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Article of the week: Location, Location, Location

Rehab Regs, February 29, 2008

How to create consistency among multiple rehab branches

If you work for a large rehab chain or a smaller organization that is spread out geographically, you may have therapists floating between locations to ensure proper coverage for all your patients.

Read on to find out how all branches can provide the best care possible and why operations synchronicity is so important.

Aside from wanting to make sure that your quality of care is high at all locations, uniform procedures also make life easier on therapists. By streamlining documentation and billing protocols, a therapist always knows how to explain the skilled services he or she provides. This is even more important when you have one therapist subbing for another at a branch location. He or she should be able enter the clinic, look at a patient's chart, and know what services to provide during the visit.

"Everyone is in a recruiting pinch right now, so there are many therapists floating out to different locations," says Karen Eyberger, MEd, CRC, rehabilitation development manager for Genesis HealthCare System in Zanesville, OH. "It's essential that when they go [to a branch location] 30 miles away, they can walk right in and do their job."

The larger your facility is and the more locations it contains, the easier it is to find differences in the way therapists complete and record treatment. Although you may want to ensure that therapists retain the freedom to use their own clinical judgment in treatment, at minimum, provide them with a guideline to follow, especially when it comes to documentation.

"Everyone's style is different, so it's easy for a large facility with multiple locations to fall out of sync," says David O. Lane, PT, MHS, manager of Compliance Chart Links, LLC, in New Haven, CT. "Facilities are trying not to dictate how clinical care is carried out, but they should still provide some sort of foundation."

If your facility has multiple locations, use the following list to make sure all therapists know how they can contribute to clinical and regulatory consistency:

Create a list of protocols that all therapists must follow regardless of location. It should include procedures for documentation and other paperwork-related matters, productivity, scheduling, and appointment length.

Plan for meetings of the entire staff. Through e-mails, memos, or newsletters, you can make sure that your staff follow the same procedures. Additionally, plan to get everyone together at least quarterly for a breakfast or lunch meeting.

Invest in training and education. Instead of sending therapists out to earn their continuing education credits, bring those courses in-house. This way, a larger group can attend and everyone learns the same techniques.

If you work in a lone therapy practice, you can also use this list to streamline all of your operations. Your administrative policies should already be uniform, including issues such as compensation, corrective action, and time-off requests.

A few final tips

You may run into a situation where a referring physician insists on having a therapist on your staff do something his or her way, even if it doesn't jibe with your set protocol. Deal with these occurrences on a case-by-case basis.

Otherwise, your staff should benefit greatly from a streamlined process.

"We're in an environment where therapists aren't a dime a dozen," says Lane. However "[therapists] won't mind cross-covering for each other if the foundation is consistent."

When substituting for another therapist, you don't want to have to hunt down documentation or tell a patient that you're not sure what treatment he or she should receive next.

"When it comes to scheduling and documentation, it should be done exactly as if you are at the main site," says Eyberger. "Therapists are glad to float, but they don't want to be in a situation where they don't feel competent."

One way to test your staff's ability to follow the rules is to appoint one of your patients as a mystery patient, says Eyberger.

You can get an unbiased account from that patient about how operations seem to be running from a consumer's perspective.

Additionally, the looming therapy cap may affect facilities with branches early next year. See the sidebar on provider-based satellite locations below to learn more.

As the therapy cap looms, provider-based satellites should review exemption regs

If CMS reinstates the therapy cap in 2006, private practices and other freestanding clinics could end up competing with facilities that don't face the same financial restrictions that they do.

The therapy cap sets an annual limit on the amount of Medicare reimbursement CMS will pay for therapy services. It has been in moratoria since Congress passed the Medicare Prescription Drug Improvement and Modernization Act of 2003 . The current moratorium is scheduled to be lifted on January 1.

Hospital outpatient clinics are not subject to the cap because CMS wanted to provide a safety net for beneficiaries who required services beyond what the cap would reimburse. Likewise, satellite locations affiliated with these hospitals are also exempt.

But there are some requirements that these branch locations must meet before Medicare will exempt them from the cap.

For example, satellites must be located within a 35-mile radius of the hospital campus.

An exception to this rule exists when a clinic is outside the radius but at least 75% of patients who use this location are within the same ZIP code as 75% of patients seen at the hospital site. CMS may make an additional exception if a satellite provides charity care.

Although CMS has created factors to determine whether a facility meets the exemption criteria, it doesn't monitor whether providers meet those exceptions.

"The provider just produces this information, it doesn't have to be confirmed by CMS," says Ken Mailly, PT, of Mailly and Inglett Consulting, LLC, in Wayne, NJ. "The most likely that way they would be checked is if CMS conducted a random audit or survey or if there was a complaint."

Potential imbalance

If the therapy cap takes effect next year, it could result in an advantage for provider-based clinics over freestanding ones.

"Provider-based facilities can tell patients that they can come to them and have basically no financial limit on therapy," said Mailly. "If [these two groups] are treated differently under the Medicare program, private [therapy facilities] might be very upset."

Right now, provider-based facilities don't benefit from any cap regulations, but that could all change in a few months. And if they are exempt from the cap, it's a good bet that Medicare may begin scrutinizing both their claims and their exemption eligibility.

" The giant is sleeping, but [it'll] be awake in about six months," says Mailly. "As long as CMS doesn't pay more to one provider than another, it isn't paying as much attention. But once they're on the hook for that additional money, that could change."