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As many of you who have attended the workshops know, Pamela Crouch, M.A., CCC-SLP is my partner in the Speech Team, and my best friend. Her faith in our profession and in the care we provide to patients in crisis are real and enduring. I hope her poem gives you strength in your life and profession as she has given to me." Karlene Stefanakos, M.A., CCC-SLP
As we have entered into the Medicare reform rollout period, which began last October 1, 2011, our lives are now characterized by increased stress due to company requested higher productivity levels, which in many cases will become a red flag to investigative teams seeking out fraud. Medical records of patients are now being copied for the RAC teams, and other investigative teams, and fines are being leveled because “perfection” is the rule of the law. Even we here at the Speech Team are altering our tests to include the patient’s name and date of evaluation on every single test page since RAC team reviewers require “absolute coherency” in every chart. The point being that a patient’s medical chart must read like a novel by non-medical accountants! No more “off or low energy days” for any of us, even though we are human beings.
Psychoactive (psychotropic/pharmacological) drugs are among the most frequently prescribed medications for the elderly in skilled nursing facilities and assisted living facilities designed for dementia residents. Psychoactive drugs are medications designed to alter behaviors through their tranquilizing effects, reduction of anxiety and depression, and sedative and hypnotic effects. CMS (Center for Medicare Services) has mandated that these medications are NOT to be used unnecessarily. The regulations state that an unnecessary drug is any drug when used in excessive doses (including duplicate therapy), for excessive duration, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combinations of these reasons.” Duplicate drug therapy is defined as “any prescribed medication that duplicates a particular effect on an individual.” This includes two or more drugs used in combination to produce a similar effect on behavior. Duplicate drug therapy should always be analyzed for accumulative adverse effects. (Long Term Care Guidelines, CMS, 1992).
It is interesting to note what is expected of the Speech Language Pathologist in Medicare law as regards the appropriate evaluation of the dysphagia patient. To quote the law: “If you conduct videofluoroscopic assessment (modified barium swallow), document that the exact diagnosis of the swallowing disorder cannot be substantiated through oral exam and there is a question whether aspiration is occurring. The videofluoroscopy assessment should be conducted and interpreted by a radiologist (often with assistance and input from the physician and/or individual disciplines). The assessment and final analysis and interpretation should document a definitive diagnosis, identification of the swallowing phase(s) affected, and recommend the treatment plan. “ (Medicare Intermediary Manual, Part 3 – Claims Process, Transmittal No. 1528, section 450. Subsection D, paragraph 2).
Through my travels and as I read my emails, I am uncomfortable with the lack of knowledge that SLPs have regarding the laws that govern their responsibilities for evaluation and functional maintenance programs required for the dementia patients. Even if SLP’s have “some” knowledge of their “job” with the dementia patient, a fully implemented program is not instituted within the facility. So here’s a brief synopsis of the SLP’s responsibilities under the law.
As I continue in PRN work, I am amazed at the “longevity of the absurd” as exemplified in an SLP’s documentation notating a 15-minute evaluation for a Medicare Part A patient, regardless of their admittance diagnosis. This oxymoronic documentation is the end product of some very flawed thinking stretching all the way from Washington, D.C. through the corporate offices of rehab companies, and down to the street level rehabilitation service centers throughout the nation. At the root of this medical corruption is the germinal fact that Medicare Part A evaluations are not reimbursed financially by Medicare. So, when the patient is admitted to a rehabilitation center from hospital, OBRA guidelines which compel a “comprehensive evaluation” (Federal Tag 272) of the patient, places the SLP in the “no pay zone” of Medicare. Work without pay used to be called slavery.
As I travel and lecture across this country, the question continuously surfacing in each workshop is "What did I spend my money on for my master's?" This question is usually generated by a feeling that somewhere in their graduate studies, the workshop attendees should have had instruction on the workshop topic areas, since these topics have such basic implications on their SLP practices. Quite frankly, as I look at the catalog curriculums of some of our schools, it is difficult to discern curriculum differences since the time when I went to school - twenty years ago.