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Therapy Management

In reviewing charts lately, there seems to be a severe lack of therapy management in home health agencies that depend upon contracted therapy. It seems that in some parts of the country, therapists are in such high demand that we allow them to do as they please as long as they will see our patients. We choose between the lesser of two evils – having a rogue therapist or two or not providing therapy to our patients. This can result in poor care to the patient but most often it results in financial disasters. It doesn’t matter how much you are paid for an episode, if you spend more than you make. These are some of the problems I see regularly throughout agencies.

Referrals: An agency makes a referral to a therapist and when it is convenient, the therapist sees the patient. If therapy isn’t managed, the agency may not know that a therapist didn’t admit the patient until five days after referral. This results in poorly crafted OASIS assessments, impossible resource management and overall sloppy care. A surveyor would deem this practice as poor coordination of care and in some states, a serious hit on survey for admissions processes.

Subsequent Orders: I have never reviewed charts in an agency where all therapy orders were on the chart. In agencies that have solid therapy management plans, this happens less frequently. In agencies that take a haphazard approach to therapy management they have given the surveyors an easy tag.

Extension Orders: This happens when the agency and the therapy provider agree on a plan of care and then the therapist requests additional visits directly from the physician. One therapist I reviewed at an agency consistently did 19 visits because they knew CMS looked really hard at 20. (I don’t make this stuff up.) All home health services must be rendered under the guidance and supervision of the home health agency. I would think twice about paying for additional visits if they were requested outside of the processes of the agency.

Frequency Errors: Missed visit slips are often turned in weekly with therapy documentation. Most times the agency doesn’t even know the visits were missed prior to receiving the paperwork. If the missed visit occurred on the prior week, no agency intervention such as scheduling an alternative therapist can be made. When this results in five or thirteen visits for patients who truly needed seven or 14 visits, it makes me want to cry. Chances are my entire consulting bill could have been paid out of the loss incurred by the agency for sloppy therapy management.

Our biggest problem is that many agencies are okay with this sloppy case management because the alternative is not having a therapist. They will continue to be okay with it until a state agency places them on a termination track for repeated offenses. And no, they don’t often clear therapy related deficiencies on a desk review.

In order to manage therapy, agencies should have in place processes that include:

  • Communication with the therapist the very same day as the referral was sent
  • Inclusion of therapists in case conference even if it is only a phone call prior to the therapist by the primary nurse or case manager.
  • A system for tracking orders
  • A system for tracking visits

Additionally, agencies need to remember that all arrangements by third party providers conform to a written agreement that contains at least the following criteria as outlined by CMS:

……when a provider provides outpatient services under an arrangement with others, such services must be furnished in accordance with the terms of a written contract, which provides for retention by the provider of responsibility for and control and supervision of such services. The terms of the contract should include at least the following:

• Provide that the therapy services are to be furnished in accordance with the plan of care established according to Medicare policies for therapy plans of care in section 220.1.2 of this chapter;

• Specify the geographical areas in which the services are to be furnished;

• Provide that contracted personnel and services meet the same requirements as those which would be applicable if the personnel and services were furnished directly by the provider;

• Provide that the therapist will participate in conferences required to coordinate the care of an individual patient;

• Provide for the preparation of treatment records, with progress notes and observations, and for the prompt incorporation of such into the clinical records of the clinic;

• Specify the financial arrangements. The contracting organization or individual may not bill the patient or the health insurance program; and

• Specify the period of time the contract is to be in effect and the manner of termination or renewal.

If a therapy provider after signing such an agreement violates these terms and conditions, both the agency and the therapist may be held accountable. CMS really doesn’t care if there is an abundance or a shortage of therapists in your area!

As always, I am interested in your comments. If anyone has an effective way to manage therapy, please share it with your colleagues. You can email it to me directly to include as a blog post or paste it in the comments box below.

4 Comments Post a comment

  1. Excellent write up and I could not agree more!

    the only thing you left out was it could cost them their freedom.
    I was recently solicited by an agency that the owner was arrested at and the payments have been placed in suspension.

    if you or I would have been in there two years ago the would be operating smoothly and not facing prison time.

    Great Write up !

    January 19, 2011

  2. Our Therapist call in initial assessment report on adm to our business office and discusses pt status and the # of visits might need. Couldn’t miss the opening. If call does not come we call therapist. to get data re pt eval for willingness and compliance posssible missed # visit dec by appro with missed visit and plan for the week helps advise dr with MVN. Oasis $ =
    # to be made. I am home after dinner and drinks so…….eval apprppriately.

    January 19, 2011

  3. I am a huge advocate of processes. When a patient is admitted to our agency, the nurse calls a secretary to let her know what therapies a patient needs. The secretary calls the therapist(s) and gives the referral(s). The secretary is responsible for tracking the SOC date, the patient, the therapist, date referral given and 1st visit date. If the therapist doesn’t call her with the date of the first visit within 2 days, the secretary calls the therapist back. If the therapist is unable to visit within 48 business hours, the case manager is notified who contacts the doctor. We verify that the delay is approved or we give the referral to another agency that can see the patient more timely. The approval is documented as an order if one is received. Our therapists are requred to call weekly to case manager with updates and order requests. They are also required to call the therapy coordinator if they are unable to make a visit due to their schedule. The therapy coordinator then gets the visit(s) covered by another therapist. All orders go through nursing. Therapist are not permitted to get visit orders for themselves. At the end of each month, secretaries check all charts to ensure we have orders and notes for every visit made. Claims are not permitted to be made without the proper orders. If we don’t have orders or the orders are not back, the claim is held and corrected if needed. If a therapist wants to make more visits than what the therapy coordinator has determined appropriate for specific dx, the therapist must call her and discuss the case. I think we have a good process but someone has to be in charge of the therapist and oversee what they do. I understand the concern about lack of staff. We have dealt with this in the past but agencies should remember that if they can’t provide the care appropriately or timely, the doctor needs to be contacted and for the sake of the patient, offer to give the referral to someone who can provide the needed care.

    January 27, 2011

  4. Hey, that post leaves me feeling fiooslh. Kudos to you!

    May 12, 2011

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