As Healthcare workers we are used to consistently dealing with annual changes to the “game” we have to play. This is extremely apparent in skilled nursing. Unfortunately this is also something that has trickled out to everyone.
Continued pressure on reimbursement
There has been a longstanding debate over the fairness and really unfairness of the Physician Fee Schedule which sets reimbursement for just about all aspects of healthcare. Annual changes to the fees for procedure codes have been the norm. It has always been forced to stay neutral with cuts versus increased reimbursement for codes.
In this realm the codes for services performed by a physician might go up for a certain code, and there must be a reduction in another. Unfortunately that always seemes to not effect the same provider type. So basically a physician code raised means a therapy code gets cut.
Further pressure from reimbursement cuts
Multiple procedure payment reduction was established in 2011. The basic simple idea of it is that if you are already encountering a patient for one procedure there is little to no preparation or expenses involved by going to another procedure. So in that reference, the first code pays at the regular rate while the subsequent code are reduced by 50 percent.
There have been more changes over the years with some adjustments by Congress. Unfortunately these changes still do not level the playing field. The major flaw in the system is this actually affects reimbursement for all 3 therapy disciplines. So to simplify, Physical therapy does a treatment then magically when Occupational Therapy sees the person there is no labor involved to set up, and the Occupational Therapists can swiftly dive right on into the treatment session. It was even admitted that the site of care does not factor in. When therapy is performed in a skilled nursing facility, it might be hours before the other discipline is able to encounter the patient.
Hidden Reduction of Payment
When the payment values are calculated for the reimbursement rate in the fee schedule, there is a deduction built into the code for “practice expense” for each code to develop a reimbursement rate. When factoring in the billing aspect of that code and reducing by 50% for “practice expense”, the same rational for reducing the value of the code actually occurs twice.
Reduction of payment based on license
Another hidden reduction of payment applies to billing for services performed by a licensed therapist versus a licensed Therapy Assistant. So according to that rule, a Physical Therapist performing gait training with a resident while assisting physically and using cues for proper movement and safety is worth one amount of reimbursement, but the exact same treatment using the exact same assistance and cueing by a licensed Physical Therapy Assistant is worth less?
So according to that rational, if you go to get your oil changed and the head mechanic does it you would have to pay a certain amount, but you will pay a discounted rate if the other mechanic does it? When you go to the doctor and pay a co-pay, do you get to pay a smaller co-pay when you see the nurse practioner instead?
The Further Complicating of Managed Care
Comercial insurance, as well as Medicare Advantage Plans, get to make up their own rules. They can set reimbursement models however they desire. They also will force a beneficiary to get prior authorization for services. Along with that prior authorization that is submitted in writing to the provider is a lovely clause at the bottom of every one I have ever seen. This clause is : “Authorization is based on information provided, it does not guarantee payment for services rendered. ” So basically stating we say go ahead and perform the service, but we might not pay you for it anyway.
Significant change must be done
So until there is some significant change in the system, we are really not sure if any of us will be able to have Healthcare. Without proper reimbursement for services, providers can no longer perform the service. In the long run the people most in danger of losing access to Healthcare are the majority of our country.
As more and more financial pressures are put on providers of Healthcare services, the large insurance companies make a hefty profit for shareholders along with the massive financial packages for the C suite of the company.
Squeaky wheel gets the grease
The only way to protect ourselves is to make it very well known to our representatives that are supposed to be a voice for us. It’s time for our elected officials to actually look out for our interests, and not theirs.
