Analysis Raises Concerns About Nursing Homes’ Medicare Billing
Nursing homes might be taking advantage of higher payment levels for providing extensive amounts of therapy to Medicare beneficiaries to garner larger reimbursements, the Wall Street Journal reports.
Under payment rules Medicare adopted in 1998, nursing homes can bill Medicare more per day if they provide more therapy. Nursing homes increasingly have billed Medicare for higher therapy levels, according to the Journal. For example, nursing homes in 2013 provided an "ultra high" amount of therapy (more than 720 minutes per week) to patients on about 54% of the days they billed Medicare, compared with 7% in 2002.
According to an analysis of billing records by the Journal, Medicare in 2013 reimbursed nursing homes about $560 per day on average if they provided more than 720 minutes of therapy per week. In comparison, Medicare reimbursed an average of $445 per day for "very high" therapy (500 to 719 minutes) and $325 for "low" therapy (45 to 149 minutes).
Nursing home patients are receiving ultra high care until near death. From 2010 to 2013, nursing homes billed Medicare for at least 51,000 patients until they were transferred to hospice, and about 110,000 patients died within five days of ultra high therapy billings.
Providers Feel Pressure
According to interviews with more than two dozen current and former nursing home employees in 17 states, caregivers often feel pressured by their managers to reach the 720-minute threshold of care. They said ultra high therapy is sometimes provided to patients even when they:
- Are unlikely to benefit;
- Are unresponsive; and
- Have declined to receive such care.
A report published by the Medicare Payment Advisory Commission and the Urban Institute in January found "the present payment system continues to encourage providers to furnish clinically unnecessary services for financial gain."
Others Argue Therapy Is Necessary
Meanwhile, others have argued the increase in therapy can be attributed to factors other than financial incentives, including:
- Greater patient demand for therapy;
- Hospitals sending patients to nursing homes sooner after surgery;
- More educated patients;
- Providers more thoroughly documenting treatment; and
- Sicker patients being admitted to nursing homes.
According to the Journal, Medicare has implemented a number of changes in response to concerns about therapy billing and has hired a contractor to look into alternative payment models (Weaver et al., Wall Street Journal, 8/16).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.