A recent Senate Committee on Finance report discussed the results of a review of home health therapy practices at four of the largest publicly traded home health companies following a Wall Street Journal article on medically unnecessary therapy utilization.
The Committee found that the companies, prior to reimbursement changes in 2008, encouraged therapists to provide therapy visits at or just above the ten-visit threshold at which Medicare paid a ''bonus'' under the prospective payment system (PPS) for home health services. The companies are alleged to have encouraged the visits over the threshold even if patient medical necessity alone would not have justified such care when the reimbursement formula went into effect. The pattern was demonstrated by the change in the number of home health episodes having between 10 and 13 therapy visits. These episodes increased by approximately 90 percent between 2002 and 2007. When new therapy thresholds were introduced in 2008, the Committee found that the home health agencies rapidly altered their therapy visit patterns to match the new 6-, 14- and 20-visit thresholds. MedPAC called the changes in utilization ''the swiftest one-year change in therapy utilization since PPS was implemented."
The Committee found that therapists and managers were pressured to adjust the number of home health therapy visits to maximize Medicare profitability. The report cites from internal company e-mails describing the need to move patients to more profitable numbers of therapy visits following the 2008 reimbursement changes. To address these concerns, in 2011, CMS modified therapy coverage policies to require stronger documentation, and for 2012, CMS proposed revising the case-mix weights by lowering high therapy case weights and increasing the weights for episodes with little or no therapy to reduce the profitability incentive based upon pre-2008 data. CMS also has indicated that it intends to undertake a more comprehensive review of home health payments in the future.
While the home health report is interesting for the specific issues addressed, it may prove to be a more powerful roadmap for the future of OIG investigations. Consequently, providers should carefully monitor their response to payment changes to avoid evidence of reimbursement gaming. In addition, the review may add impetus to the reshaping of the terms upon which services are offered to Medicare beneficiaries and the government's approach to cost containment.