Blogs and Opinions

New CMS Jimmo Information Website

Finally, after more than four years CMS launches an informational webpage regarding the Jimmo class action lawsuit settlement.

Even after four years many therapists and administrators struggle to understand what it really means for therapy services and your residents. Hopefully, this blog can offer some insight. Please feel free to share with others.

Even after four years many therapists and administrators struggle to understand what it really means for therapy services and your residents. Hopefully, this blog can offer some insight. Please feel free to share with others.

First, the Jimmo class action lawsuit was filed on behalf of some chronically ill Medicare beneficiaries who were being denied ongoing therapy services because the Medicare payers (MACs) said they did not show improvement as a result of the therapy services. Their claim was that Medicare actually has no stated policy that therapy must show improvement to be a covered service, only that therapy must be medically necessary and that are receiving skilled services provided by skilled professionals (and cannot be provided by unskilled caregivers). They claimed this includes therapy to not only show improvement but also to maintain their condition, and slow or prevent deterioration. The judge agreed. The settlement requires CMS to better educate the MACs as to what therapy is acceptable. This new website is part of that settlement. CMS, on their Jimmo website states:

"Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program."

So what does this mean for your and your therapy team?

There are two big takeaways for therapists to incorporate into their daily treatment encounters.
1. Expand Clinical Programming. Many therapy departments, fell into ruts in terms of what types of therapy to offer residents. We would self limit therapy to ambulation, stairs, repetitious types of exercises because it was easy to demonstrate improvement; 10 feet yesterday, 20 feet today or 15 SLR's last week, 30 this week. And this made discharge easier as well. a few days go by without increasing distance or repetitions, they are discharged ("they have plateaued!").

Now we can and should expand our therapy "toolbox" to include programming that is medically necessary but not always easy to quantify improvement. It is time to look at all of the things that therapy can/should do to ensure a safe discharge to home. Dive deeper into balance and vestibular issues, look at endurance and energy conservation, address low vision, cardiac stability, poor safety awareness.

We can and should take a fresh look at what therapy programs and services we provide our long term care residents. Medicare is very clear that maintenance programs are an appropriate treatment choice. It is better to develop maintenance therapy programs to slow deterioration rather than abruptly ending skilled therapy and getting patients on the endless on/off therapy cycle that so many LTC patients seem to be stuck in. From CMS' FAQ section: (Find it here)

Q7: Can a patient change from an improvement course of care to a maintenance course of care, and vice versa?
A7: Yes. The therapy plan of care should indicate the treatment goals based on an individualized assessment or evaluation of the patient. Skilled services would be covered where such skilled services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.

2. Significantly Improve Our Therapy Documentation: For years our documentation habits have justified and enforced the "improvement based" model. Our notes record distances, repetitions, etc. We must fundamentally change the way we write our notes to reflect the attributes that define medical necessity and skilled therapy. CMS states: "that the specialized judgment, knowledge, and skills of a qualified therapist,...are necessary."

We must better describe the types of ongoing assessments we perform throughout a treatment session, the education, and the cueing (both tactile and verbal). These are the things that a trained professional can offer that an unskilled caregiver cannot. Anyone can "ambulate" a patient but only a therapist can assess and correct the different phases of a patient's gait during that ambulation session. We do it but don't document it.

Want to Learn More?

Terapia Consulting, LLC
call: 978/877-9878

Copyright 2017 Terapia Consulting, LLC

CMS Announces New "Probe and Educate" Fraud Audit Process.

Earlier this week CMS announced a new audit process aimed at reducing fraudulent behavior and claim errors by providers. This new approach instructs Medicare Administrative Contractors (MAC) to use a sampling of 20-40 claims per provider, per item or service, for each round (up to one year). Those providers with high error rates will receive education, allowed some time to correct their processes, then be re-sampled.

According to CMS "Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, or other action."

Providers who are found in compliance with the probe will be excused from further action for at least 12 months.

Take Away Messages

#1 Make sure you are one of the providers "doing it correctly"

This new audit process appears to be keeping with the CMS themes of "don't be an outlier" and "keep off the radar". Medicare is over burdened with their various fraud investigations and as we know their appeals process is overwhelmed. This new process seems to be aimed at focusing their limited resources by rewarding providers who are doing it correctly and going after those who aren't.

#2 Make sure your therapy program is "doing it correctly"

One of the biggest areas of fraud investigations in SNFs is therapy billing and documentation. Over the past few years we have seen dozens of therapy related findings costing providers (both national and regional) hundreds of millions of dollars in penalties.

#3 It's OK to Ask for Help

Therapy rules and regulations have changed significantly over the past few years making it more difficult for therapy managers to stay ahead.

Terapia Consulting can provide your facility with a one day onsite independent assessment of your therapy program's compliance with billing and documentation regulations. Our review will look at coding, minutes utilization, RUG category patterns, PEPPER Report comparisons, and assess clinical documentation for medical necessity and skilled services requirements. Our approach is to both review and educate. We can provide staff education as part of our audit process.

And for those providers using a contracted therapy service, Terapia can do an independent assessment to assure their practices are not putting your facility at added risk.

Call, text, or email me to set up a free initial consultation to see how we can help your facility.

Copyright 2017 Terapia Consulting, LLC

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