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.
On the other hand, ever conscious of the bottom line, rehabilitation corporations have added their own twist to this never ending absurdity. But, their germinal factor is greed. The corporates add their own oxymoron to the mix, hypnotizing the SLP to the fact that an evaluation can actually be “thought of as treatment”!! Of course since treatment is reimbursed, and evaluation is not, let’s start thinking of the evaluation as “more treatment” with less “evaluation.” Their regional representative’s spiel goes something like this: “Well, if you think about it, when you are evaluating a patient, you really are trying out some treatment techniques, and so you really could think of this as treatment along with your evaluation.” Just a couple of things wrong here. First of all, you are supposed to be using a standardized evaluation which is published as an evaluation (Federal Tag 272, OBRA Guidelines), not a treatment tally sheet. Secondly, comprehensive and accurate care plans are to be developed from the standardized test results, with a continuum of treatment goals developed and itemized (OBRA Guidelines, F-tag 279). So, a true evaluation analyzing a patient’s medical history, motoric abilities, cognitive status, swallowing status, and sensory analysis simply cannot be achieved in 15 minutes. (I can barely get a chart read in 15-30 minutes!) Now, a few companies promote themselves by stating they allow their therapists “30 minutes” per evaluation. Same result of incompetent evaluation holds. And, the same penalty fines for Federal Tag 272 and Federal Tag 279 hold. Just one poignant point here, too many times still, SLP’s are supplying their own tests, and too many times they fail to test patients appropriately since no tests are provided for them by their companies. These practices only endanger the SLP in the end. Additionally, this is a blatant breach of the Code of Ethics of our profession.
Then, in the PRN world, there is the issue of 100% productivity, to which I say, “this is impossible, so it won’t happen, “spoken quietly but firmly." Where does this brain rot come from, and worse, why do some SLP’s fall for it and then commit fraud documenting it? Do they think that some reviewer is going to believe this somewhere down the line? No reviewer I know would believe this. There is time required in walking down the halls trying to find your patient. There is time required in bathroom breaks. There is time required when it’s just a difficult day when your patients are in PT and OT, and they can’t be worked with immediately. This is reality, and 100% productivity is “not reality.” It is a lie. Then, it becomes a matter of character – yours.
Now what are we supposed to do? Start pushing back. If PT’s and OT’s can get the expensive equipment they need for patient care, what is so impossible for a rehabilitation company providing the necessary tests required to develop appropriate care plans for their patient populations? The corporate will experience fewer denials, and less fines at state review time. Also, there will be hard copy test documentation/back up over time which can be retrieved during audits, despite the paperless chart path we are on. And, we as SLP’s, don’t have to feel uncomfortable since we have known what an evaluation is and what treatment is since graduate school! Don’t get confused over the term “diagnostic treatment.” Diagnostic treatment is not an evaluation. Diagnostic treatment is when a treatment strategy is altered because it has been shown over a number of sessions not to be effective. It is the SLP’s responsibility to be doing diagnostic treatments each session to assess the effectiveness of her strategy and alter, or change the strategy as needed.
In the end, it comes down to “strength of character.” Do you stand up for an appropriate time period for an evaluation (1-2 hours) on behalf of the patient, or do you feed the greed of the corporate? It is not the SLP’s job to fight Washington, D.C.’s injustice for institutionalized slavery, it is the rehabilitation company’s job. Your job is to provide appropriate services to the patient. Nothing more, and certainly nothing less.