What SLPs Need to Know About the New Medicare SNF Payment Model

Know the Facts!

On October 1, 2019, skilled nursing facilities (SNFs) will implement the patient-driven payment model (PDPM) for Medicare reimbursement, which bases payment for patients with speech-language pathology needs on their clinical characteristics. Here’s what speech-language pathologists (SLPs) need to know!

The transition to PDPM should not lead to the end of employment for SLPs in SNFs.

If PDPM is appropriately implemented by SNFs, SLPs will be empowered to identify and treat patients who need their clinically necessary services rather than count the minutes of therapy provided to each patient. SNFs who state that SLPs are being laid off because of the transition to PDPM are not being transparent about the rationale for terminating therapists. SNFs that plan for the transition and appropriately assess the role of SLPs are not likely to terminate employees.  

Changes to the SNF reimbursement model are driven by patient needs, not therapy minutes.

Under the previous system (RUG IV), payment was driven by the minutes of therapy provided. Some SNFs manipulated treatment time to maximize reimbursement. SNFs that required therapy beyond a patient’s need to maximize reimbursement may struggle to maintain staffing because their capacity was disproportionately inflated. Additionally, such SNFs may establish administrative mandates to provide as little therapy as possible to maximize profit under PDPM. SLPs should always reinforce the ethical and legal obligation to provide therapy based upon the clinical need of the patient as opposed to administrative mandates for the purpose of maximizing reimbursement.

PDPM does not dictate productivity requirements.

Neither did the previous payment system (RUG IV). Productivity standards are an industry-developed mechanism to maintain profitability and manage staff, not a payment policy. It is not clear what impact PDPM will have on productivity standards.  

Medicare has not established minimum requirements for group or concurrent therapy sessions.

Under PDPM, group and concurrent therapy are restricted to 25% of a patient’s total episode of care, per therapy discipline. The use of group and concurrent therapy should always be clinically appropriate for the patient and part of an individualized plan of care. Administrative mandates to provide a certain percentage (e.g., 10%) of group and/or concurrent therapy for every patient regardless of need are inappropriate, unethical, and a violation of Medicare policy.  

Medicare is not requiring changes to who can perform therapy.

Each facility makes determinations on how to use therapy clinicians in compliance with state licensing laws. If your facility tells you Medicare no longer allows you to perform certain types of services, then it is not based on Medicare policy. For example, Medicare is not dictating that cognition or swallowing service can only be provided by occupational therapists or SLPs.  

Medicare does not require mandatory evaluations for every patient.

A brief assessment or screening can help you determine if a full evaluation is warranted. Your clinical judgment and the needs of the patient remain paramount in the decision-making process. Administrative policies that mandate an evaluation and at least one treatment are inappropriate, unethical, and fraudulent when not clinically necessary.  

Medicare has not changed the definition of skill that triggers coverage in SNFs.

Care in a SNFs is covered under Medicare Part A if the following four factors are met:

  • the patient requires skilled nursing services or skilled rehabilitation services (i.e., services that must be performed by or under the supervision of professional or technical personnel); are ordered by a physician and the services are rendered for a condition which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF;
  • the patient requires these skilled services daily; and
  • as a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF; and
  • the services delivered are reasonable and necessary for the treatment of a patient’s illness or injury (i.e., they are consistent with the nature and severity of the individual’s illness or injury, the individual’s medical needs, and accepted standards of medical practice). The services must also be reasonable in terms of duration and quantity.

See: Chapter 8, Sections 30.2-30.7, Medicare Benefit Policy Manual [PDF]

Medicare has not replaced clinical judgement and professional standards of practice with SNF-developed administrative mandates.

The need for clinical judgment and corporate compliance reporting remains your professional obligation. Administrative mandates that run counter to the clinical needs of the patient are inappropriate, unethical, and considered Medicare fraud.  

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