If you live in my neck of the woods, you are most likely looking forward to gaining one additional hour of sleep this weekend!  That’s right, it’s time to “fall back” and set our clocks back one hour before we go to bed Saturday night!! (Daylight Savings Time to Eastern Standard Time).  And with the changing of the clocks and falling leaves, it is November already—where did the year go?  Well, the year isn’t over yet and we have so much more work to do!

I once worked in a facility where they would place an autumn leaf on someone’s door or on their assistive device so we would know that the resident was a fall risk.  Due to multiple comorbidities, progressive disease processes as well as a multiple of other physical, cognitive, environmental factors all of our residents are at risk for falls.  Falling isn’t something that is “normal” when you get older.  There are underlying impairments causing the fall and/or fall risk and it is up to us as skilled clinicians to be able to determine what underlying impairments exist prior to a fall, a pressure ulcer, weight loss, inability to perform personal care, any other event…..would you call that preventative medicine?  Or how about ensuring that a resident is able to achieve their highest functional level?

I was at dinner with my family recently, and the discussion of our health care system came up.  My parents and uncle are Medicare beneficiaries, my brother-in-law, sister, and their kids are on my brother-in-laws insurance through his employer.  My brother-in-law made a comment that our Government will be the ones making the clinical decisions regarding our medical care in the future—they will determine what we need and don’t need, not our primary care providers (physicians, nurse practitioners, therapists, etc.) .  It was then I realized that our society doesn’t really know that our government has already been doing this for years–indirectly!

Limiting the Medicare part B benefit, DME, RUG levels, pre and post-payment audits, just to name a few are ways our government takes the clinical decision making out of the hands of our health care providers.   The geriatric population have been feeling it for years especially in home health and SNF settings.  Where is everyone?  How could you not know that the big ticket cost items are cut which adversely affects our most vulnerable population? Yet those who are able to work receive prescription, food, transportation, and educational assistance at the same time while our geriatric population and even some folks 60 years of age or older have to decide whether to pay for their medication or buy food.  What’s wrong with our healthcare system?

I know I am not going to change the world all by myself—we all have to come together to improve our healthcare system by making our voices heard.  As an industry, therapy providers have been appealing therapy claim denials to make our voices heard! United together, our industry is letting our government know that what they are taking away from our Medicare beneficiaries is NOT okay!

And now, again, it is time to fight for our residents/patients.  If Congress doesn’t act, we will see a hard therapy cap!  That’s right folks—you think it’s tough now to provide therapy with the automatic exceptions process and the $3,700 threshold per cap, try providing medically necessary therapy services for an entire year with a hard cap (limit) and that’s it!

The Sustainable Growth Rate (SGR) reform legislation generally has the therapy cap issues attached within it however the Senate Finance and House Ways and Means Committees recently released a draft that outlines their ideas for SGR reform and the therapy issues were not addressed in the reform document.

I am asking for compelling patient care stories to share with members of Congress.  I will be heading to Capitol Hill with NASL November 19th to request extension of the therapy cap exceptions process (expires 12/31/13) in 2014 and to request changes to the manual medical review process for therapy claims over $3,700.  I cannot do it alone—I need your help.  If you have a compelling story, please send your 2-3 minute story summary to my email address below.

Thank you!

Gina Tomcsik

Director of Compliance

Functional Pathways

gtomcsik@fprehab.com