Back to Basics – Reasonable and Necessary

I had been practicing in the field of geriatrics for a “while” when I found out. Before that, I had many a day where I cursed Medicare for their “crazy” rules – rules that seemed to change every time I learned them. I was amazed how some therapists “just knew the rules.” How did they know?

And then one day, it happened. I learned the news. I was shocked. There was A MANUAL. What? A rulebook? Really? Why didn’t anyone say so! (or why didn’t I think to ask sooner?) Did I learn about the Manual in school? In on the job orientation? Did I miss it?  OMG Everyone but me knows about this Manual! So I printed it and started reading, and reading, and reading…. How could it be that information this vital to our practice would be something barely {not even} covered when I went to school, or covered on any new employee orientation I have participated in…ever!HOW DID I MISS THIS?

Then I realized…I wasn’t the only one. There were others. They missed it too. They didn’t know about…The Manual.

Well, decades later, I’m still reading, and reading, and reading and thought it was time to share the following with those of you working in geriatrics in the off chance that you may not know about…The Manual. Now, more than ever, we should give it a read! The integrity of our profession may depend on it!

The Medicare Benefit Policy Manual for Medicare Part A and B

The Medicare Benefit Policy Manual is one of many on the list of Internet-Only Manuals (IOM) provided by the Center for Medicare and Medicaid Services (CMS). The Manuals are CMS’ day-to-day operating instructions, policies and procedures. They are based on statutes, regulations, guidelines, models, and directives. The CMS program components, providers, contractors, Medicare Advantage organizations and state survey agencies use the IOMs to administer CMS programs. They are also a good source of Medicare and Medicaid information for the general public {though not likely on anyone’s top 10 reading list}.

A list of all the IOM’s with links to each can be found here.

The Medicare Benefit Policy Manual (MBPM)

The Medicare Benefit Policy Manual (MBPM) is otherwise known as “Publication 100-02.” It is made up of 16 Chapters and covers Medicare guidelines for multiple settings, including: Inpatient Rehab Hospitals, Home Care, Skilled Nursing Facilities and Outpatient Therapy. A list of the 16 Chapters can be found here.

In general, the MBPM guidelines discuss Medicare coverage in the above settings from a “Part A” perspective. The only Chapter that is dedicated to “Part B” covered therapy services is Chapter 15. The Medicare rules and specifications are different for each practice setting (though there are some similarities). When referring to the regulations you are looking for, it is important that you are pulling them from the correct Chapter of the Manual, or you may be applying the wrong rules to your setting.

The guidelines for providing skilled services, services that are deemed “reasonable and necessary” are addressed here.

Based on your practice setting, these are the Chapters that may interest you:

Chapter 1: Inpatient Hospital Services for Part A

This Chapter should not be confused with short term/inpatient rehab services provided in a skilled nursing facility. This is strictly inpatient hospital beds, not long term care Medicare/Medicaid certified beds.Here is the link to Chapter 1.

Chapter 7: Home Health Services

This Chapter is specific to home health services covered under “Part A.”  If a home care agency provides home health under Part B, the rules in Chapter 15 will govern this. Here is the link to Chapter 7.

Chapter 8: Extended Care Services Under Hospital Insurance (SNF Part A)

This is the Chapter pertaining to Medicare Part A covered services in a skilled nursing facility (SNF). Residents covered under Part A in a SNF follow the Prospective Payment System (PPS) Minimum Data Set (MDS) schedule. Reimbursement is allocated based on the Resource Utilization Group (RUG) a resident is in—for therapy, this is determined by the total number of days and minutes listed on the MDS during any given MDS cycle. Here is the link to Chapter 8.

*All recent lawsuits against skilled nursing facilities alleging therapy services provided that were unreasonable and unnecessary fall under the regulations of this Chapter. Over-utilization of Rehab Ultra High therapy RUG category is in question in these lawsuits when it comes to reasonable and necessary.

Chapter 15: Covered Medical and Other Health Services (Outpatient Therapy)

This is the Chapter that encompasses all therapy services covered under the category “outpatient.” Outpatient refers to physical, occupational and speech therapy services provided and paid utilizing the Physician Fee Schedule (Billing codes and units of services). The title, “outpatient,” may be misleading, as residents of a SNF are included, as are home care residents and hospital residents in an observation stay. Traditional therapy outpatient settings are also in this category. This Chapter is, by far, the most detailed Chapter of the MBPM when it comes to laying out rules and requirements for therapy services, including documentation, supervision and coverage. Here is the link to Chapter 15.

Integrity in Practice

As therapists, we have the wonderful flexibility in our profession to work in our choice of a variety of practice settings. We can work in private practice, acute care, long term care or the school setting, to name just a few. With this flexibility also comes responsibility…responsibility to understand the regulations that govern each setting. Therapists in private practice apply for Medicare Provider Numbers, and with that, undertake the responsibility of knowing and abiding by the Medicare rules and regulations in Chapter 15. Therapists that work in other settings providing treatment to Medicare patients (skilled nursing facilities, home health, hospitals) may not have their own individual Medicare Provider Number, but are equally responsible for knowing and abiding by the rules. In those settings, the facility or entity has the Medicare Provider Number and those in an administrative role in those facilities are charged with the responsibility of making sure the staff {therapists included} are educated on the rules and practices for each governing body.

Does your employer ensure you have access to the most up to date Medicare regulations and/or provide training as such? If not, ask.

The APTA recently initiated the APTA Center for Integrity in Practice. Click here to check it out. You do not need to be an APTA member to access it. It is designed specifically for therapists, educators, students, and leaders to better understand fraud, abuse, and waste in health care and the impact they have on the profession of physical therapy, on individual PTs, and on their freedom to practice. The goals of the center, as noted on the website, are:

to help PTs and PTAs identify and understand the risks and possible pitfalls associated with fraud, abuse, and waste. The site will provide specific solutions and resources to reduce those risks and improve care, and to navigate the complex regulatory and payment environment while promoting value and quality in care.

Anyone can visit the site and earn 2 contact hours (.2 CEU’s) free by taking the online course “Navigating the Regulatory Environment: Ensuring Compliance While Promoting Professional Integrity.”  (You do not need to be an APTA member but will need to create a user account to access the free course).

Reasonable and Necessary – Something to think about

Medicare has recently recouped millions of dollars from skilled nursing facility providers and hospital systems across the country for therapy services billed that were not supported by documentation or deemed reasonable and necessary.

Here are just a few – and can be found in detail on Justice.gov

• Released 11/19/13. Medicare recoup of $48 Million from 6 SNF’s in California operated by the Ensign Group.
• Released 9/5/14. Medicare recoup of $3.75 Million from 2 SNF’s: 1 in Iowa and 1 in California. Rehab services provided by subcontractor RehabCare
• Released 9/15/14. Medicare recoup of $3.5 Million from 1 Maryland SNF. Rehab services provided by subcontractor RehabCare
• Released 3/2/15. Medicare recoup of $3.5 Million from 3 NY SNF’s. Rehab services provided by subcontractor RehabCare
• Released 3/30/15. Medicare recoup of $1.2 Million from 1 Maine SNF. Rehab services provided by subcontractor RehabCare

Ironically, the therapy services were often provided by an outsourced rehab company,  therefore the penalty went to the provider…the facility…the one with the Medicare Provider Number…the one who submitted a “false claim” likely without knowing it was “false,” NOT the therapy provider.

Two NEWEST lawsuits for unreasonable and unnecessary therapy services have come to light and have yet to be settled. These will be the biggest yet…and you can be sure these won’t be the last. These are currently allegations only and amounts have not yet been determined.

• Lawsuit filed 11/28/12. US vs. LifeCare Centers of America, an owner/operator of 200 SNF’s providing in-house Rehab.
• Lawsuit filed 4/21/15. US vs. HCR Manor Care, an owner/operator of 281 SNF’s providing in-house Rehab through an affiliate “Heartland Healthcare Services.”

There is quite a ruffle out there in long term care with stories of therapists working for rehab companies who may be feeling “uncomfortable” with the day to day expectations….minutes and more minutes laid out for them to provide with minimal clinical input as to why. Therapists are assigned a schedule of treatments to follow with the total expected treatment minutes predetermined.

Reasonable and necessary can only be determined by the evaluating clinician and clinicians involved in the direct care of the resident. Clinicians involved in establishing a frequency and duration for therapy, as well as the treatment plan of care, would be the ones to have the insight into determining the amount of daily therapy reasonable and necessary for a resident to achieve set goals. There is absolutlely an appropriateness for the use of Rehab Ultra, particularly in the sub-acute true short term rehab population in the skilled nursing faciltiy setting. However, when Rehab Ultra is blindly provided to all who enter your facility without the ability to clinically determine why, that’s an issue.

More is not always better. More is not always necessary.

More should not be determined at the corporate level.  

This is the common thread weaved through each of these lawsuits. Who is determining the amount of therapy your resident needs and is this amount reasonable and necessary?

If you are a Rehab Manager, click on the lawsuits above and read the detail in them. They are not about the individual clinicians in the long term care setting providing unnecessary therapy. They are much more than that. These lawsuits came to light because therapists and managers did not agree with their company “top-down” practice of MORE. These lawsuits will continue until the usage of the Rehab Ultra RUG is the exception and not the rule, or at least, justified in the documentation.

The APTA Center for Integrity in Practice web site has resources to help clinicians sort through issues such as these, as well as examples of fraud, abuse and waste that may be surprising to some. Today, I urge you to do just 1 thing. I urge you to read the attached 2 page document from APTA, AOTA and ASHA entitled “Consensus Statement on Clinical Judgement in Health Care Settings.” Print it. Post it. Keep it.

Today’s blog is a step toward directing professionals in the field to the source documents provided by Medicare, the Manuals. We all have a professional responsibility as providers and our lack of awareness will not protect us from allegations of fraud and abuse.

We all want to do the right thing, we all want the best for our residents…and it is NEVER too late to start reading the Manual!

It’s reasonable AND necessary!

As always, if you have any questions, submit them to our Q&A Forum, JustAsk!

In Your Corner,

Dolores