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Therapy:

AGENCIES EXPECT MOST PATIENTS NOT TO MEET THERAPY THRESHOLD

Published on Wed May 01, 2002 Print Friendly and PDF PDF

If your home health agency anticipates that the majority of patients will meet the10-visit therapy threshold on M0825, you're out of whack with national averages and that could put you on the feds' radar screen.

At start of care, 36 percent of agencies expected the patient to require 10 therapy visits, according to data culled from almost 700 agencies in the fourth quarter of 2001. That percentage dwindled to 31 at resumption of care assessments, and bottomed out at 13 percent at recertification, show data that Seattle-based Outcome Concept Systems Inc. has provided to Eli. That means at SOC, ROC and recertification, agencies predicted that 64, 69 and 87 percent of patients would not meet the 10-visit therapy threshold, respectively.

Further, according to data based on Medicare patients with only one prospective payment episode of care, HHAs are much more accurate when it comes to determining that a patient will not meet the threshold than they are when determining a patient will. OCS found that 97 percent of agencies surveyed were correct when marking 'no' on M0825 (therapy need), but only 65 percent were correct in marking 'yes.'

It is extremely important to answer M0825 as accurately as possible, because it can have "a dramaticimpactonrevenue,"notes ChristineLang, OCS product manager. For example, an agency could have two patients with identical assessments in all respects except M0825. If the agency marks 'yes' for one patient and 'no' for the other, it could mean a difference of as much as $2,200 in reimbursement, Lang says.

"Agency executives using these data might start by using them to understand if their agencies have more or less high-therapy cases than the national average," Lang coaches. It's important for HHAs to figure out where they stand in comparison to national averages, because agencies that over- or underestimate therapy visits too often could raise medical reviewers' eyebrows, Lang warns.

If you determine that your agency has a higher percentage of high-therapy patients (i.e., patients who require 10 or more therapy visits) than the benchmarking data, your next step is to dig up the reasons why. Lang advises agencies to ask themselves the following questions when investigating differences between your averages and those culled from national data:

  • Does the difference seem appropriate? To answer this question, HHAs should compare their patients' functional acuity with those of other agencies, instructs Kathy Green, director of education with Provider Solutions Corp. in Tampa, FL. If the populations are equally acute, then they should be about equal in terms of therapy visits, she says.

  • What are the defining characteristics of patients who require more therapy, and are those same characteristics prominent in your agency's patient population? If so, what impact does this larger-than-average subset of patients have on the agency's outcomes?

  • How does the fact that your agency has more high-therapy patients affect the agency's revenue and expenses? How does it impact staffing?

    Below-Average Therapy Rates Deserve Investigation

    Agencies that fall well below the national average of high-therapy patients should ask themselves the following questions, Lang advises:

  • Do your agency's patients actually need less therapy?

  • Does your low percentage of high-therapy cases have to do with the availability of therapists at the agency?

  • Is the availability of therapists at your agency reflective of a shortage in your market? If so, how does that impact agency practices?

  • Are more non-therapy visits required to make up for the lack of therapy?

  • Are patient outcomes negatively affected by a lack of therapists?

    Agencies that don't hit the 10-visit therapy threshold as expected also should "look at their processes to make sure they're not missing visits they should have performed," Green notes.

    Using these questions to analyze your performance on M0825 compared with national norms can shed light on your agency's inner workings. Benchmarking can help HHAs "set expectations for the accuracy rate of their clinicians, and provide a heads up on a potential problem area that may raise a red flag for Medicare," Lang concludes.

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