More Is NOT Always Better-The Pitfalls of Rehab Ultra

Good, better, best. Never let it rest…’til your good is better and your better is best.

Is more better? More of this…more of that…if a little bit is good, more must be better, right? A gallon of soda and a bucket of fries? Sure! Why not? But when it comes to therapy, supersizing it is not always the answer. With a payment structure in long term care that rewards more therapy with more reimbursement, it is no surprise that Medicare is re-thinking things!

Even though change is on the horizon for Medicare’s current payment structure to transition to a value-outcomes-based system, long term care professionals are still left to function with the system we currently have for as long as it takes to sort out the details…which, with Medicare’s track record, could be a while.

So let’s look at therapy services in the long term care setting and see how they are reimbursed, what the going rates for Medicare Part A actually are and how it all ties into what Medicare considers “reasonable and necessary.”  Why? Because as the therapy professionals providing the service, it is important for us to recognize the value of our services – both the value to the resident {based on outcomes} and the value to the facility {based on fiscal impact or revenue}. Let’s see what all the Ultra-hype is about.

A Bit About RUGs

The Prospective Payment System [PPS] in long term care was implemented in 1997 [Balanced Budget Act] as a per diem payment system to cover all costs of SNF services furnished to beneficiaries under Part A of the Medicare program. Rates were established for the corresponding Resource Utilization Groups (RUGs) and have been updated annually based on a multitude of factors and ongoing system wide changes. As of October 2011, the RUG scores produced by the MDS 3.0 have been utilized to determine reimbursement based on the rates set for each of the 66 possible RUG IV scores.

What is important to note is that facilities are reimbursed based on the RUG scores achieved on a series of MDS 3.0 assessments performed from day 1 of Medicare Part A coverage through the last day of coverage. {You know the ones – 5, 14, 30, 60, 90 day – and the more recent COT, to name a few}. For therapy, RUG score “groups” are determined based on the amount of therapy [days and minutes] provided during an assessment period, and each RUG score has a daily payment rate associated with it.

RUGs provide a systematic method to categorize the levels of care each resident receives, taking into account the residents’ clinical condition and the Resources needed to provide the care. RUG stands for Resource Utilization Group – the payment associated with each group or score was pre-calculated to cover the facility cost for the Resources that would be needed to take care of a resident at that level.

Think of the RUG groups and scores as rungs of a ladder. As you approach the top of the ladder, the scores increase, as does the payment. Each MDS places the resident somewhere on that ladder, and that rung will determine the payment the facility will receive per day.

• Higher score = More facility resources (staff time and $) are needed to care for the resident = Facility will receive higher reimbursement for this resident in order to care for them
• Lower score = Less facility resources (staff time and $) are needed to care for the resident = Facility will receive a lower reimbursement rate for this resident to cover the cost of care

Think about the cost of care for a dependent resident on a ventilator as compared to a resident requiring only supervision for ADL’s and mobility. The cost of  RN staff time for vent management and the cost of providing total care 24/7 far outweighs the cost of RN staff time for the general supervision of a mobile resident 24/7.

See the attached for the Rehab RUG categories and corresponding daily reimbursement rates –  2016-2017 Rates

If you want to know the exact rate for your state and region, here is a good resource to look each up individually.

The ADL Score

Once the RUG “group” {the first 2 letters of the RUG} is determined based on the clinical condition of the resident, the level within the group will then be determined based on the ADL score from Section G of the MDS. This level is identified by the last letter or number in the RUG, typically A,B,C,1 or 2. The amount of assistance required with 4 ADL’s: Bed Mobility, Transfers, Toileting and Eating, will place that resident in a hierarchy within the RUG. The need for more assist translates into a higher RUG score, and thus a higher level of reimbursement, as the cost of care rises with the increased need for help.

• Example: RMA is a Rehab Medium with a low ADL score (more independent resident / less resources needed to care for) vs. RMC is a Rehab Medium with the highest ADL score (more dependent resident/ more resources to care for)
• If you refer to the attached, you can see that the RMA is reimbursed at a much lower daily rate than the RMC

If you look closer at the attached RUG IV PPS Rate sheet, you will also note that because of the ADL score, there are RUGs lower on the “ladder” that actually have a higher daily reimbursement rate than those rungs above them. This includes part of Rehab Ultra.

• Rehab Ultra (720 minutes per week): The reimbursement ranges from $509.89 (2016-17 Urban) for the more independent resident (RUA) to $609.80 for the more dependent resident (RUC).
• Rehab Very High (500 minutes per week): The upper level of Very High (RVC) pays $523.13, which is more than Ultra (RUA) $509.89
• Rehab High (325 mintues per week): The upper level of High (RHC) payes $455.85, which is higher than Rehab Very High RVA $451.27 and RVB $453.02.

Reimbursement Based on Need

One thing worth repeating {over and over} is that the current reimbursement system is set up to pay facilities according to the resources needed, or the cost for the care a resident needed. It is not solely about what was provided to the resident, but about what was provided based on what that resident needed. A resident receiving IV therapy scores higher than a resident that does not. Would you ever give an IV to a resident that didn’t need it? Absolutely not! Care is provided based on need. Hold that thought.

And how do you know what a resident needs? It all starts out with a plan…a unique plan…an evaluation. For therapists, this is what we were trained to do — assess the resident, identify “problems,” identify potential to improve the “problems,” determine specific goals, determine a time frame to reach the goals and determine a specific plan, including treatments that will be provided at a set frequency and duration to achieve those goals.

If we as therapists can figure {all of that} out through an assessment, we should also be able to figure out how many minutes of treatment will be needed daily to achieve our goals. We should provide what is assessed as needed, no more, no less. And if what we originally planned does not work, we can modify the plan – increase or decrease approaches, days, minutes. All it takes is a little documentation as to what the change is and why it is needed.

Rehab Ultra – The Ultimate NEED

There is absolutely a need for therapy at the Ultra intensity level! There are long term care facilities throughout the country providing sub-acute care to the short term and long term rehab population with great success.

There is a time and place for Ultra – for sure. The problem sets in when “everyone” as a rule receives Ultra intensity. Ultra is the most intensely scrutinized Rehab RUG today by Medicare auditors, partly because it has become an increasing trend. How is it possible that the therapy needs of the Medicare population have increased significantly to an Ultra intensity level over the past few years? What’s different? Is the need increasing or are we adapting to the reimbursement system?

Here is where the whole “reasonable and necessary” premise kicks in…Medicare is wondering why Ultra is now necessary. Medicare is not wondering if therapy is necessary {they know it most often is}..Medicare is wondering if that much therapy is necessary. Does someone get Rehab Ultra because they need it? Because it pays more? Because the census is low and therapists have more time available? Would a facility provide Ultra if it paid the same as High?

It is up to therapists as skilled clinicians to separate want from need and to determine what is necessary based on our skilled assessment of each resident. We are not a cookie-cutter profession where every treatment plan is the same {right}?

What Is Good, Better, Best?

It all starts with a plan, a therapist’s plan, your plan. At a time when as therapists you may not feel like you have control over the course of therapy you are providing, realize you have all the power you need in your pen {or keyboard} though your evaluation and daily documentation. If your resident needs an Ultra High level of service and is responding well, document that. Shout it from the rooftop! Provide supportive documentation for each level of therapy needed. If your resident is set up for Ultra High or any other level of care that does not clinically fit, that too should be documented and discussed. Remember:

1. A therapy plan is not based on what a resident can tolerate – it is based on what a resident needs…what is “reasonable and necessary.” Just because a resident can tolerate more does not mean they should get more.
2. “Everyone starts as an Ultra” is not a valid motto. Not everyone needs it. Therapy should not be set up at the maximum level to “see what happens.” It should be planned out via the evaluation findings and ongoing documentation.
3. A Rehab High is not a “failed” Rehab Ultra.  It is a valid RUG that some residents need – and this need may have nothing to do with tolerance. It is pre-determined.
4. Documentation should support the amount of therapy needed from the initial evaluation through to the discharge summary, including all the ups and downs {COT’s}.
5. Medicare wants to know why your residents are receiving therapy at the RUG level provided. What makes one resident a Rehab High and another a Rehab Ultra? There should be a clinical reason for the difference in minutes provided. Medicare needs to be able to find the answer to that question in our documentation.
6. If your therapy staff is outsourced, how does your therapy company get paid? Do they get paid hourly or based on the RUG scores achieved? The answer does not matter if you, as the clinician, are setting the RUG target based on clinical need and documenting as such. The answer matters if you are not!

The most telling question you can ask yourself is “Would I be providing therapy at an Ultra High intensity if all RUG categories paid at the same rate? Or would I save it only for those who needed that time and level of attention to recover?”

Medicare set up the current reimbursement system based on “reasonable and necessary” with the premise that providers would only provide what is needed. If we, as therapy providers, don’t determine what is needed and support this need through documentation, Medicare WILL make that determination for us through lawsuits, recouping dollars and increased regulations…and that is not good, better or best for anyone!

As always, if you have any questions, Just Ask! via our Q&A Forum.

In Your Corner,

Dolores