RCS - Another Winner?

I've been critical of the proposed rule change known as RCS for two primary reasons: the questionable use of ADLS and the fact that RCS might end up costing more

There has been nothing from CMS regarding therapy targets so far. About all I've seen is that there will be limits on how much concurrent and group they will accept. CMS wouldn't mention those things if they weren't thinking about therapy.

While I don't know exactly what CMS has planned, I have an idea: What if CMS simply issued guidance to the effect of "Therapy outside customary levels could be subject to audit or denial of payment." It's not really a rule so it doesn't need to be included in RCS.

Then, CMS can do one of two things:

  1. Don't define what "customary levels" means. That would leave maximum ambiguity for providers and maximum flexibility for CMS.
  2. Use the same data for the RCS study (2014) to suggest (but not define) what the expectation is. Look at the table below, the average Med A patient received 76 minutes per day. (weighted)

There is a certain beauty to this approach. SNFs and therapy providers have been trying to justify that most patients need UH therapy. This would be CMS agreeing to that and suggesting providers continue to do that much therapy while being paid a fixed rate or risk denials or an audit.It also blunts the complaint about RCS locking the budget at the level CMS and OIG have been arguing is inflated due to abuse of therapy. CMS can honestly make the argument that they are paying for every Part A patient to get at least 76 minutes per day. (12% weren't getting any therapy in 2014.) You don't have to do therapy on any particular patient, but you're being paid to. (No therapy RUG has CMI of zero so it would appear that all patients would have some therapy money.)

See what just happened? Either provide as much therapy as before or be a hypocrite and risk denials and audits.

This would not be unprecedented. Think about the "15 minute" rule for Part B therapy. CMS suggests that they expect the average unit to be 15 minutes, even though they'll pay if the last unit is 8. We just assume that if you depart from 15 minute averages too far, you could be in for trouble.

Another winner

I wrote a previous posting called RCS Winners and Losers, if CMS goes this route, we'll have another winner: the auditors. This becomes another tool to use to deny and delay payment.

I'm not certain what CMS will do, but I am certain we haven't heard the whole plan when it comes to therapy delivery for Part A patients.