Question: I'm writing to you as I'm very frustrated with my employer's "standard of practice." Every day of the week, there are a minimum of 500 minutes of billable time under each therapist's name on the board to treat that day. Each therapist is required to be 95 percent productive and in order to do so, dovetail/concurrent treatments are necessary. I've questioned this practice to my rehab manager, who states it's appropriate to do so, and sees nothing wrong with this practice. I've been a therapist since 1995.  I remember the day PPS began and what that did to the company I was employed with. I know we are on a spiraling path, once again, and are "shooting ourselves in the foot" with this "standard of practice.

Just yesterday I was scheduled for 600 minutes. I work eight hours, so you do the math. It's absurd to get through your day in one piece, safely and morally, watching the way management dictates to the therapists what they will do, how much time they will see someone, regardless of what is appropriate. In fact, I see therapists working with up to 3 patients, "concurrently" and two out of the three are "resting" for half the time they are billing. This is wrong.  I am ethically and morally challenged daily and have no support in what I am saying.  I'm alone.

The other therapists are quiet, thankful they have a job. I need my job, yes. But I will not be part of a team who is tricking the system to get as much money as we can out of one person's Medicare A benefits, just to make money. I cannot.  I'm hoping that you can help me. This is happening in other places, I am certain. I just think these companies should be, no, must be stopped. How can we do it? Whatever happened to quality care, care driven by the discretion of the skilled therapist, not by the manager who is just money hungry? This is wrong. The patients are being taken advantage of. Acute rehab provides up to three hours/day of therapy for patients, we at the SNF are providing just under three hours a day; this is wrong. Each person must be seen for 75 minutes by both OT and PT and sometimes SLP. If the patients need that much therapy, why are they not still in their "rehab" centers and not SNF/LTC facilities? This is crooked and wrong and I will no longer be quiet on this. I'm hoping you can help me put a stop to this practice before it's too late.

Answer: We know your pain and can truly empathize with your concern. The main thing to remember is that you are not alone with your very valid concern. There are many more therapists who voice this concern to us. This is expressed to us many times through e-mails just like yours along with comments at our seminars. Unfortunately, even if reported, we have found out that the contractor or the government (in the role of the Office of Inspector General) usually does nothing as they consider the amount small for the amount of manpower it would take to investigate and prove.

The only thing that we can say at this moment is, be true to yourself and your profession and still take the time to report this practice, even if no follow-up occurs. Maybe eventually, if enough voices are heard, we will get the problem rectified.

CMS is now attempting to address this concern through the new guidelines for SNF that were published in the Federal Register in August and will become effective October 1 next year. In the preamble, they acknowledge that treatment of multiple patients at the same time is occurring in some facilities, and they indicate that they do not approve of the practice of taking advantage of Medicare's approval of "concurrent therapy being appropriate, but only at the discretion of the therapist, not the dictates of management".

The new guidelines identify that concurrent therapy of ONLY 2 patients will still be allowed, but it must be documented separately from the direct treatment time, just as we presently do with the use of group therapy. They also identified that if more than 2 patients were being treated at the same time, then NONE of the minutes for ANY of the patients can be counted.

With this regulation in place we, as therapists, will have the ability to refuse to perform treatment on more than 2 patients and, if demanded by management, should refuse to bill for that time, so as to be compliant with the Medicare regulation.

Disclaimer: The answers that we provide are based on Medicare guidelines for what is payable under the Medicare Part A and Part B Benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the State Practice Act and the State Administrative Code. In any scenario, the practitioner must go with the most stringent requirement in order to be compliant. The information provided is current as of the time of publication.

Pauline M. Franko, PT is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Consulting, Compliance and Training, based in Tamarac, FL. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. As an associate in Comprehensive Medicare Consultants, LLC, she is responsible for assisting with and directing compliance programs to Rehab Agencies. Danna Mullins is an associate and lecturer with Encompass. You may contact the authors through the Encompass website at www.encompassmedicare.com or by phone at 954-720-4087.