For years now there was the idea in the Healthcare world of the reduction of paperwork and streaming care so patients not only got the care they needed, but providers got paid for services rendered.
While this is a great concept, I believe the train has seriously went off track. It has seemed that each consecutive year more and more paperwork needs to be completed.
While working in Therapy in a skilled nursing facility, each treatment session much be documented. Our documentation has had to evolve from simply what was done so we can track change and someone else can treat that person into a need to justify everything we do.
At one point in my career, short term rehab was documented on a weekly basis. It was expected that because when working with the geriatric population the progression of strength and functional mobility either happens at a slow pace of small gains or has a large jump in progression. This was able to be documented on a weekly note.
So suddenly that was not enough. We needed to document what happened daily. That would surely justify paying for services. But wait, daily notes are not enough. There needs to be a progress note every ten treatments to summarize what has happened. Kinda sounds like the weekly note that was not good enough earlier.
The daily note is no longer good enough
Over time the daily note has had to evolve. It went from simply stating what happened during a session to how your skills were needed to complete this episode. So we have to explain for every part of a treatment session why we needed to be there and why someone else could not do it.
I don’t know about you, but spend 5 mins in a therapy room and you will see that 99 percent of people cannot even perform a simple exercise without intervention to help them do it right. There is a reason why home exercise programs rarely get performed correctly and consistently after discharge.
The transition from Medicare to Medicare Advantage
So after Medicare guidelines have gotten us to the daily skilled note with progress notes and discharge summaries, Medicare Advantage have gone even further.
Medicare Advantage plans typically have a third party gatekeeper. This gatekeeper is tasked with managing rehab stays. The first step is intitial authorization to admit to the facility. This is quickly followed by a submission of evals typically the day after completion.
Depending on the information submitted a certain number of days are authorized and a new date of note submission is given.
Overall does not sound to bad right?
So the increased scruitiny and growth of managed care started to change the playing field. These gatekeeper companies were being tasked with decreased lengths of stay and a quicker transition to home. Good in theory but depends on the practice.
The growth of AI
So in 2020 United Health group aquired a gatekeeper company called Navihealth. They had been using the data from our documents to establish nhPredict. This was a computer program that would show averages of risk of readmission to a hospital as well as the amount of therapy time and length of stay on average a certain diagnosis would require.
The more information submitted into the program the more it grew. When we submit information there is a summary form filled out with certain values for the program to gather the data. We also submit the discharge summary as well as the treatment frequency and time spent to achieve those outcomes. This further established data for the program.
In 2023 the first lawsuit came to light of using this data to fully determine care and establish a denial rate. According to the lawsuit filed in Minnesota, United Healthgroup, as well as Humana and Cigna who had contracted with Navihealth to manage their Medicare Advantage plans., were cutting services only based on the algorithm and not an individual basis.
According to the lawsuit the algorithm would establish a discharge date just based on the diagnosis as well as initial evaluations by therapists. It was also claimed that the date rarely changed regardless of what happened during a rehab stay.
Significant rate of appeals
It has been shown a high rate of denials of care being overturned upon appeal of the notices of non coverage. Unfortunately all this does is asked for us providers to resubmit documents again and a repeat notice of non coverage with the required 48 hour notice. So all it becomes is a hassle for 2 more days.
Ideally for the insurance companies the hope is it becomes so much work that people just give up and go home. Unfortunately there have been documented cases of poor outcomes as well as reports of deaths from a return to home.
Unfortunately time is money
All the time that gets wasted on all the staff that needs to complete these updates on every beneficiary is very counter productive. As a Director of Rehabilitation, for each update the therapy records from the last update through the date of request need to be printed out, summarized on their form, and submitted to the next team member. From there the nursing notes need to be printed, and all needs to be submitted by the buisness office to the representative.
This ridiculous time waste has become a daily grind for us in skilled nursing due to the massive increase of Medicare beneficiaries signing up for these plans. So often I am needing to do this for multiple residents on a daily basis.
So who wins?
Unfortunately we are all playing against a loaded deck. The massive insurance conglomerates will always win out in the end. As much extra work that has been brought about on us providers, we will continue to adapt and fight. Unfortunately the ones hurt the most are the poor beneficiaries that payed for and deserve this care. It is almost impossible for them to put in the amount of work to truely get what was promised to them. Maybe someday it will change. I sure hope so.
