Final Rule Overhauls Medicare Therapy-Based SNF Payments A new system replaces therapy minutes with patient characteristics to determine payment in skilled nursing facilities. Policy Analysis
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Policy Analysis  |   October 01, 2018
Final Rule Overhauls Medicare Therapy-Based SNF Payments
Author Notes
  • Sarah Warren, MA, is director of ASHA Medicare policy. swarren@asha.org
    Sarah Warren, MA, is director of ASHA Medicare policy. swarren@asha.org×
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Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   October 01, 2018
Final Rule Overhauls Medicare Therapy-Based SNF Payments
The ASHA Leader, October 2018, Vol. 23, 26-27. doi:10.1044/leader.PA.23102018.26
The ASHA Leader, October 2018, Vol. 23, 26-27. doi:10.1044/leader.PA.23102018.26
Under the final rule for a new payment system, skilled nursing facilities (SNFs) will receive reimbursement based on a patient’s clinical characteristics, rather than the amount of therapy the patient needs.
The new system, which takes effect Oct. 1, 2019, removes incentives for SNFs to increase their reimbursement levels by providing more therapy than may be medically necessary. Over the past several years, many SNFs and rehabilitation companies have paid billions of dollars to settle allegations of this type of Medicare fraud (see “Companies Pay $10 Million to Settle Allegations of Unnecessary Rehab,” and “Federal Government Recoups $2.6 Billion From SNFs for Fraud”).
The change may also decrease administrative pressures on speech-language pathologists to comply with productivity standards. The value of the full range of speech-language services will be evidenced in patient outcomes rather than in the volume of therapy minutes provided.
Several aspects of the new system directly affect SLPs working in SNFs.
Payment. In its claims-data analysis, the Centers for Medicare and Medicaid Services (CMS) determined that beyond a patient’s primary diagnosis—usually acute neurologic conditions—the need for speech-language services is related to a swallowing disorder, a mechanically altered diet, a comorbidity related to speech-language disorders, and/or cognitive impairment. Under the new payment systems, combinations of these characteristics produce 12 speech-language pathology case-mix groups that warrant additional payment.
For example, if a patient has an acute neurologic condition, a comorbidity related to a speech-language disorder, a cognitive impairment, a swallowing disorder and a mechanically altered diet, reimbursement for that patient would be higher than for a patient with only an acute neurologic condition and swallowing disorder.
Because speech-language services are provided consistently across an episode of care, per-diem payment for those services will also remain consistent. In contrast, payment for physical and occupational therapy services—which taper off over time—lowers over the course of the episode.

The new system, which takes effect Oct. 1, 2019, removes incentives for SNFs to provide more therapy than may be medically necessary to increase reimbursement. Over the past several years, many SNFs and rehabilitation companies have paid billions of dollars to settle allegations of this type of Medicare fraud.

Group and concurrent therapy. The new rule restricts the use of group and concurrent therapy to a combined 25 percent of a patient’s total therapy per discipline across an episode. ASHA and other stakeholders are concerned that this limitation infringes on the clinical judgement of SLPs and could lead to administrative mandates to provide group and concurrent therapy for financial rather than clinical reasons.
Accountability. To ensure medically necessary therapy is provided, the rule includes Section O on the discharge Minimum Data Set (MDS, the federally mandated clinical assessment of all residents in Medicare- or Medicaid-certified SNFs to identify functional capabilities). Section O captures information about treatments and procedures—including the amount of therapy—a patient receives during an episode. Tracking therapy services helps ensure SNFs do not inappropriately withhold care they are being paid to provide. Tracking will also identify if group and/or concurrent therapy is used inappropriately or beyond the 25-percent limitation.
Assessment. Accurate identification of the patient’s clinical condition, comorbidities and needs is critical to determine the patient’s case-mix group. Facilities should include SLPs in the process of completing the MDS to ensure all appropriate patients are identified. SLPs could, for example, help complete MDS sections related to hearing, speech and vision; cognitive patterns; and swallowing/nutritional status.
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FROM THIS ISSUE
October 2018
Volume 23, Issue 10