Set up rehab contracts to avoid headaches

Define responsibilities, fees, and timelines

Implementation of the home health prospective payment system (PPS) has increased attention to effective care plans that achieve the desired goals while making the most effective use of resources.

Surprisingly, this may mean adding a service rather than decreasing types of service, says Wanda Koerner, BSN, MS, administrator of Hays (KS) Home Health & Hospice Center.

"We are beginning to recognize that the use of rehabilitation therapists can impact the patient’s outcome in an efficient and effective way." For this reason, it is important to identify rehab therapy needs as soon as possible, she adds.

The first step to improving assessments of therapy needs was to educate her staff, Koerner says.

"Therapists use terms that are unfamiliar to nurses and vice versa. We began to include all therapists, staff and contract, in case management meetings and encouraged the therapists to speak up when they had suggestions or ideas that might help patients," she adds.

The ongoing communication helped nurses who were assessing patients upon admission identify issues that could be addressed by the therapists, she explains.

Make a cheat sheet’

Koerner also developed a "cheat sheet" for both nurses and therapists that lists appropriate reasons for referral to therapists and to skilled nursing services. The combination of the case management meetings, the cheat sheet, and the encouragement for both sets of clinicians to offer suggestions and ask for advice has worked well, Koerner says.

"All of us have expanded the scope of our thinking to include therapies as another way to help our patients," she says.

If your patient requires therapy that is not feasible in the home environment, PPS does allow for therapy to be provided in an outpatient clinic.

"If the therapy requires equipment that is too cumbersome for the home, such as parallel bars or therapy related to wound care, our patients go to outpatient clinics," explains Katie Riley, vice president of clinical for Advocate Home Health Services in Oakbrook, IL.

If your patient has to go outside the home for therapy, there are several actions you need to take to make sure you can bill and be reimbursed properly for the care, Riley says.

Educate providers on proper billing

"First, be proactive in setting up contracts with rehab providers in your area," Riley suggests. Not only does the contract process enable you to define who is responsible for different activities, but it gives you a chance to educate providers in your area, she adds.

"When we first started setting up contracts prior to implementation of PPS, there were many rehab providers that did not realize that outpatient therapies are a consolidated billing process for home health patients," Riley explains.

"We made sure they understood the process and realized that they could not bill Medicare on their own; they have to provide the service and bill us as the coordinator of the patient’s care," she says.

In fact, home health agencies are not responsible for reimbursing rehab providers that provide services without the home health case manager’s knowledge or a contract in place, Riley says.

If you do end up with an invoice for therapy provided outside your care plan, you may have to judge whether or not to pay it based upon your relationship with the referring physician, the patient, or even the rehab provider, she says.

Identification of patients who require therapy in an outpatient clinic should be made at the initial admission assessment, Riley suggests. "If no rehab provider has been specified by the physician or requested by the patient, we refer them to a provider with whom we have a contract," she says. If, however, either the physician or the patient requests a noncontract provider, Riley will contact the rehab provider, explain the agency’s policy, and see if the provider is willing to enter into an agreement.

"We do encounter organizations that don’t want to contract with us for several reasons," Riley says. In an urban environment, a hospital may not want to contract with a multitude of home health agencies because of the complexity of managing many contracts or the hospital may not be willing to turn over documentation. "We will offer to have the patient sign a release of records form, but one hospital we contacted just did not want to turn over the documentation for our records," Riley says.

In this particular case, the rehab department of the hospital did treat the patient but chose to write off the cost of therapy, she adds.

Another issue with outpatient rehab is when the physician recommends it to the patient or the family and arrangements are made without the home health agency’s knowledge, Koerner explains.

"We try to prevent this by educating the patient and the family that we need to know as soon as any change in care is made. We stress that they should not assume the physician will let us know and they should tell us," she says.

"We also educate the physician," Riley points out. Many times physicians are unaware of the consolidated billing and don’t realize that the home health agency has to coordinate the care in order to assure reimbursement, she adds.

[For more information about rehab services under PPS, contact:

  • Katie Riley, Vice President of Clinical, Advocate Home Health Services, 2311 W. 22nd St., Suite 300, Oakbrook, IL 60523.
  • Wanda Koerner, BSN, MS, Administrator, Hays Home Health & Hospice Center, 2501 E. 13th St., Building Four, Hays, KS 67601. Telephone: (800) 248-0073 or (785) 623-5000. E-mail:]

Therapy cheat sheet for clinicians and therapists

One way that staff at Hays (KS) Home Health & Hospice Center improved their knowledge of how rehabilitation therapy and skilled nursing could work together to improve patient outcomes was using a simple list of when it is appropriate to refer a patient to a therapist, says Wanda Koerner, BSN, MS, administrator of the agency.

Because it is easy to think in terms of your own area of expertise, the following list reminds therapists and clinicians that certain patient symptoms or concerns might warrant an assessment from the other perspective, Koerner says.

Appropriate nursing-to-therapy referrals

Physical therapy

  • Decreased ability to ambulate
  • Transfer difficulty
  • Poor balance or endurance
  • Diminished strength
  • Safety issues
  • Physical limitations of lower and upper extremities
  • Decreased bed mobility
  • Contractures
  • Pain management related to mobility
  • Wound care

Occupational therapy

  • Activities of daily living/adaptive equipment needs
  • Cognitive skills such as memory or sequencing
  • Home management skills such as orientation, safety awareness, and problem solving
  • Functional mobility/transfers
  • Vision perception
  • Physical limitations of upper extremities
  • Stress management
  • Energy conservation/work-simplification training

Speech therapy

  • Dysphasia/swallowing difficulty
  • Impaired cognitive function
  • Communication difficulty
  • Impaired auditory comprehension
  • Poor verbal expression or unusual vocal quality
  • Significant weight loss

Appropriate therapy-to-skilled nursing referrals

  • Patient with primary rehabilitation diagnosis that develops skilled nursing needs after admission to therapy service
  • Knowledge deficit regarding disease process and management
  • Multiple medication changes
  • Knowledge deficit regarding diagnosis/patient with multiple questions about diagnosis
  • Demonstrated knowledge deficit or change in caregiver that affects care
  • Patient education needs
  • Patient who requires close coordination of nursing and multiple therapy services in order to meet maximum rehabilitation potential