advanced therapy larger the risk the more management incentive … therapy... · 2013-08-28 · 1....

ZIMMET HEALTHCARE SERVICES GROUP, LLC 1

Advanced Therapy Management

Thoughts About Risk

• Medicare is shifting from a Fee‐For‐Service model to Risk‐Based systems

– Bundling

– Shared savings (ISNP, ACOs)

• Our entire business model is based on per‐day FFS and utilization (RUGs, HCPCS)

• Shift towards “episodic” payment and “shared savings” will require new metrics

• The time is now to start gathering data

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Risk

“The larger the risk the more incentive to actively change behavior to control costs and

provide only those services that are medically necessary”

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Agenda

• Therapy Department Operations

• Productivity vs. Efficiency

• Cost per Unit/Minute

• Profitability

• Episodic Cost

• Outcomes

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Daily Operations

• Therapist Staffing

• Therapist Scheduling/Caseloads

• Interdisciplinary Meetings

• Activity (Medicare/Managed Care/Medicaid) Monitoring

• Therapist Staffing

• Therapist Scheduling/Caseloads

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Regulations Dictate Modalities

• Therapy is one of our biggest cost centers and is our greatest revenue driver… today.

• Loss of Concurrent and Group therapy has altered treatment models and made therapy more expensive– Efficiency becomes essential (Resident Readiness)

– How do we treat Managed Care residents?

– How will we alter model under Bundled payment?

– How will we pay Contract Therapy companies?

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Productivity

• Straight v. Adjusted

– Straight Productivity = Hours Billed/Hours Worked

–Adjusted = Hours Billed/Therapy Clock Time

• Clock Time is defined as the actual amount of time needed to complete the resident caseload, incorporating the mode of therapy

• Factors in Mode of Therapy

Straight Productivity


Adjusted Productivity

Cost Per Unit/Minute

• Department Costs

– Therapist/assistant salary

– Benefit burden

• Cost of Health Insurance

• PTO

• Employer costs

– Administrative staff

– Per diem/weekend staffing

– Agency costs

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Cost Per Unit/Minute

• Therapist treatment time

–Billable hours, units or minutes

– Excludes: 1. Screens

2. Team/family meeting

3. Documentation

4. Administrative management

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Factors Impacting Costs

• Manager productivity

• Therapist/Assistant ratio– NY: 4:1

– NJ: 2:1

– Median salary: PT $88,000: PTA $48,000*

• Benefit burden– Medical/Dental Benefits

– PTO

*APTA 2010 and 2009 Median Income of Therapist Summary Report

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High Cost Care Center

Physical Therapist #1 $88,000



Therapist Assistant $48,000

Total Salary $312,000

Total Cost* $474,240

*(inclusive of Benefit Burden of 52%)

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Efficient Care Center

Physical Therapist $88,000

Therapist Assistant #1 $48,000



Total Salary $232,000

Total Cost* $336,400

*(inclusive of Benefit Burden of 45%)

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What this Means……

• High Cost Care Center

Total Cost $474,240/6,587 (Treatment Hours billed) =

$72/Hour or

$18.00/Unit or

$1.20/Minute

• Efficient Care Center

Total Cost $336,400/6,587 (Treatment Hours billed) =

$51/Hour or

$12.75/Unit or

$0.85/Minute

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Efficiency

• Cost per Unit v. Revenue per Unit

– What are reasonable #s?

– Can this be applied to compare in‐house v. contract?

• High Productivity and Low Efficiency

• Medicare Part A resident with 900 minutes

• Two hour initial evaluation

• Documentation

• High Cost Therapy Department

–Maximize Therapist: Assistant Ratio


Limiting Non‐Billable Tasks

• Morning Meeting

• Family Meeting

• Care conferences

• Screens

• Completion of MDS assessments

• Use of non‐clinical/administrative staff

Episodic Cost

• Why is this important?–MedPAC Recommendations:

• Revise PPS immediately

• Payment for therapy services should be based on patient characteristics (not services provided)

• Broad reform needed! (Move toward ACOs, Bundled payment, Uniform assessment instrument, single‐payment system, New Quality Measures & Care Transitions, PAC H readmission penalties)

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Getting Started

1. Know your therapy caseload

2. Determine common resident characteristics

3. Group resident diagnostic groups (e.g. post‐op orthopedic, neurologic, complex medical)

4. Drill down groups (e.g. neurologic with severe impairment vs. neurologic with minimal impairment)

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Next Steps

• After grouping residents characteristics, perform length of stay study to identify the following:

1. Record start date

2. End/discharge date

3. Disposition

4. Average length of treatment session or sum total of treatment units/minutes provided

5. Number of actual treatment days

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Episodic Cost Analysis

• Calculate Cost/Minute for the entire department

– All therapist, management and administrative staff costs

• Calculate Cost/Episode

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Episodic Cost

High Cost Care Center

Treatment Days in Episode 24

Average Treatment Time per Day 120Minutes of Treatment throughout Episode 2880

Cost per minute 1.20

Therapy Cost per Day $144

Therapy Cost per Episode $3,456 22

Episodic Cost

Efficient Care Center

Treatment Days in Episode 24

Average Treatment Time per Day 120Minutes of Treatment throughout Episode 2880

Cost per minute 0.85

Therapy Cost per Day $102

Therapy Cost per Episode $2,44823

Implications

Current

• Admissions Process

• Managed Care Negotiations

• Case Management

Future

• Marketing to Acute Care

• Profitability

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Outcomes Reporting

• Monthly, Biannual, or Annual

• Utilized for:

– Quality Assurance

– Hospital Readmission Rate (MI, CHF, Pneumonia)

– Marketing to Acute Care Hospitals

– Marketing to Resident/Family

– Length of stay study

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Outcomes Reporting

• Similar to Episodic Study in structure

• Added component of ADL functioning

– ADL status at onset

– ADL status at discharge

• Functional Assessment Tools

– FIMs

– Part B Severity modifiers

– CARE

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Tracking Performance

0

20

40

60

80

100

120

Nuero Post‐opOrtho

MedicallyComplex

Severe ADL

MedicallyComplex

Minimal ADL

Length of Stay

Average FIMImprovement

Percentage of ResidnetsD/C Home

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Outcomes Reporting

• Analyze Results

• Track Improvement/Decline

• Identify Poor Outcomes

• Market Good Data

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Conclusion

• Keep Looking Ahead

• Focus on Improving Quality and Decreasing Costs

• Determine Your Cost per Unit/Episode

• Track and Analyze Outcomes

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Avoiding Medicare Part B Coding Losses

Medicare Part B Therapy

• 4.9M Medicare beneficiaries utilized in 2011

• $5.7 billion in outpatient therapy

• 37% of total spending billed by SNFs (an increase from 29% in 2004)

• PT = 2/3 of therapy billed ($4.1B)

• 2013 Annual “Caps” on OT / PT+ST ($1,900 each)

• Exception process continues (KX modifier)

• $3,700 threshold, then prior auth (auto ADR)– NGS: progress reports required at least every five treatment days after limit???

• MPPR to 50% reduction to practice expense31

Recoupment

• SNFs may not realize they did not receive full reimbursement

• Examine each claim to verify if full reimbursement was received because more lines may have been disallowed per claim

• The AVERAGE facility leaves behind ~ $3,000 per month (based on ZHSG audits)

• Can only go back one year to correct

• Are you affected?32


Common Coding Issues

• CCI edit violations

• Therapy cap adjustments

• Incorrect / missing diagnosis code in support of service rendered

• Timed versus untimed billing issues

• Overlapping date issues

• Modifier codes

• Non‐reply to ADR letters

(30‐day limit)

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Correct Coding Initiative (CCI)

• January 1, 2006 these edits applied to SNF Part B billing

• Edits CPT code pairs billed together because either the code pair represents mutually exclusive services or one code is a component of a more comprehensive procedure code

• Therapeutic Activities (97530) and Gait Training (97116)

• 59 modifier application

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• The Law: Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012

– Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) amended Section 1833(g) of the Social Security Act to require a claims‐based data collection system for outpatient therapy services, including physical therapy (PT), occupational therapy (OT) and speech‐language pathology (SLP) services. The system will collect data on beneficiary function during the course of therapy services in order to better understand beneficiary conditions, outcomes, and expenditures. This data will be used in developing an improved payment system.

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Functional Reporting

• Requires CMS to implement by January 1, 2013:

– Implemented Functional Reporting with a 6‐month testing period

– January 1 through June 30, 2013

– Claims will be returned/rejected without applicable G‐codes and modifiers for dates of services on and after July 1, 2013

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• Required to bill these “non payable” G codes:– At outset of episode (evaluation)

– Every 10 treatment visits

– Re‐evaluation

– At discharge of episode

• Modifiers indicate severity of symptoms

• Therapist should report on only one code set.

• At each reporting period the therapist will report on 2 codes (either Current/Projected or Projected/Discharge)

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The 6 sets typically reported for PT or OT

The 8 sets typically reported for SLP

4 sets are for categorical functional limitations:

• Mobility: Walking & Moving Around

• Changing & Maintaining Body Position

• Carrying, Moving and Handling Objects

• Self Care

2 sets are for “Other” functional limitations:

• Other PT/OT Primary

• Other PT/OT Subsequent

7 sets are for categorical measures:

• Swallow

• Motor Speech

• Spoken Language Comprehension

• Spoken Language Expression

• Attention

• Memory

• Voice

1 set is for “Other”:

• Other SLP

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Code Set Status Documented When?

Current Functional Status •Initial Evaluation•End of reporting interval•Formal re‐evaluation•Start of subsequent limitation

Projected Goal Functional Status •Initial evaluation•End of reporting interval•Formal re‐evaluation•Start of subsequent limitation•Discharge from therapy

Discharge Functional Status •Discharge from therapy•When ending the reporting period of one code set and continuing therapy for a subsequent limitation

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Coding Guidelines

• Used to report severity/complexity for the code set

• 7‐point scale using percentage range of limitation which is assessed by the therapist or the result of a standardized test

• These modifiers are attached to the end of the code set on the bill and are required in all cases

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Severity Modifiers


Modifier Impairment Limitation Restriction

CH 0 percent impaired, limited or restricted

CI At least 1 percent but less than 20 percent impaired, limited or restricted

CJ At least 20 percent but less than 40 percent impaired, limited or restricted

CK At least 40 percent but less than 60 percent impaired, limited or restricted

CL At least 60 percent but less than 80 percent impaired, limited or restricted

CM At least 80 percent but less than 100 percent impaired, limited or restricted

CN 100 percent impaired, limited or restricted

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Severity Modifiers

Manual Medical Review

• October 1, 2012 – December 31, 2012 prior approval required after the beneficiary reached $3,700 threshold

• No preapproval effective January 1, 2013, claims proceed directly to ADR process

• Pre payment review by the

intermediary (MAC) or

Recovery Audit Contractor (RAC)

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MedPAC’s June 2013 Report to Congress

• Improving Medicare’s Payment System for Outpatient Therapy Services (Medicare Part B)

– 2011: 4.9M beneficiaries (15%) used outpatient Tx

– SNFs provide 37% of Part B therapy $ (up from 29% in 2004)

– $ for patients exceeding “cap” are significantly more ($3,698 v. $576 for those not exceeding)

– Significant differences among regions

– Fraud initiatives are working

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MedPAC Recommendations

• Reduce certification period from 90 to 45 days• Develop national guidelines for therapy; implement edits that target aberrant providers

• Reduce caps to $1,270• Implement manual review for requests to exceed cap• MPPR to 50%• Prohibit use of V codes as the principal diagnosis• Collect functional status info using detailed standardized assessment tool to provide the basis for development of an episode‐based or global payment system

• Other:– Lower payment rates after spending exceeds trigger– Increase cost sharing

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• Jimmo vs. Sebilus (see ZHSG Alert) settlement re: Medicare coverage of maintenance therapy

• Coverage based on SKILLED NEED rather than on demonstrated progress

• CMS will revise manual (expected by 01/14) to state that coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy but rather on the beneficiary’s need for skilled care.”

• Implications for CMI may be determined by individual State Medicaid Payment

• MDS 3.0 Section O definitions

• OMIG interpretation?

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Jimmo

advanced therapy larger the risk the more management incentive … therapy... · 2013-08-28 · 1....

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