On October 1, 2019, skilled nursing facilities (SNFs) implemented 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!
If PDPM was appropriately implemented by SNFs, SLPs should 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 planned for the transition and appropriately assessed the role of SLPs are not likely to terminate employees.
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.
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.
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. (See also: Modes of Service Delivery for Speech-Language Pathology)
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.
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.
Care in a SNFs is covered under Medicare Part A if the following four factors are met:
See: Chapter 8, Sections 30.2-30.7, Medicare Benefit Policy Manual [PDF]
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.