Many Home Health Forum readers contact us with a wide variety of questions that relate to a multitude of homecare topics: clinical concerns, programming, best practices, regulatory, etc. Over the past few months, an increase in correspondence relating to agency-based directives regarding clinical programming and delivery illustrate a trend that we find troubling. We are referring to therapists receiving questionable instructions regarding the Medicare Home Health benefit from administrators or clinical supervisors. Much of the direction we are discussing can be characterized as misleading interpretations of CMS regulations regarding homecare. Coincidentally, the directives are always interpreted in a manner that would prove to be financially beneficial for the provider. Today, we will examine some of the topics heard regularly and share our opinions.

            Most of the concerns revolve primarily around therapy visit totals prompted by the 2008 New Rule refinements. Prior to the introduction of the New Rule, therapy reimbursement was centered around the 10-visit, high therapy threshold. Therapy programs consisting of 6-10 visits were all reimbursed at the same, low threshold level. Not until the combined therapy visit total reached 10 did the payment level change, and then it increased approximately $2300/episode. The New Rule altered the therapy model by “smoothing” the payment levels along a graded scale (see comparison reimbursement graph) as a means of eliminating the gaming that was occurring around the ten visit threshold (pre-PPS therapy visits average of 17 had declined to 11). This change was implemented by the creation of a new Service, or “S” score (of the HHRG), mechanism that serves to identify a more specific payment/visit total paradigm.

            Most of the concerns revolve around the Service levels that denote visit ranges: S3 & S5 (Equations 1&3) or S1, S2, or S3 (Equations 2&4). In this case, the issue in question relates to the comparable rehab costs based on visit totals that are included in the ranges. To be specific, an early episode S3 patient receiving 7-9 rehab visits would capture approximately $2406 for the agency. If the agency needs to pay the therapist for seven visits, the agency realizes $344/visit ($2406/7). If the agency needs to pay the therapist for nine visits, the agency realizes $267/visit ($2406/9). Clearly, agencies that specifically instruct therapists to avoid visit totals of 8 or 9, 12 or 13, 15,17,or 19 are continuing to participate in a contemporary form of the “gaming” the New Rule intended to minimize. I would point out that I have not heard of any providers offering to share this desired level of savings with the therapist.

          Other readers have described agency instructions regarding Modification of Home Exercise Programs (HEP). The tendency to convert the need for modification into an ongoing Home Health program, sometimes resulting in multiple re-certifications, is clearly an example of an abusive practice. Also troubling are reports to continue therapy services to patients who have met their goals under the guise of assuring that the patient is “stabile” and will not exhibit further decline. The CMS and Medicare regulations on all of these topics are clear and not open for interpretation. Agencies and providers who participate in these practices will soon find that pure clinical programming and efficiency will be the only path to Home Health success in the near future.

            The combination of many factors will change the realities of Home Health programming in the months and years to come. The introduction of the Recovery Audit Contractor (RAC) program, which began Home Health audits as of March 1^st of this year, will require homecare providers to assure skilled progress exists in all service delivery. How will RACs respond to visit totals that seem to be derived from a desire to maximize agency income? How will they view extended (and recertified) episodes to modify HEPs? And how will they view the continuation of episodes after the patient has reached their goals?

            All Home Health therapists, whether employed or contracted, should challenge the use of their professional licenses in the manners described above. Rehab professionals are mandated by their Code of Ethics and their State Practice Acts to act in the best interest of their patients and follow professional standards of conduct. These principles should guide all clinicians to find the correct clinical and programming paths for their programs to follow.