The shift in the delivery of therapy services in the SNF setting over the past decade has some therapists scratching their heads. For those therapists who have been engrossed in the SNF setting for years, the shift may have been gradual enough to go unnoticed. However, therapists entering the SNF world from other practice settings including private practice, home care, peds and acute care, are perplexed with the methodology behind SNF Rehab Management strategies and therapy delivery in some facilities today.

So what has happened to the delivery method of therapy services?

It’s all about the minutes…

This delivery method, of course, is not found in all facilities, and hopefully what will be discussed here will not pertain to yours! But the shift IS prevalent in enough facilities today to warrant a discussion.

SNF therapists are expected to deliver therapy minutes.

Therapists {in all practice settings} are born and bred to use critical thinking skills, assessment skills, reasoning and decision making skills to drive care and positively impact the lives of patients. On top of those skills, SNF therapists have the additional love for treating the geriatric population, as well as the complexity and autonomy that goes with it. Geriatric therapists are masters of neurology, orthopedics, wound care, comorbidity management, pharmacology, medication interaction, bargaining, family counseling, team building, compassion, peace-making and much more!

Never once was it mentioned in undergraduate, masters or doctorate level education…”make sure you get all your minutes.”

This wonderful knowledge, expertise and autonomy that geriatric therapists possess has, in some facilities nationwide, been reduced to having therapists and assistants follow a “To-Do” list every day. Sure, we all have a “To-Do” list that we use to guide us…a list of general items or tasks we want to accomplish in a set period of time. But the “To-Do” list for therapists in the SNF setting can be a bit more detailed and can strip clinical judgement from the therapeutic delivery process. This “list” is comprised of patients in need of treatment for the day, and includes the exact {preferred} number of minutes the treatment should be. Why? Well, that’s a long story, but in short, to ensure reimbursement targets are hit. For Medicare Part A, an accumulation of treatment minutes roughly every 7 days ultimately creates a RUG score by which the facility is paid, and assigning “minutes” to therapists ensures the projected targets are hit every 7th day. For Part B, therapy is billed in units with unit thresholds at specific intervals. Whether therapy is provided at the lower or upper minute level threshold of each unit, the reimbursement is the same…so why not just provide the minimum? Sounds harmless, right? Well, it can be…but the problem is that when the “minutes” are assigned without regard to patient need, and are solely to hit the highest paying targets, the “therapy” gets lost in the “minutes.” To learn more about RUGs and the potential abuse associated with them, see the article “The Pitfalls of Ultra High Rehab.”

Let’s look at the structure of a typical SNF therapist’s daily treatment schedule, or “To-Do List.” It is handed off to the therapists upon arrival and off they go!

  1. Resident 1: Individual Treatment 67 minutes
  2. Resident 2: Individual Treatment 72 minutes
  3. Resident 3: Concurrent Treatment 58 minutes
  4. Resident 4: Evaluation 15 minutes; Treatment 65 minutes

As you can see, the minutes are not in a range or rounded, they are often exact…and the expectation is NOT to exceed the assigned minutes. The control of minutes seeks to not only hit the target RUG but also prevent “over-delivery” or “wasted minutes.” When taking a step back to look at this delivery structure, it makes great business sense – maximizing efficiency with resulting increased revenue. “Not a minute wasted.” However, those in the profession of treating patients {A.K.A. “humans”} know that “nothing” is exact, especially time. How can it be? Unless therapists use stopwatches and are willing to stop a treatment regardless of what the resident is in the middle of doing as soon as “time is up,” the ability to provide exact predetermined minutes seems highly impossible. Wouldn’t clinical judgement tell you when the session was over, not a “To-Do list?”

How can someone other than the clinician involved pre-determine treatment minutes? Are therapists expected to function like Robots? Resident #1, 67 minutes….?. Resident #2, 72 minutes…?…Resident #3…

Looking at other professions {that are also revenue driven} illustrates how silly the SNF therapy delivery model of being “assigned and confined to minutes” really is. Can you imagine your physician spending 43 minutes with you on 1 visit and 27 minutes on the next visit…because that’s what he was assigned based on what someone in his office pre-determined? Based on HIS reimbursement and not YOUR need? Or your dental hygenist cleaning you teeth “a second-time” because she had “more minutes” to deliver that day.

Sure, other practice settings are productivity-based and the push may be to “do more” in order to maximize reimbursement. Acute care may push seeing as many patients per day as possible, as well as in outpatient and home care. But in “doing more” the clinical judgement is not taken away from the therapist. There is a difference between being told “do more” and “do this” {exactly as assigned, down to the minute}.

So why is therapy delivery in the SNF so different? Well, it is not meant to be – it was not always this way. Honest. When the RUG system was developed, it was modeled based on what was actually happening in therapy. Therapy was observed with all patient types and the reimbursement rates were assigned based on what was actually happening across the country. The Ultra RUG was a rarity, and established to reimburse for those complex residents that required extra therapist time. If the resident had complex medical and/or therapy needs, the facility was reimbursed more than if those needs were not there. Makes sense right? A facility needs revenue to support the care of the residents. Facilities that provided complex treatments or lengthy therapy sessions should be reimbursed to cover the cost of those expenses. But over time some saw the incentive to provide more care to get more revenue – the exact opposite of how it is supposed to be. If we provide it, they will pay.” Gradually the shift occurred from 10-20% of billed days at RU to >50% across the country. In some facilities, practice patterns changed….”Time” was assigned first and then the “time” was filled with therapy. The days of providing the therapy needed and then billing the time it took to provide it began to fade away.

One significant misconception heard from therapists in the SNF setting is “but Medicare requires 75 minutes/day for a Rehab Ultra RUG. Medicare needs to change the reimbursement system so this won’t happen. It’s Medicare’s fault.” Noooooo! While Medicare is not perfect, this is NOT Medicare’s fault. Medicare will never tell a therapist how much therapy to provide or for how long. Medicare regulations stipulate that what is provided must be reasonable and necessary in frequency, duration {and minutes}, and require the skills of a therapist. Medicare will never dictate how much to provide. That is where the skill of the therapist comes in. Medicare will only outline what the reimbursement will be based on what was provided.

It is not about minutes. It is about need. Need determined by a therapist through the evaluation process. An ongoing evaluation process.

The therapist determines the need {RUG level} {treatment minutes} and this need should be supported through documentation. Unfortunately, not all facilities are identifying a clinical documented need and providing care accordingly, but instead, are providing a level of care at a high RUG (lots of minutes) and do not have the documentation to support it. If you have heard about the multiple SNF False Claims Act lawsuits (great article) this is what they center around. The Department of Justice in these cases cites fraud when the level of therapy services are established based on financial targets rather than the patients clinical need. 

Now, you don’t have to be a facility that determines care based on financial targets to be dragged into a FCA lawsuit. You can be a facility that thinks they are following all the rules, yet be missing the supportive documentation from a therapist to back up the level of services you are providing. The only way to support what is being provided is through documentation of need – done by a clinician.

So, long story short, can you trace back the amount of therapy your residents are receiving to therapy documentation? Do you know if your “To-Do List” and the minutes assigned for treatment are backed up by documented clinical need? Or is it possible the minutes are assigned to achieve financial targets? If someone reviewed your documentation, what would they find? Departments that are more focused on targets vs the clinical need of the resident may favor staff that function more like “robots” rather than clinicians as this makes targets easier to attain.

What are some signs that your department may have “robot” issues?

  1. The treatment schedule is managed by 1 person with little or no clinical input from therapists
  2. All therapists receive an assignment including exact minutes expected to be provided, no overage
  3. Treatment schedules and minutes assigned are never questioned
  4. Therapists have limited access to view treatment times for prior days or other disciplines in order to see the big picture
  5. Treatment minutes that are not provided today are then added to tomorrow
  6. Resident treatment minutes have major fluctuations from day to day {ie: 35-80}
  7. Resident treatments are juggled between multiple therapists – lack of consistency
  8. There is a large number of per diem staff {as they may not question their assignment since they may not be there enough to notice an issue}
  9. Staff unfamiliar with the residents are asked to complete the progress notes and Recertifications
  10. Therapists are seeking ideas to “fill up the time” assigned for treatments due to multiple minutes to provide

Ironically, some of these aforementioned “issues” can be found in the DOJ Lawsuits as red flags pointing to a lack of resident-centered care.

So as a therapist, what can you do?

  • Make sure therapist clinical judgement is part of the decision making from evaluation through discharge
  • Include rationale for the amount of therapy the resident receives in your documentation. It is ok to talk about RUGs and minutes in your documentation!
  • If you are assigned a treatment time that does not appear to be based on clinical need, document recommendations in your daily note
  • As a therapist, take an active role in managing your residents. Advocate for a consistent caseload
  • Educate others {yes, this includes some managers} that exact assigned minutes with no overage is unrealistic and offer alternate suggestions
  • Ask questions!
  • Provide what is needed – over or under- you’re the clinician!

There is nothing wrong with providing a service that generates revenue – it is the only way to sustain an organization and continue to provide the care residents need. The key is that the level of therapy provided is based on need, not targets. The current defects in the SNF therapy delivery system will be around for as long as therapists working in this setting allow it. {Ouch!}

Therapist or Robot? YOU get to choose:

Therapists use Skill to determine Need….. they then provide therapy based on that Need.

Robots complete “To-Do Lists.”

Choose wisely.

In your corner,


Dolores Montero, PT, DPT, GCS, RAC-CT, RAC-CTA

SNF Therapy & MDS Compliance Team


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