In the days of high-therapy thresholds, my agency was one that did push for the 10 visits.  It was a constant battle for all of us therapists to do what we thought was right for our patients. A colleague came to me with the following question. She evaluated a patient that she deemed would benefit from 2-3 visits for HEP review and caregiver education.   Prior to this year she would have been forced into seeing the patient for 5 visits to avoid a LUPA. I understand there are no LUPA's anymore but I also understand that if we start changing our "practice" we may flag ourselves. Her dilemma was whether to see the patient 2-3 visits or to keep it at five since this is how she "used" to do things.  What would you recommend and how would you recommend making changes in frequency if you have unfortunately been working for a company that was always asking, "Can't you just do one more visit?"

Good for you to have fought the fight to do what the patient needed. That is in large part why the reform came to be – too easy to game the system for fiscal gains and not pay attention to the clinical correctness of programming. The early PPS 10-visit high therapy threshold was based on the premise that patients got better with approximately 8 hours of skilled therapy treatment- broken out into 48 minute visit time average treatment sessions. The Medicare refinements of 2008 are in place to pay for the appropriate number of therapy visits required to get a patient’s goals met and functional outcome scores will help to reinforce this. Remember that pay-for-performance is still on the horizon as Medicare has demonstrations underway in 6 states now.

Your colleague’s concern about “flagging” her agency with a change in practice pattern now is real. The Office of the Inspector General (OIG) in 2007 did audits and found a great deal of issues with visit totals hovering around the 10-12 range. Many agencies came under focused review and found themselves paying back monies they had received for visits that did not qualify as skilled, reasonable or medically necessary. For us, the concern is not that the 2-3 visit patient receives 2-3 visits, but that they received 5 “just because” in the first place. As a clinician, listen to your professional conscience and let the clinical guide what you do ALWAYS. Medicare has reformed their reimbursement structure to force this model on agencies that may have been less than flexible under the old system. Regardless of your fears surrounding the ramifications of drastic changes in your plans, your primary focus should remain crafting clinically responsible and reimbursable programs today.

Teri N. Thompson and Arnie Cisneros are physical therapists with nearly 40 years of combined home care experience. Co-owners of Home Health Strategic Management in East Lansing, MI, they provide clinical service management and home care consulting expertise. They are nationally renowned speakers regarding the PPS refinements of 2008 and therapy utilization under the New Rule.