Posted by: Robert Markette
June 26, 2007
Topic: New from CMS

I was reading another article on the new Home Health PPS and was struck by something a consultant said. The consultant was discussing the new therapy thresholds in the revised PPS system and mentioned that in his experience many agencies were not utilizing OT sufficiently. He suggested that agencies could justify higher numbers of therapy visits if they properly utilized OT.

While this may be a legitimate clinical point, the article made me a little uncomfortable. In the comments to the new PPS rule, CMS discusses that prior to the implementation of the original PPS rule, the statistical analysis they performed showed therapy visits clustered at around 7. When they began analyzing data for the new PPS rule, the visits clustered around 10. Needless to day, CMS things agencies have been gaming the PPS system in order to increase their reimbursement.

Because CMS is suspicious as to the basis for the upswing in therapy visits, CMS has revised the therapy thresholds. In response, consultants are already offering strategies to better utilize therapy visits, which will lead to an increase in the number of visits. This in turn would help an agency reach a higher therapy threshold and larger reimbursement. One article suggests that agencies are using 10 visits when they should be making 13-14 visits. While this may be true, I would be very cautious ramping up therapy visits as the new PPS goes into effect.

Given that CMS has stated in the comments to the revised PPS that it believed agencies were gaming the system to increase reimbursement, I cant help but think CMS will be very suspicious if it begins to see the number of therapy visits performed by agencies increase after the new PPS rule goes into effect. (They will be even more suspicious if your visits jump from the old ceiling to the new ceiling.) You can be certain they will examine the data from after the new PPS and they will notice a sudden increase in the use of therapy. It will be hard for the home health industry to argue that clinical practice determined a larger number of visits were always appropriate at the same time the new PPS rule went final.

In the same vein, it will be hard for agencies to say that they have been providing too few visits for years and just happened to discover this failing at the same time the therapy threshold jumped to 14. Again, I agree that in some cases this may be possible, but if the standard number of therapy visits jumps after PPS changes, OIG may very well take a long hard look at the industry.

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