United States General Accounting Office

GAO Report to the Ranking Minority Member,

Committee on Commerce, House of

Representatives

August 1996 MEDICARE

Early Resolution of

Overcharges for

Therapy in Nursing

Homes Is Unlikely

G O A

years

1921 - 1996

GAO/HEHS-96-145

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-272062 

August 16, 1996

The Honorable John D. Dingell

Ranking Minority Member

Committee on Commerce

House of Representatives

Dear Mr. Dingell:

Medicare is the nation’s largest single payer for health care. In 1995, it

spent an estimated $177 billion, or 12 percent of the federal budget. On

average, Medicare spending has grown by over 10 percent a year since

1990. The costs of some services, however, have risen at a much faster

rate. These services include occupational, speech, and physical therapy

provided by hospitals, skilled nursing facilities (SNF), rehabilitation

agencies, and home health agencies. Therapy charges billed to Medicare

by such institutional providers have more than doubled, rising from

$4.8 billion in 1990 to $10.4 billion in 1993, the latest year for which these

data are available.

In March 1995, we reported that some providers were exploiting

weaknesses in Medicare’s payment system for therapy services delivered

to nursing home patients.1

 Two weaknesses that we identified were

especially notable. First, the Health Care Financing Administration (HCFA),

Medicare’s administrator, places no absolute dollar limits on Medicare

reimbursements for occupational and speech therapy. Second, charges for

therapy services are not linked through billing codes to the amount of time

spent with the patient or to the specific treatment provided; it is not

readily determinable whether a charge is for 15, 30, or 45 minutes of

treatment. These weaknesses make it difficult for HCFA to control the

amount Medicare pays for occupational or speech therapy.

Our report recommended that to avoid paying more than a prudent

purchaser would, HCFA should (1) develop salary guidelines that set

explicit limits on the amount Medicare will pay for occupational and

speech therapists’ services and (2) require that bills for these services

specify time spent with patients. HCFA generally agreed with our

recommendations and estimated in December 1995 that implementing

salary guidelines for occupational and speech therapists—combined with

1

Medicare: Tighter Rules Needed to Curtail Overcharges for Therapy in Nursing Homes

(GAO/HEHS-95-23, Mar. 30, 1995).

Page 1 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

adjusting existing salary guidelines for physical and respiratory

therapists—could save $1.4 billion over 7 years.

Because implementing these guidelines could prevent making further

excessive payments from an already stressed Medicare budget, you asked

us to follow up on our earlier work to (1) determine HCFA’s progress in

curbing overbilling and (2) assess the prospects of early resolution to the

overbilling problem.

To respond to your request, we performed additional analyses of data we

collected during our study reported in March 1995. To be more current, we

also reviewed 618 charges for services provided to 238 patients in SNFs

with more than 100 beds. The charges were submitted by seven providers

to one claims-processing contractor and were paid in January 1996. In

addition, we examined selected contracts between SNFs and rehabilitation

companies. To determine the steps that have been taken to prevent

overbilling from occurring and HCFA’s ability to quickly resolve the

problem of overbilling, we interviewed HCFA officials and reviewed

documents. We also reviewed an industry study of therapists’ salaries and

interviewed industry representatives about their views on HCFA’s initiatives

to curb overbilling. Our work was done between December 1995 and

July 1996 in accordance with generally accepted government auditing

standards.

Results in Brief Our recent work continues to show that SNFs and therapy companies are

billing Medicare very high charges for occupational and speech therapy. In

addition, the billing units on which these charges are based are not

defined—either within the industry or on the claims submitted.

We also found that the weaknesses we reported over a year ago—the lack

of salary guidelines to set limits on Medicare reimbursements for

occupational and speech therapists’ services and unclear billing units for

these services—still exist. Although HCFA recognized as early as 1990 that

Medicare was being inappropriately charged for occupational and speech

therapy, it is still working to establish salary equivalency guidelines for

these services. Between 1993 and 1995, HCFA proposed guidelines based on

a Bureau of Labor Statistics (BLS) survey of average salaries of hospital

therapists, but the industry was not satisfied and conducted its own

survey. HCFA received the survey results in April 1996 and is analyzing

them.

Page 2 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

The prospect for a quick resolution to the billing problem with therapy

services is unlikely. Historically, it has taken HCFA years to reduce high

payment rates for supplies or services. Given the usual time involved in

meeting federal notification and publication requirements for changing

Medicare prices, salary equivalency guidelines may not be implemented

until at least summer 1997. Reporting last September on this issue,2

 we

asked the Congress to consider granting HCFA legislative relief from these

requirements. Our recent work reinforces the need for legislative relief

that would allow HCFA to promptly set maximum limits on the basis of

market surveys and other methods of assessing the reasonableness of

rates or—if the existing formal notification and rulemaking process is

preserved—to make interim adjustments while the process takes place.

Background In 1990, legislation took effect that required SNFs and other nursing

facilities3

 to assess and provide for their residents’ needs for therapy

services.4

 Subsequently, the number of rehabilitation agencies providing

physical, occupational, and speech therapy increased dramatically—as did

Medicare spending on therapy services delivered in nursing homes.5

Most nursing home residents receive their therapy services from

outpatient rehabilitation therapy companies (OPT) that send their

employees to the nursing home. Once approved to participate in Medicare,

either a SNF or an OPT can bill Medicare. Both are regarded by Medicare as

institutional providers and, as billing providers, are reimbursed on a cost

basis. SNFs and OPTs must file annual reports detailing the actual costs of

services that were delivered to Medicare beneficiaries and billed to the

program throughout the preceding year.6 HCFA claims-processing

contractors reconcile these actual reported costs with the interim

payments made to providers throughout the year, either by making

2

Medicare Spending: Modern Management Strategies Needed to Curb Billions in Unnecessary

Payments (GAO/HEHS-95-210, Sept. 19, 1995).

3

SNFs are nursing homes that maintain a full-time staff of medical professionals who provide daily

care for patients with complex medical or rehabilitative needs. Other nursing homes do not offer this

level of care, do not choose to participate in Medicare, or have patients who do not require this level of

care. In this report, the term “nursing facilities” includes both categories.

4

Omnibus Budget Reconciliation Act of 1987, 42 U.S.C. 1395i-3(b), 42 U.S.C. 1396r(b).

5

Medicare’s basic nursing home benefit covers a portion of posthospitalization costs for up to 100 days

in a SNF. Patients in SNFs and nursing homes who have exhausted their coverage or who do not

qualify for the SNF-level of care can still receive therapy services that are paid for by Medicare.

6

If a SNF submits a bill for OPT-provided services (in lieu of the OPT billing Medicare directly), the

amount the SNF paid the OPT becomes part of the SNF’s therapy costs along with therapy-related

costs for services and supplies and general and administrative expenses.

Page 3 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

additional payments to providers or by collecting overpayments from

them. In the reconciliation process, the contractor determines whether the

claimed costs are “reasonable.”

Medicare has a number of principles to ensure that only reasonable costs

are used in determining its final payment, such as a prudent purchaser

principle. Under this principle, Medicare compares claimed costs with the

“going rate” for the item or service. For example, if a SNF contracts with an

OPT at $500 for 1 hour of therapy services and the going rate is $100 per

hour, only $100 would be approved for inclusion in the cost report during

the year-end settlement; the $400 would be disallowed.

Two problems occur in applying the prudent purchaser and other

principles. First, to ensure that these rules are followed, Medicare’s

claims-processing contractors must audit cost reports. But because

auditing is resource intensive and funds for auditing are limited, therapy

costs are rarely audited. Second, establishing a “going rate” may involve

conducting a survey of current practice and pricing among comparable

providers in the same geographic area, which may also be resource

intensive. For these reasons, if the SNF in the example above included the

full $500 per hour contract cost in its cost report, there is little assurance

that this amount would be adjusted downward.

Under certain billing conditions, salary guidelines have helped Medicare

limit the amount it will pay for certain services. For example,

reimbursements for OPT-provided physical therapy services that are billed

by SNFs and subject to salary equivalency guidelines7

 (and, hence, are

referred to as capped) increased 646 percent between 1989 and 1995.

Speech therapy and occupational therapy reimbursements, for which

similar guidelines have not been imposed (referred to as uncapped), have

grown at about two and three times this rate, respectively, as shown in

figure 1.

7

These guidelines were established in 1975. In 1983, salary rates were recalculated and have since been

adjusted annually by an inflation factor. The American Physical Therapy Association, however, claims

that the current physical therapy rates are well below market and that occupational therapy and

speech therapy charges are higher than would be expected to compensate for the low physical therapy

rates.

Page 4 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

Figure 1: Comparative Growth Rates in Charges for Capped and Uncapped Therapies Billed by SNFs

Percent of 1989 Charges

646%

Increase

1,968%

Increase

1,270%

Increase

2,100

1,900

1,700

1,500

1,300

1,100

900

700

500

300

100

1989

Physical Therapy

Occupational Therapy

Speech Therapy

1990 1991 1992 1993 1994 1995

Source: GAO analysis of national claims data provided by HCFA.

The absence of information on the amount of time spent providing a

service also makes it difficult to determine whether a claim is reasonable

Page 5 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

prior to payment. Under current HCFA regulations, OPTs and SNFs are not

required to specify on their claims how much therapy time they are billing

for or what specific service was provided. Instead, OPTs can choose one of

at least six methods to bill Medicare. Although each of these methods

requires costs to be associated with a “unit,” claims generally do not

specify what the unit denotes. In these cases, the Medicare

claims-processing contractor does not know the amount of time involved

in delivering the therapy services or what the services included, making it

all the more difficult to detect inflated charges and identify unreasonable

costs.

Limited Progress

Made to Control

Overbilling for

Occupational and

Speech Therapy

Services

SNFs and OPTs are continuing to charge excessively high rates for therapy

services, particularly occupational and speech therapy, when services are

provided under arrangement.8

 Charges for claims paid during January 1996

by one contractor showed extreme variations similar to those found in our

March 1995 study. Because salary guidelines and units of service have not

been established, Medicare has no easy way to determine whether any of

these charges were excessive or whether they resulted in excessive

payments, but that is most likely the case.

HCFA Attempts to

Implement Salary

Guidelines Have Not Yet

Been Successful

Since 1990, HCFA has taken a number of interim and long-term actions to

curb inappropriate charges for SNF therapy services. HCFA has focused its

efforts on implementing salary equivalency guidelines for those providing

occupational and speech therapy services under arrangement.

Between 1990 and 1992, HCFA received numerous complaints about

inappropriate charges for therapy services. In 1993, it established a task

force to address the problem. As a result of this task force, HCFA sent a

series of memorandums in 1993 and 1994 to its claims-processing

contractors, advising them of the nature of existing problems—such as

inflated therapy service charges—and providing guidance on how to focus

review activities.9 HCFA outlined a number of steps that contractors could

take to ensure that services were medically necessary and to help

determine whether costs were reasonable and allowable. For example,

HCFA suggested that contractors audit any provider with therapy costs

exceeding $95 per hour. However, this measure was probably ineffective:

8

“Under arrangement” refers to a contractual relationship whereby the OPT bills the SNF for services it

provides and the SNF in turn bills Medicare. The OPT’s charges become the SNF’s costs.

9

In April 1994, HCFA also took the unusual step of arranging with the Journal of the American Medical

Association to publish an appeal from the HCFA Administrator for physicians to resist pressure to

authorize excessive therapy services.

Page 6 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

“Per hour” rates cannot be determined without intensive auditing because

units of service are not defined in units of time. Moreover, some providers

that had been billing significantly less than $95 per hour reacted by simply

raising their charges close to that level.

In 1995, HCFA developed draft salary guidelines for those providing

occupational and speech therapy, and revised guidelines for other

therapies, reviewing for this purpose 22 separate data sources. The

recommended levels were based on the 75th percentile of hospital salaries

for therapists (as surveyed by BLS) plus a 5-percent differential to adjust

for likely differences between hospital and SNF salaries.10 In August 1995, a

clearance package containing a notice of proposed rulemaking was sent to

the Secretary of the Department of Health and Human Services (HHS).

Forwarding this package was a significant step, given the complex and

lengthy process that HCFA must go through to lower payment rates.

At this point, however, officials of the rehabilitation industry complained

that the HCFA guidelines were inappropriate and out of date because they

were based on 1991 hospital salaries for therapists. Industry

representatives offered to commission their own survey of SNFs that

employ therapists. HCFA agreed and put implementation of salary

guidelines on hold pending completion of the survey. HCFA officials told us

that, in their judgment, this would increase the prospects for developing

fair and effective guidelines and reduce the chance of a time-consuming

and expensive legal challenge.

HCFA reviewed the design for this survey, which ultimately encompassed

both hospitals and SNFs. The raw survey data and an industry analysis were

delivered to HCFA in April 1996. However, the survey response rate was low

(10 percent for hospitals and 30 percent for SNFs), which raises questions

about how representative the data are.11 HCFA is conducting its own

analysis of the results to determine if they are meaningful. According to

HCFA, a proposed regulation should be published shortly after its analysis

is complete. The final regulation is then likely to be issued sometime in

1997.

10The Clinton administration’s legislative proposal subsequently recommended a 10-percent

differential.

11Official government surveys generate a much higher response rate. The BLS White Collar Pay Survey

(one component of which was the hospital salary data survey on which the draft guidelines were

based) had an overall response rate of 82 percent. Typically, BLS response rates exceed 80 percent.

Page 7 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

HCFA Has Not Defined

Units of Service

Claims for therapy services are required to specify the number of service

units provided; claims-processing contractors’ databases store this

information in terms of “units” or “services.” These units, however, are not

defined. In our March 1995 report, we recommended that HCFA define units

on the basis of time, such as 15-minute intervals. In commenting on that

report, HCFA said it did not agree with using time as the basis and believed

it would be better to have therapy units defined by the procedures actually

performed. HCFA has not yet defined billable therapy units for SNFs in terms

of either the exact procedure furnished or the amount of time actually

spent with the patient.12 Therefore, Medicare does not know how much

service it is buying at the time it pays the claim.

Neither HCFA nor the industry observe any standard usage for “unit” or

“service,” as illustrated by the wide variation in “per unit” charges. While

some interpret “unit” as 15 minutes, there is no consensus.13 We analyzed

data from five HCFA claims-processing contractors14 for 1988 through 1993

and found extreme variations in “per unit” charges. For each therapy type,

per unit charges for the highest quartile of providers were more than

double those of the lowest quartile, and differences among individual

providers were even more extreme. Results were similar for our more

recent data set. For this follow-on, we also reviewed a range of hourly

rates identified in contracts between OPTs and SNFs under the jurisdiction

of one HCFA contractor. In those contracts that specified hourly rates for

occupational therapy, the rates varied considerably, from $54 to $210 per

hour.

Prospects Poor for

Rapid Resolution of

the Problem

As we reported in 1995, Medicare has paid substantially more than market

rates for some services, which not only increases Medicare costs but also

can encourage providers to supply excessive services. We also reported

that HCFA has generally been slow in addressing overpricing problems.

Delay in drafting and implementing regulatory changes such as price

corrections and salary guidelines is inherent in the rulemaking process

12The Clinton administration’s current Medicare legislative proposals include a provision to require use

of HCFA’s Common Procedure Coding System to identify more precisely what services were

performed.

13This uncertainty does not apply in all circumstances. The 1996 Medicare resource-based relative

value fee schedule has several codes for at-home training done by occupational and physical

therapists. These codes have values of about $18 for each 15-minute period.

14These claims data were provided by five Aetna Life Insurance Company field offices (California,

Connecticut, Florida, Illinois, and Pennsylvania).

Page 8 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

established by the Administrative Procedures Act15 as well as in the

complexities of intra- and interagency coordination (see fig. 2).

155 U.S.C. 551.

Page 9 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

Figure 2: HCFA’s Regulatory Process

Development HCFA Clearance OS/OMB Clearance

RS Drafts/Revises Regulations HCFA Comments to ORM

Sent to Lead and RS

Lead Office Submits

Specs to RS

ORM Circulates Regulations for

HCFA Review

RS Clears Draft & Sends

to Lead Office/OGC &

Appropriate Components

RS Revises & Sends to Lead

ORM Submits to OS/ES for

Department Clearance

Comments to RS Lead Office Reviews

and Returns to RS

OS/ES Circulates to STAFFDIVS

(9 offices) & OPDIVS (3 offices)

RS Sends to Lead for Clearance RS Finalizes and Sends to

Lead to Clear

OS/ES Forwards to Immediate

Office of Secretary

Administrator Signs

OS/ES Forwards to OFR

OFR Publishes Regulation

Lead AA Signs & Forwards to

Regs. Mgmt. (ORM)

Lead Sends to AA:

AA Sends to ORM

Secretary Signs

OIRA Circulates Reg. to OMB

Budget Office

ORM Sends to Administrator

OS/ES Forwards to OMB

(OIRA)

OIRA Forwards OMB Response

(OIRA or Budget Office Comments)

to OS/ES

Revisions?

Revisions?

Revisions? Revisions?

Revisions?

Legend

RS - Regulations Staff

ORM - Office of Regulations

Management

OGC - Office of the General Counsel

AA - Associate Administrator

OS/ES- Office of the Secretary,

Executive Secretariat

OMB - Office of Management

and Budget

OIRA - Office of Information and

Regulatory Affairs

OFR - Office of the Federal Register

OS/ES

Forwards

Comments

to ORM

No No

No

No

No

Yes Yes

Yes

Yes

Yes

Page 10 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

For it to fully satisfy formal rulemaking requirements, HCFA has projected

that it could take 7 years or longer from the time it learned of the problem,

and almost 3 years from the time it started assembling salary data, to

establish salary equivalency guidelines for professionals providing therapy

services. HCFA, therefore, has drafted proposed legislative language under

which salary equivalency guidelines for occupational and speech

therapists would be established directly by statute, negating the need for

formal rulemaking. The proposal was included in the December 1995

summary of the President’s Medicare proposal.

In our September 1995 report, we suggested a similar approach to the

effect that the Congress consider allowing the Secretary of HHS to set

maximum prices on the basis of market surveys or, if the formal

rulemaking process is preserved, allowing the Secretary to make an

interim adjustment in fees while the studies and rulemaking take place.

HCFA officials consider the establishment of salary guidelines the most

urgent step in solving the problem of inappropriate therapy charges. They

do not believe it is absolutely necessary to achieve a standard definition of

a therapy unit, such as a 15-minute interval, especially since this process

would take another 2 or 3 years. Their reasoning is that salary guidelines

would provide the necessary link (through the cost report settlement

process) between hours of therapy time and costs claimed. Auditors could

then confirm that Medicare payments did not exceed salary limits.

However, as discussed earlier, such an approach is vulnerable to abuse

because few cost reports are audited in sufficient detail to permit such

judgments to be made and any audit may be delayed a year or more even

when one is performed. Moreover, as long as units are not defined on a

time basis as we suggested or on the basis of the exact procedures

performed as HCFA believes would be better, Medicare’s claims

reviewers—even after salary guidelines are implemented—will not be sure

of the amount of services being provided. This in turn makes it more

difficult to assess the medical necessity for therapy services.

For a long-term solution to the problem of therapy overcharges, HCFA

officials emphasized the importance of more systematic legislative

approaches, such as requiring unified billing. We presented this option in a

report released earlier this year:16 Unified (or consolidated) billing would

require nursing facilities to bill Medicare for all services they are

16Fraud and Abuse: Providers Target Medicare Patients in Nursing Facilities (GAO/HEHS-96-18,

Jan. 24, 1996).

Page 11 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

authorized to furnish to patients. OPTs rendering these services would be

prohibited from directly billing Medicare; financial liability and medical

responsibility would reside with the nursing facility. This would make it

easier for Medicare to identify all the services furnished to residents,

which in turn would facilitate controlling payments for these services.

Conclusion Despite HCFA’s efforts to deal with the problem, SNFs and OPTs continue to

bill Medicare high charges for occupational and speech therapy. To

correct this problem without expending large amounts of administrative

resources, HCFA needs to implement salary equivalency guidelines for

occupational and speech therapists as soon as possible. Given HCFA’s

experience with payments for physical therapy, such guidelines should

help moderate payment growth rates.

Legislation to limit reimbursement, as we suggested last September, is the

most practical way to enable Medicare to avoid continuing excessive

payments for overpriced services.

Agency Comments

and Our Evaluation

In a letter dated June 19, 1996, HCFA generally agreed with our concerns

about inappropriate billing and delivery of therapy services. It also agreed

with the first recommendation in our March 1995 report that HCFA should

develop salary guidelines to establish explicit cost limits on occupational

and speech therapy services, though not necessarily with our assessment

of the current status of these guidelines. HCFA officials did not entirely

agree with our second recommendation, that bills for these services

specify the time spent with patients.

In its comments on a draft of this report, HCFA claimed that “the emphasis

on excessive charges obscures the fact that Medicare is not actually

paying the reported charges,” and asked that our report “specifically state

that GAO has not identified any specific instances in which excessive

charges are actually paid.” As discussed on pages 3 and 4 of this report, the

amount Medicare actually pays is not known until long after the service is

rendered and the claim processed. Although aggregate payments are

eventually determinable, existing databases do not provide actual payment

data for any individual claim—hence, our focus on charges. In any case,

we found HCFA’s own estimate of a potential $1.4 billion in savings over 7

years as a result of implementing salary guidelines (and revising those

already in place) to be persuasive evidence that excessive payments are

being made.

Page 12 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
B-272062 

With regard to the uniform definition of time units, we concur with HCFA

that “Ideally, we would prefer reporting that would identify the exact

procedure furnished, not just on the basis of time units.” Either way of

defining the unit of service for therapy would be better than leaving the

unit undefined. More specific claims would make it easier to determine

whether charges are appropriate for the actual services provided and

whether the patients needed those services.

We also concur with HCFA on the importance of systematic approaches,

such as unified billing, to resolving concerns over payment for therapy

services. As we stated in correspondence last September,17 unified billing

would make it easier for Medicare to identify all the services furnished to a

facility’s residents, which in turn would make it easier to control payments

for those services.

Other HCFA comments were incorporated in the report where appropriate.

See the appendix for a copy of HCFA’s comments.

As agreed with your office, unless you publicly announce its contents

earlier, we plan no further distribution of this report until 30 days from the

date of this letter. At that time, we will send copies to the Secretary of HHS,

the Administrator of HCFA, interested congressional committees, and other

interested parties. We will also make copies available to others on request.

Please call Barry Tice, Assistant Director, at (202) 512-7119 if you or your

staff have any questions about this report. Other major contributors

include Audrey Clayton, Andrea Kamargo, Steve Machlin, and Karen Sloan.

Sincerely yours,

Edwin P. Stropko

Associate Director, Health

 Financing and Public Health Issues

17Preventing Abusive Medicare Billing (GAO/HEHS-95-260R, Sept. 5, 1995).

Page 13 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
Appendix 

Comments From the Health Care Financing

Administration

See p. 12.

Page 14 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
Appendix 

Comments From the Health Care Financing

Administration

Discussion of inherent

reasonableness deleted.

Sources added.

Statement deleted.

Sources added.

Figure 2 of draft deleted.

We did not question the

agency’s judgment.

Page 15 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
Appendix 

Comments From the Health Care Financing

Administration

See p. 13.

See p. 13.

Page 16 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
Appendix 

Comments From the Health Care Financing

Administration

(108282) Page 17 GAO/HEHS-96-145 Salary Guidelines for Therapy Services
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