More individuals could be blocked from Medicare, Medicaid under new bill

Individuals affiliated with fraudulent healthcare companies would face tougher government scrutiny under a bill introduced in the House on Tuesday.

The “Fighting Medicare Fraud Act, 2016,” introduced by Reps. Lois Frankel (D-FL) and William Keating (D-MA), would give the Department of Health and Human Services greater ability to exclude individuals linked to companies penalized for fraud from participating in federal healthcare programs.

That increased ability would close a “loophole” that allows employees to resign before a company receives a penalty and “potentially launch a new Medicare fraud scheme,” the bill's authors said. Current laws only exclude individuals who are still employed by the company, so the HHS Office of Inspector General is blocked from excluding individuals who voluntarily leave, Kirk Ogrosky, an attorney with Washington-based law firm Arnold & Porter, told Bloomberg BNA.

The bill would expand the OIG's exclusion abilities to individuals who had ownership, control interest, or an officer or managing position with a fraudulent company who knew or “should have known” about fraudulent conduct.

“We need to ensure taxpayer dollars are committed to providing vital services for our seniors, not lining the pockets of fraudulent businesses and CEOs,” said Keating in a statement on the bill. “This common-sense legislation stops the cycle of deceit amongst the worst actors — toughening the consequences felt by those who illegally exploit our elderly population while strengthening the Medicare system in the process.”

The proposed legislation would also make stealing Medicare, Medicaid or Children's Health Insurance Plan numbers a federal offense carrying a possible prison sentence of up to 15 years.

Medicare Advantage and Part D organizations would also be required to report incidents of potential fraud and abuse within 60 days of identification under the bill. Research has indicated that instances of fraud and abuse in those programs “may be unreported,” the bill's authors said.

The bill has been referred to the House Energy and Commerce and Ways and Means committees. Similar legislation was introduced in 2013, but never received a full House vote.






Treating Alzheimer’s in the nursing home

More than 50 percent of residents in assisted-living and nursing homes have some form of dementia or cognitive impairment, and that number is increasing every day. The Alzheimer’s Association’s Campaign for Quality Residential Care offers strategies aimed at helping skilled nursing homes better respond to this growing healthcare demand.

The campaign incorporates four strategies:

• It encourages adoption of recommended practices in assisted living residences and nursing homes by advocating with direct care providers.

• It ensures incorporation of the practice recommendations into quality assurance systems for nursing homes and assisted-living residences by working with federal and state policymakers.

• It encourages quality care among providers by offering training and education programs to care staff in assisted-living residences and nursing homes.

• It empowers people with dementia and their caregivers to make informed decisions through the Alzheimer’s Association CareFinder™, an interactive online guide that educates consumers on how to recognize quality care, choose the best care options, and advocate for quality within a residence.

These recommendations are the foundation of the campaign:

Management goals. Because there is no cure for Alzheimer's disease, the chief goals of treatment are to:

• maintain quality of life

• maximize function in daily activities

• enhance cognition, mood and behavior

• foster a safe environment

• promote social engagement.

Elements of a strategy to maximize dementia outcomes include regular monitoring of patients’ health and cognition, education and support to patients and their families, initiation of pharmacologic and nonpharmacologic treatments as appropriate, and evaluation of patient/family motivation to volunteer for a clinical trial.

Treating cognitive symptoms

Alzheimer's medications cannot alter disease progression, but the FDA-approved drugs that treat the symptoms of Alzheimer's disease can temporarily slow the worsening of symptoms and improve quality of life for those with Alzheimer's and their caregivers.

Managing behavioral and psychological symptoms

Behavioral and psychological symptoms of dementia (BPSD), especially agitation, aggression, depression and psychosis, are the leading causes for assisted-living or nursing facility placement. Early recognition and treatment can reduce the costs of caring for these patients and improve the quality of life of the patient and caregiver.

Monitoring Alzheimer's disease

After a diagnosis of Alzheimer's disease is made and a treatment plan implemented, patients should return for evaluation on a regular basis in order to allow adaptation of treatment strategies to changing needs. Patients may not be a reliable resource for history-taking, so it’s wise to encourage a family member, friend or caregiver to accompany the patient.

Consider these nonmedical needs for patients with Alzheimer’s:

• ongoing information and support

• a living will

• a durable power of attorney for health care

• review of finances

• planning for changing care needs over the course of the disease

• preferences for end-of-life care

Alternative treatments

There are legitimate concerns about using alternative treatments, "prevention" food and vitamins, or "memory/brain booster" supplements as an alternative or in addition to physician-prescribed therapy. Effectiveness and safety are unknown, purity is unknown, adverse reactions are not routinely monitored, and dietary supplements can have serious interactions with prescribed medications.


Risk factors identified in studies and clinical trials show that cardiovascular risk factors, such as hypertension, hypercholesterolemia and smoking, increase the risk for cognitive decline. Remaining physically active and socially and intellectually engaged can have a positive impact on cognition.

The caregiver, your partner in care

Most patients with Alzheimer's disease have a primary caregiver, often a family member, who helps to ensure appropriate care. In striving to meet the needs of the patient, the caregiver often neglects or her own needs. Many report high levels of stress; nearly 40 percent suffer from depression. Health care professionals can help by looking for signs of caregiver burnout, treating medical problems and referring them to support services, such as the Alzheimer's Association's 24/7 Helpline (800.272.3900). The Association’s Caregiver Center offers guidance on how to maintain physical and mental health in the midst of caregiving, as well as advice on how to manage their loved one's daily care, enhance their daily life, and respond to negative behaviors.

More resources:

For providers:

Alzheimer's Association Position Statement on Therapeutic Goals (pdf)

Alzheimer's Association Position Statement on Right to Treatment (pdf)

For patients and caregivers:

Alzheimer's Disease: The Basics – Symptoms, diagnosis, treatments and more.

Find a Support Group – Patients with Alzheimer's or another dementia and caregivers can find support and get advice at their local Alzheimer's Association support group, and can also join message boards.

Alzheimer's Navigator – Free online tool designed specifically for individuals with Alzheimer's disease and their caregivers, helping them create customized action plans and providing access to information, support and local resources.

Medicare updates its 5-Star Nursing Home Quality Rating system


Medicare recently announced three updates to its Five Star Nursing Home Quality Rating System. If you see a lower quality measure rating for your facility, it’s because of these changes, even though the underlying QM data may not have changed.

Medicare outlines these three changes, which it describes as significant improvements, to its system:

  • Incorporated the two nursing home quality measures for antipsychotic use into the Quality Measure Rating.
  • Increased the number of points necessary to earn a Quality Measure Star Rating of two or more stars.
  • Changed the scoring method for the Staffing star rating. Nursing homes must earn a 4-star rating on either the RN or total Staffing rating to achieve an overall Staffing rating of 4-stars.

Because of these changes, Medicare cautions, it’s not appropriate to compare your facility's QM ratings that appeared in February with those that appeared in earlier months.

Here’s how the ratings are calculated:

Medicare creates the overall 5-star rating for nursing homes based on three parts:

  • Health inspections rating: The health inspection ratings are based on the three most recent comprehensive (annual) inspections, and inspections due to complaints in the last 3 years. More emphasis is placed on recent inspections.
  • Quality Measures (QM) rating: The values on eleven QMs (a subset of the 18 QMs listed on Nursing Home Compare) are combined to create the QM rating. QMs are derived from clinical data reported by the nursing home.
  • Staffing rating:

The staffing rating is based on two measures:

o 1) Registered Nurse (RN) hours per resident per day; and

o 2) total staffing hours per resident per day. Total staffing includes: RNs; Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs); and Certified Nurse Aides (CNAs). Staffing data are submitted by the facility and are adjusted for the needs of the nursing home residents.

Star ratings are given for each part and the overall rating ranges from 1 star to 5 stars, with more stars indicating better quality.

The overall 5-star rating is assigned in these steps:

1. Start with the health inspections rating.

2. Add 1 star if the staffing rating is 4 or 5 stars and greater than the health inspections rating. Subtract 1 star if the staffing rating is 1 star.

3. Add 1 star if the quality measures rating is 5 stars; subtract 1 star if the quality measures rating is 1 star.

4. If the health inspections rating is 1 star, then the overall rating cannot be upgraded by more than 1 star based on the staffing and quality measure ratings.

5. If a nursing home is a special focus facility, the maximum overall rating is 3 stars.

The 5-star rating system has strengths and limitations. Here are some things to consider as you study the ratings system:

Health inspection results


  • Comprehensive: The nursing home health inspection process looks at all major aspects of care – about 180 different items -- in a nursing home.
  • Onsite visits: This information comes from a team of objective inspectors who visit each nursing home to check on the quality of care, inspect medical records, and talk with residents about their care.
  • Federal quality checks: Federal inspectors check on the state inspectors' work to be sure the national process is being followed and that any differences between states stay within reasonable bounds.


  • Variation among states: There are some differences in how different states carry out the inspection process, even though the standards are the same across the country.
  • Medicaid program differences: There are also differences in state licensing requirements that affect quality, and in in-state Medicaid programs that pay for much of the care in nursing homes. Thus, it’s safe to assume best comparisons are made by looking at nursing homes within the same state.



  • Overall staffing: The quality ratings look at the overall number of staff compared to the number of residents and how many of the staff are trained nurses.
  •  Adjusted for the population: The ratings consider differences in how sick the nursing home residents are in each nursing home, since that will make a difference in how many staff persons are needed.


  • Self-reported: The staffing data are self-reported by the nursing home, rather than collected and reported by an independent agency.
  • ‘Snapshot’ data: Staffing data are reported just once a year and reflect staffing over only a two-week period of time.

Quality measures


  • In-depth look: The quality measures provide an important in-depth look at how well each nursing home performs on important aspects of care. For example, these measures show how well the nursing home helps people keep their ability to dress and eat, or how well the nursing home prevents and treats skin ulcers.
  • National measures: The quality measures used in the 5-star rating are used in all nursing homes.


  • Self-reported: Again, the quality measures are self-reported by the nursing home, rather than collected and reported by an independent agency.
  • Limited aspects: The quality measures represent only a few of the many aspects of care.

You can view the technical manual containing additional information on the 5-star quality rating system - Opens in a new window.

Other Resources:

Comparing nursing homes

The ratings system

CDC recommends PT over opioids

The Centers for Disease Control and Prevention, concerned that sales of prescription opioids have quadrupled in the United States even though there has not been an overall change in the amount of pain that Americans report, this month released guidelines for prescribing the narcotic pain medication.

Opioid drugs work by binding to opioid receptors in the brain, spinal cord, and other areas of the body. They reduce the sending of pain messages to the brain and reduce feelings of pain. They are used to treat moderate to severe pain that may not respond well to other pain medications.

Some types of opioid drugs include:

  •  codeine (only available in generic form)
  •  fentanyl (Actiq, Duragesic, Fentora)
  •  hydrocodone (Hysingla ER, Zohydro ER)
  •  hydrocodone/acetaminophen (Lorcet, Lortab, Norco, Vicodin)
  •  hydromorphone (Dilaudid, Exalgo)
  •  meperidine (Demerol)
  •  methadone (Dolophine, Methadose)
  •  morphine (Astramorph, Avinza, Kadian, MS Contin, Ora-Morph SR)
  •  oxycodone (OxyContin, Oxecta, Roxicodone)
  •  oxycodone and acetaminophen (Percocet, Endocet, Roxicet)

The CDC guidelines, available here in their entirety, recognize that prescription opioids are appropriate in certain cases, including cancer treatment, palliative care, and end-of-life care, and also in certain acute care situations, if properly dosed.

But nonopioid approaches, including physical therapy, are recommended for other pain management, the government agency advises. Below are some hints to help the patient and provider know when to choose physical therapy over opioids.

The CDC says patients and providers should choose physical therapy when:

  • Patients are concerned about the risks of opioid use. "Given the substantial evidence gaps on opioids, uncertain benefits of long-term use, and potential for serious harms, patient education and discussion before starting opioid therapy are critical so that patient preferences and values can be understood and used to inform clinical decisions," the CDC states. Physical therapists can play a valuable role in the patient education process, including setting realistic expectations for recovery with or without opioids. The CDC guidelines note that even in cases when evidence on the long-term benefits of nonopioid therapies is limited, "risks are much lower" with nonopioid treatment plans.
  • Pain or function problems are related to low back pain, hip or knee osteoarthritis, or fibromyalgia. The CDC cited high-quality evidence supporting exercise as part of a physical therapy treatment plan for those familiar conditions.
  • Opioids are prescribed for pain. Even in situations when opioids are prescribed, the CDC recommends that patients should receive "the lowest effective dosage," and opioids "should be combined" with nonopioid therapies, such as physical therapy.
  • Pain lasts 90 days. At this point, the pain is considered "chronic," and the risks for continued opioid use increase. An estimated 116 million Americans have chronic pain each year. The CDC guidelines note that nonopioid therapies are preferred for chronic pain and that clinicians should consider opioid therapy "only if expected benefits for both pain and function are anticipated to outweigh risks to the patient."

It just makes good sense to consult with a physician and a physical therapist to discuss options for nonopioid treatment!

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.

Related Resources:

o Health Center on Opioid Use for Pain Management

o Using Opioids for More Than 30 Days Could Increase Depression Risk

o Widespread Pain is Creating Widespread Prescription Drug Use

o Health Center on Pain

o The American Physical Therapy Association

What are some strategies for reducing hospital readmissions?

The Hospital Readmissions Reduction Program, mandated by the Affordable Care Act, requires the Centers for Medicare & Medicaid (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions.

Readmission is defined as an admission to an IPPS acute care hospital within 30 days of a discharge from the same or another IPPS acute care hospital.

For Fiscal Year (FY) 2016, the Centers for Medicare and Medicaid Services (CMS) has estimated that total readmissions penalties will be approximately $420M, down slightly from $428M in FY 2015.

Penalties are being levied on 2,620 facilities for FY 2016, with the highest penalty for a single facility being more than $3.6 million. Forty-nine hospitals were penalized at least $1 million in FY 2015.

To calculate the penalty, CMS reviews the claims for five readmission measures for excess readmissions. The claims are grouped by measure based on diagnosis and procedure codes. The FY 2016 measures are unchanged from FY 2015:

  • Acute Myocardial Infarction (AMI)
  • Heart Failure
  • Pneumonia
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Total Hip and/or Knee Arthroplasty

The FY 2017 measures will include one addition: coronary artery bypass graft (CABG) surgery.

With national readmission rates as high one in five, and higher for certain diseases, many providers are seeking ways to reduce their readmission rate. Among some successful strategies are the following:  

  • Discharge Summaries
    Dictate discharge summaries within 24 hours of discharge. Standard practice and policy at most hospitals is that discharge summaries are completed within 30 days of the discharge.  But consider “anticipatory guidance" for those patients who get discharged, go home, and find they can't fill their meds, insurance doesn't cover the med or they have questions. They call their primary care provider, who didn't even know they were admitted. Information needs to be available at the time of discharge.

  • Intensify the Transition Process
    At every juncture in patient care process, especially discharge, have teams talk to each other about the patient.  Taking this person-centered approach shifts the concept from discharge — which is a moment in time signifying a sign-off —   to a transition — a shared accountability that assures the receiving providers understand who this patient is.

  • Provide Medication on Discharge
    Send the patient home with a 30-day medication supply, wrapped in packaging that clearly explains timing, dosage, frequency, etc.

  • Make a Follow-up Plan before Discharge
    Have your staff make follow-up appointments with the patient's physician and don't discharge the patient until this schedule is set up.  Make sure the patient has transportation to the physician's office and understands the importance of meeting that time frame; follow up with a phone call to the physician to assure that the visit was completed.

  • Communicate!

Health coaches, intensive care clinicians, and wireless technology can all be utilized to record vital signs on a daily basis for discharged Medicare patients.  Phone calls of between five and 15 minutes, frequently enough to gain patients’ trust, can help them stay out of the hospital.  

  • Identify those most at risk
    Customize your hospital's admission and re-admission rates for demographic and disease characteristics to identify those at highest risk, and expend extra resources on their care needs.

  • Plan Ahead

Just like Meals-on-Wheels can be scheduled in advance, so can case management, housekeeping services, transportation to the pharmacy and physician's office.

  • Say Goodbye with a critical eye

Discharge plans are often written in ignorance of the patient's pre-admission history and experience. Don’t hesitate to be critical of the plans patients get.

  • Are they really hearing you?
    Patients say they understand what they're supposed to do after they leave the hospital. But they are often heavily medicated, stressed, groggy and confused, and they may be unable to understand what they are being told, much less remember it two days later. "Teach back," in which they and their caregivers repeat back those instructions, needs to be constantly reinforced.

  • Focus on Highest-risk Patients
    Examine the readmission patterns at your hospital and see which patients, with which conditions, diseases or procedures, have the most readmissions. Push limited resources toward this group of patients in a more intense way.  

  • Listen to the Patient

Providing patients and their family members with informed choices and counseling in the emergency room setting may avert painful, unnecessary admissions. Because, even worse than a readmission is the readmission of a patient who does not want to be readmitted!


 Health Leaders Media

Centers for Medicare and Medicaid Services

Stratis Health


Are you in compliance? Here's how to know


The familiar lament that skilled nursing facilities have a heavier burden than other providers in providing services to Medicare and Medicaid beneficiaries found some support in the implementation of the Affordable Care Act.

The adoption and implementation of compliance programs had been at the option of nursing facilities until the ACA. No more: compliance is now mandatory for those who provide services to Medicare and Medicaid beneficiaries.

Specifically, Section 6102 of the ACA mandated that nursing facilities have effective compliance and ethics programs in operation by March 23, 2013. Another section of the Act requires other providers to have these programs as a condition of participation in Medicare/Medicaid programs, but nursing facilities were the first provider group to be singled out.

The push for compliance came at about the same time – 2009 – the OIG claimed that 25% of claims submitted by skilled nursing facilities for that year were in error. Reportedly, these errors were largely due to misreported therapy information – therapy being a significant factor in determining the RUG classifications. Thus the push for regulation.

Under the ACA, the Secretary of the U.S. Department of Health and Housing listed eight required components for a compliance program:

• Compliance standards must be truly effective in reducing violations of law

• Compliance program oversight should rest with high-level personnel with sufficient resources and authority

• Substantial discretionary authority should be kept away from individuals who had or likely have the propensity not to follow the law or established procedures designed to comply with the laws

• Effective and practical compliance training and education

• Monitoring and auditing systems reasonably designed to detect problems and a mechanism for employees to report without fear of retribution

• Consistent enforcement of disciplinary mechanisms

• Following detection of a problem, reasonable response must include steps to prevent similar problems/violations, including modifications to the program

• Periodic reassessment of the program to identify modifications needed based on changes within the facility

The OIG has provided guidance specific to nursing facilities — OIG Compliance Program Guidance for Nursing Facilities published in March 2000 and OIG Supplemental Compliance Program Guidance for Nursing Facilities published in September 2008.

The agency advises that there is not a "one size fits all" compliance program; instead, it recommends that the program be tailored to the individual facility, taking into account size, resources, culture, and corporate structure. In addition to the traditional billing and coding, 2

the OIG also directs us to other known risk areas based on its audits, evaluations, inspections, and investigations — quality related matters like staffing, appropriateness of therapy services, comprehensive care plans, use of psychotropic medications, and resident safety.

How can you meet these guides? Leaders of big and small nursing facilities leaders need to be much more vigilant with compliance program efforts. You may need to strengthen your existing program by

• adding or enhancing internal risk controls;

• making sure you use interdisciplinary team approaches with active physician participation and engagement; and

• developing well-known, publicized open and effective lines of communication between your residents, staff, management and the boards that govern your facilities.

Given ACA's far-reaching and growing regulatory and law enforcement scrutiny, failure to implement an effective compliance program will undoubtedly cause some headaches. It's time to meet this new day with a compliance program that meets the new challenges.

Other resources:

American Health Care Association

Centers for Medicare and Medicaid Services

October deadline looms for quality measure reporting under the IMPACT Act

On October 6, 2014, President Obama signed into law the Improving Medicare Post-Acute Care Transformation Act of 2014, an amendment to the Social Security Act that requires the submission of standardized data by the several kinds of providers of post-acute care.

The Act is the result of an invitation issued by the sitting chairmen and ranking members of the House Ways and Means and Senate Finance Committees to Medicare post-acute care (PAC) stakeholders to provide ideas for post-acute care reform. The resounding theme across the more than 70 letters received was the need for standardized post-acute assessment data across Medicare PAC provider settings.

Patients may receive post-acute care – care following surgery or a stroke, for example – from four different providers, each of which, prior to the passage of the Act, had its own set of complicated rules, procedures and costs:

  • a skilled nursing facility (SNF),
  • a hospital-based inpatient rehabilitation facility (IRF),
  • a long-term care hospital (LTCH), or
  • from a home health agency (HHA).

The new law:

  • Requires PAC providers to begin reporting standardized patient assessment data at times of admission and discharge by October 1, 2018, for skilled nursing facilities, hospital- based inpatient rehabilitation facilities, and long-term care hospitals, and by January 1, 2019, for home health agencies. This will include acute hospitals, cancer hospitals, and critical access hospitals by 2019.
  • Adds requirements for quality measure reporting (Oct. 1, 2016, for SNFs, IRFs and LTCHs, and Jan 1, 2017, for HHAs), that will include functional status changes, skin integrity and changes, medication reconciliation, incidence of major falls and patient preference regarding treatment and discharge options.
  • Requires resource use measures by October 1, 2016, including Medicare spending per beneficiary, discharge to community, and hospitalization rates of potentially preventable readmissions.
  • Requires the Secretary of HHS to provide confidential feedback reports to providers. The Secretary will make PAC performance available to the public in future years.
  • Requires MedPAC and HHS to study alternative PAC payment models, with reports due to Congress in 2016 for MedPAC and 2021-2022 for HHS.
  • Requires the Secretary to develop processes using data to assist providers and beneficiaries with discharge planning from inpatient or PAC settings.

The IMPACT Act intends to address all of the priorities within the CMS Quality Strategy, which are:

  • Making care safer by reducing harm caused in the delivery of care.
  • Ensuring that each person and family is engaged as partners in their care.
  • Promoting effective communication and coordination of care.
  • Promoting the most effective prevention and treatment practices for the leading causesof mortality, starting with cardiovascular disease.
  • Working with communities to promote wide use of best practices to enable healthy living.
  • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models.

The Secretary is directed to reduce by 2% the update to the market basket percentage for skilled nursing facilities that do not report assessment and quality data. The Act directs the Secretary to study the effect of individuals' socioeconomic status on quality, resource use, and other measures for individuals under the Medicare program, and the impact on such measures of specified risk factors.



The Act


Creative Health Solutions

April 1 is almost here – and with it, CJR

The Comprehensive Care for Joint Replacement (now known as CJR, no longer CCJR) program finalized last November by the Centers for Medicare and Medicaid Services will begin April 1 for hospitals in specified geographic areas.  With this mandated orthopedic bundle program, CMS expects to save $153 by 2018.

The final rule, all several hundred pages of it, can be accessed here: But this quick “cheat sheet” adapted from articles written by Sheldon Hamburger, a principal of Raleigh, NC-based healthcare consulting group The Aristone Group, can help get you up to speed if your facility is affected.

It’s a mandated program. That means the program is mandatory for hospitals in 67 predetermined markets, called MSAs. There’s no application process – you’re in or you’re not, and if you’re in, you already know it.

  • CJR is heavily based on the Bundled Payment for Care Improvement (BPCI) Model 2 program.
  • Hospitals alone can be episode initiators – other entities such as group practices or skilled nursing facilities are excluded.
  • The program begins April 1, 2016 and continues for 5 years – (this first “year” is only 9 months long – the remainder of 2016). You are at risk beginning Jan 1, 2017 (there is only upside during 2016).
  • Gainsharing with other providers is allowed within program guidelines.
  • Price targets become 100% regional-based by year 4 (phased in over time).

There’s more. Medicare takes 3% off the top of the total program. That means you need to drive total spend down by 3% to break even.  If the post-acute portion is about 50% of the bundle, you need to drive post-acute spend down by 6% just to break even.

  • CMS will grant these waivers:
    • An “incident to” rule for home health allows post-discharge home visits where they were previously not allowed.
    • Telehealth services are allowed in all geographies.
    • SNF 3-day in years 2-5 of the program.
  • A special ruling (see the CJR URL above) addresses safe harbor for issues such as anti-kickback, CMP, self-referral, etc.
  • All providers will continue billing FFS meaning your revenue cycle model will not change.
    • Gains/losses are calculated on a retrospective basis annually. Stop-loss and stop-gain limits protect you against big losses in exchange for limits on gains. CMS estimates that a small number of hospitals will be affected by the stop-loss and almost no hospitals will be affected by the stop-gains.
  • You must meet specific quality performance measures to be eligible for the savings you generate. A score compared to national averages will determine your eligibility to share in savings as well as possible “Quality Incentive Payments.”
  • Claims data is available on request. The process for requesting data has not yet been determined.

If you’re not in the program, you may want to consider preparing; it’s expected this program will be expanded in the future. Here are some hints:  

    • Get experienced help for your project. Do this early, as qualified help is in great demand. Consider including an analytics partner.
    • Identify your surgeon partners. Begin negotiating contract terms; contracts must be in place by April 1, 2016 if surgeons are to share in gains for 2016.
    • Establish a formal selection/integration process and associated performance criteria in order to maximize your revenue potential.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.



Again, the complete  CMs rule



RUGS IV 57-Group is here. Are you ready?

In November 2015, the State of Ohio approved the RUGS IV 57-group model for Medicaid reimbursements. The new model will affect Medicaid reimbursement calculations beginning July 1, 2016, using calculations data from the fourth quarter 2015 and the first quarter 2016.

  • The RUGS IV 57-Group Model is the same as the RUGS IV 66-Group Model, except the Rehabilitation and plus Extensive Services groups have been removed.
  • The category precedence for hierarchical classification is the Rehabilitation category (14 groups), the Extensive Services Category (3 groups), the Special Care High category (8 groups), the Special Care Low category (8 groups), the Clinically Complex category (10 groups), the Behavioral Symptoms and Cognitive Performance category (4 groups), and the Reduced Physical Functions category (10 groups).

It’s free! Richter Healthcare Consultants offers a helpful, downloadable free guideline to “beginning the crosswalk process” by recalculating ADL scores in line with significant changes in scoring process such as this:

  •   In RUGS III, the maximum ADL score was 18 and the 4 Late Loss ADLs were unequally weighted.
  • In RUGS IV, the maximum ADL score is 16 and the 4 Late Loss ADLs are equally weighted.

Words we can live with: In terms more understandable to the layman, we suggest referring to the blog of Reginald M. Hislop III, a healthcare executive, consultant, and author.

“I’ve been fielding lots of questions regarding the transition from RUGs III to RUGs IV. I’ve settled on an overview or ‘summary,’ the core of what SNFs need to know or if nothing else, get up to speed on quickly,” Hislop writes.  The following is paraphrased from his blog:

How we got from RUGs III to RUGs IV

Put simply, the major difference applies to therapy at the expense of nursing or clinical care needs. The Centers for Medicare and Medicaid Services became concerned that changes in the Skilled Nursing Facility population and patient needs altered industry practices and the allocation of resources, principally away from clinical nursing to rehabilitation therapy. CMS completed a time study to analyze the required resources provided to patients versus the clinical needs of patients.  The end result was an update to RUGs III known as RUGs IV.

RUGs IV consists of 66 groups divided into 16 categories (two were added) versus 53 under RUGs III.  CMS also revised the standardized assessment tool known as the MDS to version 3.0 in order to utilize the RUGs IV groups for payment. The final implementation rule published by CMS includes assurance that the goal of payment parity is maintained in calculating RUGs IV --in other words, the historical distribution of total payments to SNFs, based on 2007 claims data applied to RUGs IV, creates the same level of total PPS expenditure for SNFs as would occur under RUGs III. This is not an assurance to any particular SNF that revenues under RUGs IV will be equal or greater than revenues received under RUGs III. CMS calculates that the average rate under RUGs IV will be $431.71 compared to $420.42 under RUGs III.

Financial Impacts: Winners and losers – there will be both. Losers under RUGS IV, in terms of financial impact, will be those facilities that have run high levels of non-clinically complex rehab patients, treating on a concurrent therapy model. Clearly, the bias under RUGs IV is for facilities to provide one-to-one therapy.

Another clear category of losers is facilities that took significant advantage of the hospital look-back provisions under RUGs III to establish diagnoses, rehab and clinical care plans. RUGs IV and MDS 3.0 eliminate this provision entirely (ventilator patients being the exception).

The clear winners under RUGs IV will be those facilities that care for clinically complex patients and patients that are more ADL dependent – for example, SNFs that provide ventilator care, tracheostomy care, care for infectious diseases, etc., plus provide rehab.   Higher ADL dependency scores increase payments rather rapidly.

RUGs IV increases the nursing index weights at the expense of rehab. Essentially, facilities that typically bill below average rehab utilization (days) under RUGs III stand to come out ahead under RUGs IV, provided their clinical complexity is average or higher. Fundamentally, facilities that provide more clinical nursing care to a population with higher ADL deficits, cognitive impairments, and maintain an average rehab profile as expressed through utilization, will fare better under RUGs IV than RUGs III.


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The role of the Physical Therapist in cardiac care rehabilitation in a skilled-nursing facility

The structured program of exercise and education known as "cardiac rehabilitation" is designed to help patients return to optimal fitness and function following an event such as a heart attack. The program begins immediately after treatment, in a hospital room or ICU, and progresses through recovery in a skilled-nursing facility and, if that is the plan, the return home.

The cardiac rehabilitation team will include the doctor, nurses, and physical and occupational therapists, who will work together to help improve the patient’s functional mobility, decrease risk factors related to the cardiac injury, and help the patient and his or her family manage the psychosocial effects that may influence recovery after a heart attack.

The role of the physical therapist is to help to evaluate cardiac function, assess impairments that may limit mobility, and prescribe progressive exercise and physical activity to help the patient return to a normal lifestyle after a cardiac event.

The physical therapist’s role begins during the acute phase, in the hospital after the cardiac event, and continues through the following three phases, which will occur in a skilled nursing facility, a cardiac rehab center, or home.

Phase One: The Acute Phase

The initial phase of cardiac rehabilitation occurs soon after the cardiac event. An acute care physical therapist will work closely with doctors, nurses, and other rehabilitation professionals to help the patient start to regain his or her mobility.

In the case of severe cardiac injury or surgery, such as open heart surgery, the physical therapist may start working with the patient in the intensive care unit. The initial goals of phase one cardiac rehabilitation include:

  • Assess the patient’s mobility and the effects that basic functional mobility has on the   cardiovascular system
  • Work with doctors, nurses and other therapists to ensure that appropriate discharge planning occurs
  • Prescribe safe exercises to help the patient improve mobility and improve cardiac fitness.
  • Help the patient maintain sternal precautions in the case of open heart surgery.
  • Address any risk factors that may lead to cardiac events
  • Prescribe an appropriate assistive device, like a cane or a walker, to ensure that the patient is able to move around safely
  • Work with the patient and family to provide education about the patient’s condition and the expected benefits and risks associated with a cardiac rehabilitation program

Phase Two: The Subacute Phase

When the patient is ready to leave the hospital, the cardiac rehabilitation program will continue at an outpatient facility or a skilled-nursing facility. Phase two of cardiac rehabilitation begins

here and usually lasts from 3-6 weeks; it involves continued monitoring of the patient’s cardiac responses to exercise and activity.

Upon admission, the physical therapist will evaluate and assess the patient’s condition. Various tests and measures will be assessed by the physical therapist, including but not limited to:

  •  Heart rate
  •  Blood pressure
  •  Respiration rate
  •  Sternal precautions and scar tissue mobility assessment (if necessary)
  •  Upper and lower body strength
  •  Range of motion (ROM) of various joints
  •  Overall endurance level
  •  Balance

The physical therapist may choose to perform a specific outcome measure test to assess the patient’s general functional mobility or endurance. Common tests in phase 2 cardiac rehab include the 6-Minute Walk Test and the Timed Up and Go Test.

The main treatment offered by the physical therapist during phase 2 cardiac rehab is exercise. He or she will work closely with the doctor, nurses, and other healthcare providers to ensure that the patient safely improves exercise and activity tolerance. The PT will also teach the patient various methods to measure heart rate and to monitor exercise and activity tolerance.

Another important aspect of phase two cardiac rehabilitation is education about proper exercise procedures, and about how to self-monitor heart rate and exertion levels during exercise.

While the patient exercises, the physical therapist will monitor the body's physiological response to movement. Heart rate, blood pressure, and oxygen saturation rate will be measured. Typical exercises during phase 2 cardiac rehab may include:

  •  Treadmill walking
  •  Stationary biking
  •  Using an upper body ergometer (UBE)
  •  Rowing
  •  Using upper and lower body strengthening machines or free weights
  •  Stretching

A closely monitored exercise and activity program is optimal during the initial sessions of phase 2 cardiac rehabilitation, but as the sessions progress, the physical therapist will likely introduce more independent activities and exercises to prepare the patient for phases 3 and 4 of cardiac rehabilitation. The main focus of these phases is independent exercise and activity and a full return to a normal, healthy lifestyle.

Phase Three: Intensive Outpatient Therapy

Phase three of cardiac rehabilitation involves more independent and group exercise. The patient should be able to monitor his or her own heart rate, symptomatic response to exercise, and rating of perceived exertion (RPE). The physical therapist will be present during this phase to help the patient to increase exercise tolerance and to monitor any negative changes that may occur.

Phase Four: Independent Ongoing Conditioning

The final phase of cardiac rehabilitation is the patient’s own independent and ongoing conditioning, which are essential to maintaining and preventing possible future cardiac problems. While phase four is an independent maintenance phase, the physical therapist is available to help make changes to the exercise routine to help the patient achieve physical fitness and wellness.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.