Occupational Therapy in Skilled Nursing Facilities – Medicare Coverage

Medicare is a common scapegoat for many facility policies. Either because of a legitimate understanding or because it is easier to blame something on Medicare than to take ownership of a change the company wants to happen. One of the ripest places for Medicare misinformation is in skilled nursing facilities (SNF). Especially when discussing occupational therapy in skilled nursing facilities.

So, for this post, I’m answering another common listener and social media question, “Does Medicare limit the number of minutes an OT can provide in SNF?”

Podcast – Ep. 14 Does Medicare Limit the Amount of OT in SNF?

Social Media Question:

Hi all. I’m an OT for almost two years now, working in a SNF for a large rehab company. Recently, I’ve been scheduled for 20 minute treatments for my Medicare Part A patients. When I questioned the Director of Rehab regarding minutes, I was told that Medicare will only allow for the patient to be seen for a certain amount of minutes each day. And if they are seen by all disciplines, then we must share the minutes. Typically, PT gets 30, OT gets 20 minutes, and speech therapy gets 15.

As you can imagine, it’s very hard for patients to make functional gains during sessions, let alone do an ADL session in only 20 minutes. It’s honestly sad, and I feel as if I’m doing a disservice to my patients with acute illness who will be discharged home. Meanwhile, I will have low level Medicare Part B patients for 60 minutes each day. These patients deserve therapy as well, but you get my point. Just looking for some insight on if this is normal.

Wow! Lots to break down in this question, and unfortunately, misinformation like this is harmful to patients and is also harmful to the occupational therapy practitioner’s bottom line.

Obviously, I don’t know what company this person works for, nor do I know all the details, but generally, policies like this one come from a couple of places – being short-staffed or controlling costs by limiting therapy provision.

There is also a chance that they are using Medicare as a scapegoat for their own policy change because they know that clinicians tend to be intimated by Medicare policy and won’t put up as much of a fight vs if they announce that the company is changing a policy. (Psst… If you want to avoid the feeling of helplessness in this situation and be your own best resource, you might want to check out Mastering OT Policy & Medicare in the Amplify OT Membership😉).

This real-world example is another demonstration of why clinicians should always think twice when a Medicare policy “suddenly changes,” especially if it is at a random time in the year. Generally, SNF policy changes on October 1st of each year.

So, if a SNF policy suddenly changes in May, this should raise some red flags. This is also the benefit of staying in the know before policies take place! No one likes surprises when it comes to their job and hours. Okay – let’s break this question down!

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Issue #1: So… does Medicare limit OT in SNF?

The sweet and simple answer to this person’s question is that NO, Medicare does not limit the amount of medically necessary therapy in SNFs. You may notice that the qualifier “medically necessary” is there. This means that Medicare does not pay for therapy services that do not meet eligibility criteria. Meaning they are either unskilled services or are not medically necessary or reasonable.

In fact, PDPM has a whole equation dedicated exclusively to determining a payment adjustment to account for possible occupational therapy needs in skilled nursing facilities. To learn more about that, check out our PDPM article here. Although PDPM does not necessarily pay for OT separately from any other services, the anticipated costs of OT services are built into the payment amount that the SNF receives from Medicare each day. So, in summary, OT is absolutely covered in SNF, and there is no maximum on the number of medically necessary and skilled therapy minutes a patient can receive.

Issue #2 – “PT gets 30, OT gets 20 minutes, and Speech therapy gets 15”

This is another red flag that this is an inaccurate policy. Medicare doesn’t get involved in a plan of care like this. In fact, policies like this go against the very purpose of the Patient-Driven Payment Model, which is the reimbursement model used by Medicare in SNFs. PDPM provides reimbursement similar to a bundled payment model with the intent that the patient receives the services that are medically necessary. This is a classic example of where a rehab agency is using Medicare as an excuse for a change in policy. You should always be suspicious when there’s just some random big change that is somehow blamed on Medicare, especially when it’s an unusual time in the year.

So… this statement is entirely incorrect. Medicare does not require disciplines to split therapy minutes, and it definitely doesn’t always give PT the most visits. If I was going to give this facility the benefit of the doubt, this might be some old thinking from the RUG system. The RUG level payment structure in SNF reimbursed facilities based on the total number of therapy visits provided. So, while there wasn’t technically a limit on therapy minutes, there were thresholds that facilities tried to hit, and they’d split the minutes between disciplines. But… RUG levels disappeared in 2019, so this is a classic example of a potential Frankenstein policy (my term for a policy that is pieces of old policies put together, and it just makes a monster).

Every patient is different with different factors and different needs, and so Medicare expects that plan of care will reflect that patient’s needs. Medicare has also explicitly stated a number of times in both their proposed and final rules that is the responsibility of the therapist to establish the plan of care.

Issue #3 – What about the Medicare Part B Patients?

Medicare Part B still pays for therapy under a fee-for-service model. Meaning the more therapy you provide, the more the facility gets paid. So, there is no incentive to try and limit the amount of therapy a Medicare Part B patient receives. Not saying it’s right, it’s just how it works. Fee-for-service is a volume-based payment system, so a large volume of therapy is expected. PDPM is a value-based payment system, so empowers expect higher value and lower volume of therapy.

What Can You Do?

In a situation like this, I always recommend clinicians to ask their supervisor to see the policy.

Now, I want you to remember this, Medicare DOES NOT micromanage therapy plans of care. Medicare doesn’t require a patient to discharge at a certain time. They don’t dictate the amount of therapy a patient can receive. Medicare is relatively hands-off. Where you might experience some of this is with Medicare Advantage, but those plans are run by private insurance companies, and that’s a whole other situation.

Does occupational therapy influence reimbursement in skilled nursing facilities?

Under PDPM, occupational therapy can still influence reimbursement in skilled nursing facilities, but it is less direct and more difficult to explain. And it is important for us as practitioners to understand it! Because if we don’t understand why our services are important or valuable, the SNF sure won’t understand. Therapy can still influence reimbursement in SNFs through accurate scoring on admission and discharge assessments, improving functional gains so a patient can discharge safely to home, can improve quality measures assessing function, mobility, and hospital readmission, and other important quality metrics. However, as you can see, that is a more complex conversation than more therapy equals more money.

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How can I advocate against inaccurate policies and stand up for occupational therapy in skilled nursing facilities?

So if I were this therapist, I would start by asking for a meeting with my supervisor. You don’t want to blindside them in front of the rest of the staff and ask for the policy on the spot. Instead, I’d recommend asking for a meeting from a state of curiosity and wanting to learn. At times, the supervisor may not even know that this policy is inaccurate or that it doesn’t come from Medicare. Even if it maybe isn’t a Medicare policy, it could be a policy that another insurer is implementing. I find the best discussions are had when we approach an issue with respect and also come prepared.

If you want to meet about a policy at work, I always encourage clinicians to educate themselves first. See if you can find information on what Medicare does or doesn’t pay for and come prepared with that information to the meeting. I encourage you to start your search for Medicare policies at AOTA.org or in the resources sections of my articles. You’ll never regret learning information that helps you successfully advocate for yourself and feel good about your job. Plus, if you can show you understand the money, you might just find yourself in that director position soon!

Have you faced an issue like this at work?

If you’ve faced a similar situation like this, don’t hesitate to send me an email and utilize resources available to you from Amplify OT. If you’re ready to be your own best resource and trade that feeling of “not-knowing” for “informed-and-empowered”, then I encourage you to check out my Mastering OT Policy and Medicare Course. It is a 5 module on-demand course designed exclusively for occupational therapy practitioners working with adults like YOU! It covered everything from the way therapy is paid for in each setting, coinsurance vs copay, all the way to how you can be an effective advocate for occupational therapy services! Check it out – you won’t be sorry!

Resources

• How Understanding PDPM in Skilled Nursing Facilities Can Make You a Better Clinician
• Reimbursement Models in OT: Do You Know What They Are?
• How Are You Using Occupational Therapy in Healthcare Quality Measures?
• Mastering OT Policy & Medicare
• CMS: SNF PDPM Slides
• Youtube: Presentation on these slides
• CMS: PDPM Home Page
• AOTA SNF Payment Policy Page
• AOTA Quality Page