Welcome to the HealthPRO Heritage Blog

A Surefire Way to Increase Audits Under PDPM

The number one question we receive regarding the new payment model, the Patient-Driven Payment Model or PDPM is, “Will we be paid for the therapy component even if therapy is not actively treating the resident?” The answer is YES!

Because of this, underutilization of therapy in PDPM will be under scrutiny.

What do I mean by scrutiny? CMS will be monitoring therapy minutes under this new payment model by way of the Discharge PPS Assessment. Therapy minutes will no longer drive reimbursement and the rate will be paid whether or not PT, OT, or ST is actively treating the resident. So you know, this may be used against you. It is imperative to be vigilant in all potential behavioral changes under the new payment model. Here are some thoughts to consider: How do you track and trend these changes and how and what do you audit to ensure strong clinical reasoning based on resident characteristics and need is delivered and documented?

Some food for thought: If you deliver 90% rehab ultra-high today and that changes significantly under PDPM, you must make sure the therapy and nursing documentation supports the decline in services provided based on the clinical needs of your resident population supported by your facility assessment.

Consider your stance and ability to better position yourself in a competitive market. Our Chief Clinical Strategies Officer at HealthPRO® Heritage, Hilary Forman, challenges providers to think outside of the box when it comes to therapy, outcomes, and preferred provider partnerships. Imagine providers in your market attempting to cut therapy services under PDPM, which will in no way affect the overall rate to ACOs or BPCI Advanced participants. What if you say: We will continue to deliver the amount of therapy necessary to get the most effective outcomes and maybe even more therapy than our competitors. How will that be viewed in a highly competitive value based market?

Today, we use our PEPPER reports to help us review for potential risk of under or over billing services. Those PEPPERs will continue to be a key part of the business, they will just look very different when PDPM begins!

Information based on Proposed Rule released by CMS on April 27, 2018.

Written by: Kristy Yoskey, MOT, OTR/L, RAC-CT, Senior Vice President 
Kristy's #HigherCalling: "Everyone has a significant purpose in life, mine is to help others become aware of that purpose - every nurse, CNA, rehab professional, one person at a time." 

Tags: CMS Update 2018, Payment Reform, Patient-Driven Payment Model, PDPM