group has been:

- an “organizational” approach to excellence and not focusing on a narrow aspects of the business;

- the ability and discipline to identify and apply the “best practices” that other organizations have used successfully in their path to organizational excellence;

- a system wide implementation of best practices to optimize the results that support excellence;

- and the continuous management and focus upon the key areas as most significant for achieving the type of results that support the transition from good to great.

The transformation of healthcare will not occur without pain and risks along the way. Leaders need be prepared with new tools and intelligence to manage these transitions. Performance management and best practices are evolving based upon measurement and data providing evidence to support operational decisions.  Now more than ever, optimizing value requires greater insight and intelligence capabilities even if you choose not to race.

See MediServe’s tools to help optimize the value of patient care

Communication and the ability to link usage of the same CPT code across disciplines to trigger modifier usage at the point of documentation is available in the MediLinks OP software solution.  When a therapist charts, interventions are linked to CPT codes and the ingenuity of cross-referenced occurrences are alerted at the point of documentation which enables therapists to apply the 59 modifier up front; securing appropriate documentation with the bill as it is created.  This workflow curtails many pain points encountered when edits are applied after the fact, especially mounting take backs, error rate testing and denials of payment that can be applied by various Medicare contractor agencies.  With less than adequate tools, leaders must increase awareness and responsiveness to ensure appropriate billing knowledge is applied by all clinicians. Let’s learn a little about CCI edits and modifiers and risks associated with non-compliance.

An excellent Medicare Learning Matters education flyer was posted in 2006 explaining when and how CCI edits would be applied.  The education article states, “Application of the CCI edits ensures that all therapy providers are subject to the same billing and coding rules and requirements. It is believed that these changes will have a positive budgetary effect as it incorporates safeguards against improper coding and over-payment of therapy services.”  Some managers are confused and believe that the plan of care or discipline specific code edits should also indicate distinct and separate care; this is NOT the case.

The claim must include one of the following modifiers to distinguish the ”skilled” discipline of the plan of  care under which the service is delivered in outpatient therapy (Benefit policy manual definition of skilled provider):

GN – Services delivered under an outpatient SLP plan of care
GO – Services delivered under an outpatient OT plan of care
GP – Services delivered under an outpatient PT plan of care

Recall that there are situations when ‘always therapy’ or ‘sometimes therapy’ must be applied depending on who renders the various procedures.  The ANNUAL THERAPY UPDATES (posted Dec. 8, 2011) provide instructions on why and how GN, GO and GP modifiers should be used. Situations such as, “They are billed by practitioners/providers of services who are not therapists, i.e., physicians, clinical nurse specialists, nurse practitioners and psychologists; or they are billed to fiscal intermediaries by hospitals for outpatient services which are performed by non-therapists”, are examples of when the modifiers are NOT applied, however those providers are also subject to CCI edits – hence two sets of codes are needed.

Unfortunately, again many managers believe that GN, GO and GP is enough to denote ‘distinct and separate’ billable care.  However, particularly in multi-discipline clinics, there are often co-treatments provided and the time is not necessarily ‘distinct and separate’.  Providers are able to bill for co-treatment in various ways.  The provider can place all time billed to one discipline, or share the time between two disciplines, as defined through CMS: “Where a physical and occupational therapist both provide services to one patient at the same time, only one therapist can bill for the entire service or the PT and OT can divide the service units.” Be aware there are newer guidelines for counting of minutes for Skilled Therapy (published August, 2011) and if you work in skilled you must review the newest guidelines for that level of service.

HOW CAN YOU keep all of this straight?  Billing software is not often able to view across disciplines to recognize CCI edit scenarios.  When edits are not properly applied, this warrants take backs for “overpaid” claims on the same day for a provider.  I often see scrubbers apply edit information in an automated fashion that is not connected with documentation by the therapist at all.  These types of occurrences lay the groundwork for improper billing.  MediLinks embeds these tools to reduce probability of adverse occurrence.

It is far more effective in managing compliance at the front end, rather than paying for mis-communicated CCI edit pairings after the fact and/or only being reimbursed for portions of the care provided because distinct and separate CCI edit coding was not applied to the bill.

Should errors lead to an unacceptable error rate percentage, all Medicare claims could be placed into prepayment review. Prepayment review has serious cash flow consequences.  CMS reports a take back of $34.3 billion in improper payments in 2010. As electronic claims analysis becomes more expedient, take backs will increase. Payment extrapolation (statistically applying fault recouped payments based on historical sample), for those with continuous high error rates or previous education/training on faulty practices can see exponential take backs applied for years of service for which you have already been paid.

One of the best education primers I have seen on the subject of audits was published by AHIMA.  ”Understanding Governmental Audits.” Journal of AHIMA 82, no.7 (July 2011): 50-55 (see chart below).  I highly recommend placing a book mark to this site and using it to educate staff on the complexity and ever-growing vigilance for leaders in healthcare.

Courtesy: AHIMA

Start these discussion with your staff:

- How do you presently determine frequency in your plan of care?
- Is frequency a stable number – starts at a level not changed in the plan?
- Does acuteness of a condition determine greater frequency at the start of care?
- Payer’s often dictate visits; how do staff utilize limited visits when establishing the plan?
- How often is the established frequency adhered to by the patient?
- Does staff modify the plan if the original plan is not maintained?
- Did the patient meet stated goals that adhered to the frequency plan?
- Did the patient meet stated goals that did not adhere to frequency plan?
- How often was the outcome unknown because the patient did not return to complete visits?

I believe these are enough questions to begin a review.  Pull the last 50 to 100 persons discharged from your clinic and be sure you gather standard demographic information (gender, age) along with the primary diagnosis code (there is no magical number, however the greater the sampling, the more data to base future decisions).

Share information with staff and discuss the impact of your findings on developing frequency. Are there any patterns given a specific diagnosis. Can staff use this information to improve realistic frequency plans? Can you help provide patients with expected outcomes based on their behavior/adherence to the plan?
Let us know how your discussions went!

What is the Next Model of Rehab Care? Read that blog from Darlene to find out!

As skilled professionals, our unique training and experiences should lead us to success in what percent of the population we serve?  Do you know your past performance? This might be a start in developing future success.  Know your performance outcomes and continuously work toward improving those measurements.

The route we take is often riddled with many unknowns, yet we overlook the fact that specific answers and lessons in taking the most direct route are within our reach.  Have we done the research or homework to develop the best route and have we created the plan to truly meet the ideal with the straightest most direct plan available?

What are the signs, roadblocks and directions to lead us in the future?  In the era of GPS, conditionally the answers should be at our fingertips.

Lets start with a few questions.

- What is the highest volume condition treated within your clinic?
- What are the most significant symptoms specific to that problem?
- What was the functional goal measurement to determine success in meeting the plan?
- What skilled treatments were provided in the plan?
- What was the established frequency in the plan for that condition?
- What was the provided frequency?
- Was the stated goal met?
- How many treatments occurred to meet the stated goal?
- What were the total charges toward meeting the stated goal?

Almost all answers lie within the data held within charting.   Let me ask again, what percent of the population had success in meeting the stated goal within your population?

At this time in healthcare reform, if your clinic is not already aggregating data like the above, now more than ever, these questions need answers because quality will be measured by outcomes and costs to achieving those outcomes.  It will be one of the most potent ways of reducing healthcare costs.  Provide only what is needed in the amounts required to be successful.  Anything more is wasteful.

More often than not, similar problems will hold similar plans of care to meet successful outcomes. Someone other than our professional skill sets should not dictate the best plan,  but  it will happen soon.  Guidelines for payment often change practice; scrutiny is only just beginning.  As professionals we need to know how successful we are in meeting stated objectives and we need to stand behind the outcomes those decisions and unique skill sets have created within our clinics.

Which route will you take?

Read how MediLink’s Outpatient Rehabilitation Software Solution to see how we help improve your facility’s plan of care.