Tag: medicare b

Summer was brought to you by the letter G

Summer was brought to you by the letter G

I shall always remember the summer of 2013 as the summer of G Codes. It has a cold weather counterpart in the winter of 1999 which was, of course, the winter of our discontent, the winter of PPS. I don’t remember what season we were in when KX modifiers hit, but that was a particularly stressful time as well.

Okay, I’m an adult with decades working in the healthcare game. I get the need for periodic changes to the rules for reimbursement. It should be a minimum expectation. As a speech language pathologist, I realize it is part of the job. As a tax payer, I welcome any changes which try to control costs. As an aging American, I hope the changes mean Medicare will be there when I’m done caring for others and need some caring for myself.

And, it is there, with thoughts about the future, where I hit my boiling point. Each new rule, each federal attempt to control costs, each smarty pants MBA or JD adding to the litany of oversight for Medicare reimbursement only seems to add to the spending. How many more manpower hours do you think were needed to “roll out G Codes” to every OP, SNF, Mobile Xray, and other MedB service providers?

Let’s use me as an example. I spent 1 hour in training for G Codes. Over the course of the next week, I spent about 2 hours actually trying to apply what I learned to my real life clients and then entering the data into our documentation system. After the first month’s billing, I spent another 2 hours trying to fix errors which were discovered during transmission. Not bad, 5 hours to figure out a new system and work the bugs out of the software.

I hope everybody working in SNF’s, PT/OT/SLP, only shed 5 hours of the direct care time to this new system. Let’s make up some numbers and see how much was spent for the roll out. Come on, it’ll be fun.
There are 123,200 SLP’s in the US as of 2010 according to the Bureau of Labor and Statistics. Only a small percentage of SLP’s work under MedB. The Bureau says about 9800 work in SNF’s or Home Health. So, we’ll use that number. They also said our mean earnings are $33.50 per hour. If each of us only lost 5 hours to the G Code roll out then the cost would be

That only accounts for the hours spent learning and not the hours of lost revenue because no treatments were provided.
For the 19,560 OT’s working in SNF, their mean hourly rate is $36.73 according to Bureau of Labor and Statistics 2010 information. The cost of their education would be

The Bureau of Labor and Statistics data from 2010 also notes there are 22,000 PT’s earning $38.39 (mean) per hour. Their education using my 5 hours as a yardstick cost

So, my grand total guess-ta-ment is $9,468,319 to education PT, OT, SLP about G Codes.

We should remember that Gnomes with good intentions and pointed hats did not emerge from our med rooms with the materials to decipher and translate the Medicare rules into English. No fairies arrived on moon beams down the elevator shaft to rework the software with sprinkles of stardust to include the G Codes into the programs. And, wanders gangs of elves did not slip in through the solarium room windows and race to rehab to teach the new rules.

All that work needed to get done by people; IT, administrators, billing departments, medical coders and middle managers. I can not even guess how many manpower hours went into that level of work. But, I think we can all agree that more than 5 hours were needed by more than 1 person at every service provider billing under Med B. It is probably safe to assume the cost at that level was at least equal to the cost to educate front line staff.

For the sake of the rest of my rant, today, I’m going to make a rough round figure guess that education for G Codes cost service providers a minimum of $20 million for the roll out. This figure does not include the losses incurred when direct line staff could not treat because they were being educated.

Where are these losses going to recouped?
How will G Codes lead to national savings or even cost controls?
What has any of this got to do with clients who need care?
When was the last time anybody in the federal government asked a direct service provided what is wrong with the system and if they have any ideas on how to fix it?

I’m beginning to despair that Medicare will even exist in 20 years when I need it. Actually, the way the rules are changing, I might be delayed in retiring until well after my 70th birthday.

Why are we all just going along with foolishness that is masquerading as Medicare policy? …

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Unreasonable and Senseless

Unreasonable and Senseless

By Marguerite Mullaney

Unreasonable and Senseless

The cornerstone words in all rehabilitation treatment plans are reasonable and necessary. They have been the yardsticks by which our Medicare reimbursement intermediaries retroactively determine if a claim for service is covered under the Medicare A benefit or Medicare B plan. Seventeen years ago when I first walked into a nursing home and began to learn the rules for providing rehabilitation services in a Skilled Nursing Facility (SNF), reasonable and necessary were applied to every goal of each individualized treatment plan written for our patients.

I might mention, those plans were handwritten by the evaluating therapists. The goals were often agonized over to be sure they fit the reasonable and necessary parameters and could be measured should proof be needed of the final outcome. Way back in the 90’s, the therapist writing the goal was more than likely to be the person carrying it to completion. PTA’s and COTA’s were utilized as an additional resource but not the primary therapist responsible for weekly updates, monthly recertification, home evaluations, and discharge summaries. In short, they assisted the registered clinician in carrying the caseload. Then as now, Speech Language Pathologist cannot use an SLP assistant at SNF level and receive Medicare reimbursement as our PT/OT colleagues can. This means an SLP carries a caseload in much the same way he/she did almost two decades ago.

The rules changed in January 1999. The Prospective Payment System arrived! It was designed to cut Medicare waste and fraud. It was marketed as a means to control the spending at the SNF level which was rocketing out of control. Many inside the industry puffed about the system forcing ‘smaller players’ out of the market thereby cutting the ‘glut’ of skilled beds. We were being told at the time there were 1000 too many skilled beds here in Massachusetts. The extra beds were alleged to be driving up the cost of care.

I have a question: Our entire economy is based on supply and demand. Has there ever been another industry that drove the costs of services up when the supply was greater than the demand?

We are on the eve of adjustments to the reimbursement system. I’ve been told the regulations are going to get even tighter. To be honest, other than knowing rules will be added in October 2010, my knowledge of the changes are very limited. However, I feel qualified based on almost two decades practicing in SNF’s to make a prediction: Nationally based For Profit Corporations will become the primary providors of skilled care beds across the United States.

I have a second question: Large, nationally based for-profit corporations are created to make money and increase profits for their investors. Who will be paying the biggest piece of that revenue? Individuals? Private Health Insurance Companies? The US Government via Medicare/Medicaid?

I might mention here that regardless of clinical setting, the best reimbursement source for an inpatient rehabilitation stay is Medicare. Yes, the same system that was redesigned to control costs in January 1999. It is the system For-Profit Healthcare Providers want well-represented in their case mix. More than want, they rely on Medicare to make their bottom-line.

Here’s a rhetorical question for those who think I’m overstating the value of Medicare A and B to SNF’s: When was the last time anybody heard an Admission’s Director say they needed to fill more beds with Medicaid recipients?

I’ve watched over the last few years as the terms reasonable and necessary have been morphed into new packaging. Many rehab providers are using software systems that have goals listed and waiting to be plugged into an evaluation. Some software triggers the goal a therapist should pick. There are courses with watch words and buzz words to prep therapist to avoid writing an evaluation or a note with a RED FLAG. I’m a realist. I know those types of formulaic programming are a natural outcome of Intermediary Help Letters, Denials, and the dreaded RAC Audits. There is nothing wrong with giving therapists tools to practice within reimbursement guidelines.

But, something more insidious happened while I was distracted watching the major changes. A phrase entered the continuum of care very casually. In fact, it sounded like a good thing on first blush. It wasn’t until it was applied against the stark white of reality, that I truly understood the danger of the concept.

“We treat all our new admissions as ultra highs until they show us differently.”

It doesn’t sound bad. It actually captures the spirit of America. Everybody gets a fair and equal shot at their bite of the apple. Makes you think the care providers don’t pre-judge based on gender, race, sexual orientation, age, or ability. Sounds like equal protection. But, this is exactly the point where everything goes wrong.

We do an evaluation so we can pre-judge and prescribe the appropriate amount of treatment. Our recommendations are supposed to be based on what the patient is able to do during the evaluation. We must take into account their general health prior to illness, their premorbid level of daily activity, the course of their illness, their age, their family’s goals, and their own hopes for their recovery. We adjust the patient’s goals as the treatment plan succeeds or fails. Weekly notes and monthly recerts are there to keep us and the patient focused on progress, or lack thereof.

However, if the expectation walking in the door before we even lay eyes on the patient is that this very sick individual who has been in acute care for at least 3 midnights is to be able to tolerate a minimum of 35 minutes of treatment per day by 3 disciplines over 7 days with 3 hours of group time being evenly divided among disciplines, then the evaluation is completely superfluous.

Most nurses and aides and family members already know a patient cannot walk, eat, talk, or care for themselves. The therapists’ evaluation is meant to provide a means of rehabilitation and a plan of implementation. Computers are able to generate goals based on assessment data of strength/weakness. Assistants for PT/OT carry out most of the plans of care. And, now registered therapists have pretty much lost their authority to determine how much time is needed per day and how many days in a row are necessary to reach functional potentials.

I fear, we registered therapists across disciplines have just become rubber stamps for a plan of care designed, programmed, and packaged to meet the standards of a reimbursement system extracting the maximum dollar amount for care provided to any patient, regardless of their reasonable and necessary needs.

About the author

Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years.

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