Wait a minute…..
Whoa!! Hold on a second, did you read part one yet? Come on, would you just jump right in and read New Moon without having read Twilight? How else would you know of Bella’s deep undying love of the undead?
Or even worse, watch Star Wars The Last Jedi without having seen Star Wars IV, V, VI, I, II, III, and VII? That is downright despicable if you ask me; but we both know you are not a despicable person. So, here is the link to Part One of why your PT authorization may have been denied. Go ahead . . . Part Two will be here when are done.
The Top 8 Reasons Care Was Denied: Part Two, Reasons 5-8.
Thanks for coming back! Sequels are all the rage anyway, right? I keep asking myself how many more Spider-man’s could they possibly make? But then another one appears and people flock to see it. Unfortunately, this sequel won’t have any super-humans, mutants, elves, hobbits, witches or demi-gods. What it lacks in fantasy characters and epic horseback rides to find a lost ring, it certainly makes up for it with real-life, use-it-in-the-clinic-today, tips and advice. I know part one was kind of harsh. I cannot promise any less straight up honesty for part two. However, if you stick with me through the end I know you will find at least a few things that you can do to improve your physical therapy authorizations today.
As with most sequels, we must take an obligatory flashback. I want you to close your eyes and picture in your mind your graduation from physical therapy, occupational therapy, chiropractic or even medical school. Feel the energy of the moment, the joys of completing school, the excitement of moving on. You are dressed in your gown and cap. Everyone has walked across the stage. You shook the Dean’s hand. Back in your seat wishing it would just be over so you could start the party, another round of speeches is commencing. A professor stands and asks each of you to stand. An oath is projected in front of everyone. You are asked to repeat it with the professor. As a right of passage, you repeat the words. You can feel the strength in the room grow. Pride in your decision to make this your career is multiplied. The Oath is done, you are now an all powerful healthcare provider…. OK, open your eyes now (Holy crap you just read with your eyes closed!! Maybe there is a bit of magic in this sequel).
#5 Lack of Progress Over Time
Even though an Oath may not be the law, most of us agreed to a certain standard when we graduated from our professional courses. That agreement, to a certain amount, was expected upon you getting licensed to practice. As such, that agreement should continue today. Not all oaths are the same but most contain similar ethical ideals. That you will value the life of your patients, that you will respect their choices, that you will recognize your limitations and those of the profession, that you will work to improve the life of your patients and help them to progress. But in the real clinical world it can become difficult to maintain hard ethical lines. You are faced with business dilemmas, productivity demands, tight schedules, documentation. The lines now start to become gray areas instead of black and white. This blurring of standards can lead to rationalization of decisions and actions. This can lead to blurring of expectations of our clinical abilities and expectations of healthcare system. We can rationalized that a patient may be progressing or that they are going to (just given enough care) when really they are not, or won’t.
I see cases of lack of progress in rehabilitation care every single day that I do my review work. Of course, some patients are not going to progress, some are getting palliative or maintenance care. Those are topics for another day. What I am referring to is care provided to patients where progress was expected at the evaluation. Where goals were established that the patient would need to improve functionally to achieve them. Yet, after months, the patient looks almost the same as when they walked in the door. If a patient is not progressing, why should their health plan continue to pay for care that is not currently effective? Remember that Oath where you agreed to help the patient improve their lives but to also recognize your limitations?
So what is a provider to do when they really think the patient is improving and the care is being effective? You have to prove it. My Part One post was almost all about care being denied due to lack of information. If you are only tracking the things that the patient is not really improving in, then your documentation is not going to prove that more care is needed. Pain and range of motion only generally does not cut it. Do you document about improvement in regular daily abilities (stairs, driving, caring for family, shopping)? Do you use functional outcomes or other standardized tests? Most payers have a higher expectation than just subjective statements of improvement these days. It is our responsibility to track it AND document it.
“Well, they are improving, just slowly” you might say. That is great, but that can’t continue for long. There is an expectation that skilled care will help the patient to improve better than if they were just on their own. This could certainly become a major tangent. Lets keep things a bit more simple on this article. What many clinical reviewers are going to be looking for is improvement within a Minimal Clinically Important Change (MCID) or possibly a Minimal Detectable Change (MDC) for the measure being used. This requires you, as a healthcare professional, to understand the statistical implications of the measures and scores you are documenting. Many things can affect a measure or a score (user error, landmark alignment or even just how the patient feels that day) so there should be enough improvement to know that it is from the care provided. For example, your patient’s knee ROM improves 2 degrees a week, so after 4 weeks they have gone from 80 degrees of flexion to 88. Well, could they have just improved that much at home on their own? What if they improved 10 degrees a week? Maybe the patient with the knee issue is not improving greatly in ROM, but you have also been tracking their Berg Balance Score. They went from a 19 to a 30 in the last 4 weeks, you know that the general MDC for the BERG is 8-9. You are sure to document this to show the patient is improving.
Peer reviewed standardized scores and outcomes will have been studied over specific time frames. Most from 6-12 weeks. So it will be important to understand these time frames. Significant progress most likely is not going to be expected within the first few weeks for any patient. However, an expectation of improvement over maybe 30 or 45 days is very usual in general rehabilitation. You have a patient with back pain and after the first two weeks of care their Back Oswestry Score (ODI) only went up 4 points. That does not meet MCID for that measure, however, you know that the ODI was studied over 4-6 week time periods in most research. By the 5th week of care your patient has now improved by 20 points. But lets say it has been 12 weeks and your patient has only improved by 10 points? That is some improvement, but little progress for that time period. So these are all things the utilization management team is going to look at when your request comes for review.
A great resource for looking up standardized tests and their statistics is the Shirley Ryan Ability Lab (https://www.sralab.org/rehabilitation-measures) I use it very often in my work.
Well, that was kind of epic. No horse rides though, sorry Legolas.
#6 Not Tapering Care As The Patient Improves
Let’s keep this one simple. As your patient improves they should need less of your help should they not? In my work, this situation generally does not result in a full denial of care, but more of what would be called a partial approval. So maybe you requested 3 times a week for 12 weeks for your post-stroke patient. They are now minimal assist with upper and lower body dressing, they can transfer to and from surfaces, are minimal assist with toileting, independent with eating, but still have most struggles with heavy tasks. They have a part-time caregiver and live with helpful family. You have given them a home program. They are not progressing fast enough to change things 3x a week. So do you need to see them 3x a week?
If the care appears repetitive then having more time between visits should be appropriate to allow for progress. Your request for 36 visits will likely get reduced to more of 1-2 x a week, and potentially over a shorter time period. Then, when you see them again, you can up their program. This should be no different if the patient is being seen for an ACL surgery or back pain. Skilled care is not repetitive! That goes the same for manual therapy or therapeutic exercise.
One note, update your plans of care!!! Don’t just copy and paste. There have been many times I have talked with providers during peer calls and their question was “we got a notice of reduced care authorization, why”. I look it up and indeed they got a partial approval. I say, “well your plan of care says 3x a week for 4 weeks. The patient is doing great and they should be ok over more time now right?” They say, “oh ya, totally, we are only seeing them about 1x a week or less, they really only need a few more visits, I just didn’t update their POC”. Most health plans are going to see your POC as your request, so don’t cause yourself extra grief by not updating those areas of your documentation. You are the professional here, you can change the POC with each visit if you see fit.
Inappropriately high usage of rehab visits is a major problem in skilled care. We have all heard the term “number mill”. This is one of the primary reasons health plans employ clinical review companies. Can’t we just stop? Put me out of a job, I dare you, I double-dog dare you!
#7 Frequency and Duration Are Too High
This one is very similar to #2, however it may be that the POC is seen as excessive at any point of care, not just as the patient improves. This is a tough subject and one that brings up all kinds of frustration. Part of the problem is that there is not much research into clinical utilization of skilled care for specific diagnoses. There is some.
Take LSVT Big for example. Their protocol asks for 16 visits in 4 weeks. For years, LSVT providers struggled to get insurance to pay for that much care. There was not good research to show it was more effective that traditional care for patients with Parkinson’s. That was until recently, there has been some great comparative research to show the program really works. I cannot speak for every health plan, but I have seen the health plans come around to allowing the 16 visit authorizations more often. This is the kind of research that is needed. (Any researchers out there? If you are choosing between researching the utility of cross-cranial ultrasound in chronic migraines or comparison of visit frequency protocols for post-ACL rehab care, go with the post-ACL studies). There is some evidence emerging in gait training, dual-task training, but still most is not conclusive or it does not show that specific protocol to be better than control.
Another part of the problem is that health insurance does have the data that shows all kinds of mixed utilization. If one provider can do just fine seeing all the back pain patients 5 visits a month for two months, then why should they approve 12 visits a month for 3 months for patient that seem similar? Especially when both providers give limited information in their documentation, don’t use outcome scores or don’t update their POC.
I know, each patient is different and they have different needs; each therapist is different in how they treat. Why should the health plan pay for 26 additional visits when according to the documentation the patients look similar? Much of this comes down to business model over clinical decision making. If you can’t show a medical need for the visits, don’t have a high frequency POC.
High utilization is a problem and it is being noticed; In high places. Like the Office of Inspector General . Unfortunately, rehabilitation care is seen more as an expense than a necessity. We are in part to blame for this. Lets fix it. Don’t provide repetitive care. Don’t see a patient to just go through their home program. Get them independent with a home program, train caregivers, educate, empower; then update when they have had time to actually practice.
#8 Milking, For a Lack of Better Term
Milking the system. We all know of real life examples. Some people just want a free ride, and they will work harder at getting that free ride than it would need to follow the program and benefit from it. It is sad, but there are instances of this in physical therapy, occupational therapy, chiropractics, acupuncture and all of healthcare. I am not going to step in the realm of fraud for this article but certainly close to the realms of waste and abuse. This really is a combination of many of the reasons we have talked about.
People with chronic conditions often very much need help. Many are in sad circumstances in many aspects of their life. Most providers really want to help and it can be hard to let go of a patient when you see some potential or they have ups and downs. May you have seen them come from a bad place and are doing better, but still have far to go. Like a baby bird, a bear cub, or each of us from our parents basements, these patients need to be let go. It may be chronic pain or a neurological condition but at some point, these patients will start to show a plateau and lack of progress. Care is no longer effective. They had shown great progress at first, but now they just kind of waver. Much like #1, this cannot go on.
I am not talking about palliative care or true maintenance care. I am talking about requesting continued manual therapy just because it helps their pain go down, but they have a home program and are capable of doing it. They feel good right after they leave, but then get worse over the next few days. They can work, go to school, make dinner, go the gym, go hiking, but they still get headaches so “they really need the skilled care.” These are examples of what I call “milking” in skilled care.
It takes a while to get to the milking stage, but what a reviewer will look for is if function is improving within MCID over a respectable time. If the patient is achieving goals. Are the goals even measurable and updated? Is treatment mainly for subjective complaints such as pain? It may seem petty, but another red flag for a milking situation is providers that commonly state “well the patient has 30 visits a year and they pay for them, so why shouldn’t they get them?”. I already addressed this Big Question In Pre-Authorization so I won’t go over that again.
Whether done consciously or not, abuse of a person’s healthcare benefit is a serious problem. When a patient is no longer appropriate for care either discharge them with the tools they need to succeed, or help them to move on to other services. Maybe they need counseling, personal training, or even another skilled care provider. It may just be time to move to a cash-pay program to help them beyond what their plan covers.
So there you have it, the 8 reasons rehabilitation care may get denied. Was the sequel as good as the original? Come on, it had a flashback, an epic diatribe, struggle between good and bad, and it all wrapped up in the end. Each of these reasons could certainly be an article of their own. If DC and Marvel can do spin offs I most certainly can. So be on the watch out for more.
As always, I welcome questions and insightful comments. If you feel like you could use additional help, just email.