Assuming Good Intentions
Published on Nov 19, 2015
Medicare for Therapy Services: Good Intentions, Bad Policy
MORE DECKS TO EXPLORE
PRESENTATION OUTLINE
Assuming Good Intentions
Medicare Regulations for Physical Therapy
I wrote a blog article about a year ago indicating that I don’t believe all of the new Medicare regulations are designed with bad intent. You can read it here: http://bit.ly/10rV35h
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Medicare has New Programs
... to contain cost, improve quality, and measure improvement
They are all well intended programs that are complex, poorly designed, and clumsily administered, but the intention is admirable.
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Therapy Services and Medicare
- Therapy Cap - Reduce Cost!
- Functional Limitation Reporting - Outcomes!
- Physician's Quality Reporting System - Quality!
- Multiple Procedure Payment Reduction - Reduce Cost!
- Manual Medical Review - Medical Necessity!
The Therapy Cap is all about reducing costs. Everyone is in favor of reducing costs, right?
Functional Limitation Reporting has the worthy intention of gathering data about effectiveness.
PQRS is designed to improve quality. I am going to step out on a limb and declare that quality is a good thing!
It is a little more difficult to see the worthy intent of the Multiple Procedure Payment Reduction program, but from Medicare’s perspective, an argument can be made that it should cost you less per procedure to provide multiple procedures, so they should pay you less for providing multiple procedures. Makes some sense, I guess.
Of course, it makes perfect sense to review charts for medical necessity after the charges reach a certain level, doesn't it?
Functional Limitation Reporting has the worthy intention of gathering data about effectiveness.
PQRS is designed to improve quality. I am going to step out on a limb and declare that quality is a good thing!
It is a little more difficult to see the worthy intent of the Multiple Procedure Payment Reduction program, but from Medicare’s perspective, an argument can be made that it should cost you less per procedure to provide multiple procedures, so they should pay you less for providing multiple procedures. Makes some sense, I guess.
Of course, it makes perfect sense to review charts for medical necessity after the charges reach a certain level, doesn't it?
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So what Could Go Wrong?
Almost Everything
So, assuming good intentions from smart people, what could possibly go wrong?
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Therapy Cap
Rationing is Rationing
The Therapy Cap is rationing.
The basic benefits are the same for everyone, regardless of their condition.
Period.
The basic benefits are the same for everyone, regardless of their condition.
Period.
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Therapy Cap
- One annual basic benefit
- Regardless of the severity of your problem
- Your therapist may treat beyond the cap
The therapy cap limits Medicare consumers to an arbitrary amount of allowed charges every year.
It doesn't matter if you are being treated for tennis elbow or undergoing rehabilitation for a stroke and an amputation of both legs, your basic benefit is the same.
It doesn't matter if you are being treated for tennis elbow or undergoing rehabilitation for a stroke and an amputation of both legs, your basic benefit is the same.
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So, it is not a "hard Cap"
... But, Continuing Treatment Beyond the Cap is Risky
Oh sure, your therapy provider can treat you beyond "the cap", but then the therapy provider is subject to being audited by Medicare to see if the services met requirements for "skilled care" and were "medically necessary".
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Therapy Cap Risk
Huge financial risk to your therapist
The auditor may not agree with your therapist that the services are necessary. If the services are not necessary, your therapist ends up treating you for free.
More on this later ...
More on this later ...
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Functional Limitation REporting
Turns Out it is Not Easy
The Functional Limitation Reporting Program is designed to gather data on the effectiveness of therapy services. Sounds reasonable, right?
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How Do you Measure Function?
The Functional Limitation Reporting Program is so poorly designed that it will not provide any useful data.
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Measuring Function
All kinds of people, all kinds of problems
It will likely be a classic case of meaningless data (Garbage In) that will be used to design new regulations and requirements (Garbage Out).
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Measuring Function
One unproven measuring system for all
There is no proof at all that the Functional Limitation Reporting system is a valid measurement of function.
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Functional Limitation Reporting
Will Medicare make policy decisions on meaningless measurements?
Why institute an unproven system to measure function that will drive policy?
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PQRS
Measuring Quality?
The Physician's Quality Reporting System (PQRS) has the worthy intention of improving the quality of healthcare.
Sounds great!
Sounds great!
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Physician's
Quality Reporting System
But, the measures were really designed for physician practices.
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But ...
Physical Therapists are not Physicians
Physical Therapy, Occupational Therapy and Speech Therapy are not at all like medicine.
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PQRS and Therapy Services
Quality Therapy is not the same as Quality Medicine
PQRS for therapy services looks more like a way to decrease reimbursement than to improve quality.
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MpPR
Multiple Procedure Payment Reduction
The Multiple Procedure Payment Reduction Program (MPPR) is designed to keep healthcare providers for charging for multiple services when it is not necessary.
Again, sounds reasonable.
But it isn't reasonable for therapy services, because the procedure codes that your therapist is required to use (designed by and for physicians) are DESIGNED so that we must charge multiple 15 minute timed procedures in a visit.
Again, sounds reasonable.
But it isn't reasonable for therapy services, because the procedure codes that your therapist is required to use (designed by and for physicians) are DESIGNED so that we must charge multiple 15 minute timed procedures in a visit.
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MPPR
Reducing Payments on Reduced Payments
Add to that that therapy services are some of the least expensive already, and it is a double whammy.
Reducing payments on already reduced payments makes no sense.
Reducing payments on already reduced payments makes no sense.
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And Now for My Favorite
Manual Medical Review for Therapy Services
Again, the intent of Manual Medical Review makes some sense. It only makes sense to do some sort of audit in selected cases.
It is for the protection of the public and for all honest, hardworking therapists who are trying to do the right thing.
So, what is the problem?
It is for the protection of the public and for all honest, hardworking therapists who are trying to do the right thing.
So, what is the problem?
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Recovery Auditors
Incentive to find "no medical necessity"
The problem is in the incentives and the requirements.
Recovery Audit Contractors are paid to find problems with documentation that does not demonstrate "skilled care" or "medical necessity".
Those terms are defined in the regulations, but they are still subjective and open to interpretation.
Recovery Audit Contractors are paid to find problems with documentation that does not demonstrate "skilled care" or "medical necessity".
Those terms are defined in the regulations, but they are still subjective and open to interpretation.
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Follow the Money
What happens if you get paid to find problems?
If you are paid to find a problem, and what defines a "Problem" is open to interpretation, you will find a problem.
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Getting Paid to Find Problems
Easy to find broken rules if you have books full of rules
There are thousands of regulations that a therapist must comply with, so if you are paid to find technical problems, it is easy to do.
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Good Intentions?
- Therapy Cap = One Cap for All!
- Multiple Procedure Payment Reduction = Unfair Additional Cut in Payment!
- Functional Limitation Reporting = Meaningless Requirement!
- Physician's Quality Reporting System = Not for Physical Therapy!
- Manual Medical Review = Incentive to Penalize Therapists!
So, good intentions?
Mostly.
Mostly.
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Good Intentions
Bad for our patients
And the bad policy affects the care for those patients who need our help the most.
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Tell congress
Clink on the Link in These Notes
Here is an easy way for you to contact your representatives and ask them to end the unfair Therapy Cap once and for all: http://bit.ly/1g8150n
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Call your Representatives
As a Medicare Beneficiary, your opinion is powerful
Click here for information on contacting your representatives: http://bit.ly/1g8150n
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This Can Be Fixed
With your help
Click here for an easy way to let congress know: http://bit.ly/1g8150n
Ask them to end the Therapy Cap now.
Ask them to end the Therapy Cap now.
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