Reimbursement based on population?

[paddler]

I heard something at work today about the agency reimbursement from CMS being based on population of the patient area served by the company. Some agencies in large metro areas getting $12,000 for a cert period for a patient with the same stats/Dx/case mix as an agency in a rural area getting $2,400. Is this true??? Is this ethical?

I have never heard the agencies I've worked for getting more than say, $3,800 MAX for a cert period for a case no matter what the case mix, but then again I don't really do much with the money end so maybe I don't know. My (rural) company is rationing nurse visits and referrals to PT because they cannot make ends meet if they allow a nurse to go more than once a week for 2- 3 weeks and then back down to QOW for the rest of the cert and encourage to discharge ASAP. That's only 7 visits a cert period we are allowed to do, let alone if the patient has wound care or other skilled needs that require more frequent visits. I just don't get it.

Other places I've worked, I've set up patients for 2, 3 or sometimes 4 visits a week and never heard a thing from the company about losing money on the case. There was no rationing of visits or referrals going on. There is something very strange happening on the business end of this new little company I am working for and I wish I knew enough about the money end of things to figure out what they are doing wrong to help them.

[KateRN1]

There is a geographical element to reimbursement, but rural locations are reimbursed at a higher rate than urban in most cases. And please don't think that you don't have anything to do with the reimbursement. If you are admitting patients and completing a SOC OASIS, you have everything to do with it. It's your scores on the OASIS that are driving the reimbursement. Are you scoring your patients correctly per CMS guidance to justify therapy? If you believe that your patient needs therapy, make sure that your ADL/IADL scores indicate that. Rationing of visits is something that we are all having to get used to. Nurses and therapists must make the most of every single visit to ensure that the proper interventions are put in place and goals are met to return the patient to independence as quickly as possible. We cannot keep patients on service forever with the same nebulous goals for episode after episode of endless therapy. Start each admission with the mindset of "What do I need to teach this patient/caregiver to get them independent as quickly as possible?" and then go from there.

[paddler]

Thanks Kate, yep I get that. I do fine on my OASIS scores, I understand that my assessments affect reimbursement, I just meant I don't deal with or have knowledge of the money end of things (expenses, overhead, how much we actually get reimbursed, etc). Which is what I meant by "not much to do with".

I also have NEVER kept a patient on service indefinitely, and in fact have been asked by management (in another job) in the past to keep patients on the books who no longer qualify, or recertify even though it is custodial care and have refused to do so. It is always my foremost goal to make a patient as independent as possible in the most expedient manner possible. I shake my head when I see other nurses cases go on and on and on.

Prior to this new job, I accomplished this by front-loading visits to get as much teaching done as possible soon in the cert period. What I don't understand is if a patient only "needs" a visit (or is only allowed a visit by our agency) once a week or less, do they even need HH at all? If so, how am I to adequately assess, teach, reassess in so few and infrequent visits? Doesn't CMS look at a 7 visit cert period and question if the patient even needed HH at all when they see so few visits and so few referrals to PT (we are discouraged from referring and utilizing HHAs).

All I know is I see a VAST change from where I used to work to my new job and I wonder what is driving the different approach to patient care and why my current agency is "going broke" while other places are not.