Tips for respiratory services success.

Post-acute providers are finding that many of their require respiratory services -- and these often pose challenges to long-term care facilities. Reimbursement, facility reconstruction, specialized equipment, specialty physicians and staffing -- all are important components and require skillful management decisionmaking.

If a post-acute facility plans on instituting a respiratory or ventilator program, then it is best to have a board-certified pulmonologist as the medical director. Certainly, pulmonologists should be involved in establishing the types of services to be offered.

In addition to services, the facility may have to undergo remodeling to address such environmental issues as convenient location, temperature control, power and space availability to accommodate the necessary equipment.

Reimbursement is a complex factor in administering and developing respiratory services. Medicare has certain regulatory parameters in reimbursing for them. Medicaid, in addition to Federal guidelines, has state-by-state regulations and methodologies of payment. Private insurers, including managed care, employ such methods as: fee-for-service; discounts off usual and customary charges; all-indusive per diem rates; exclusions to per diem rates; case rates; and partial and fully capitated rates. And the provider is supposed to understand and accommodate all of them.

It's no wonder that administrators are left scratching their heads when faced with this prospect. Recently, Nursing Homes asked several administrators with respiratory services experience for some advice. Here are their suggestions:

Joseph Martini, V.P., Amcare Medical Services, Massachusetts. Establishing a strong relationship with the hospital that supports your respiratory therapy program is critical -- not only from a patient care perspective, but from a patient referral flow perspective. A clear protocol must be established to ensure that all patients identified as having a respiratory disorder for which respiratory care might be indicated are evaluated upon order of a physician. Then a transfer process must be in place, a care plan developed, and continual assessment and treatment procedures established."

Dennie Campbell, Administrator, Heritage Eastridge Rehabilitation Center, Utah. "In a managed care environment, daily case management is crucial. Monitoring utilization of all services will enable the facility to better control costs and manage appropriate care."

Kevin Cornish, Manager, Ernst Sr Young LLP, Florida: "HCFA's interpretation of the transfer agreement for respiratory services varies by region and sometimes with a single intermediary. It is important for providers to understand completely the intermediary's interpretation of the regulations prior to initiation of service. If a transfer agreement is found invalid for whatever reason, all respiratory therapy claims are considered to be technically denied. Technical denials are not able to be appealed. Also, the associated claims could be considered false claims if a contract was determined invalid. False claims carry their own civil monetary penalties under the False Claims Act. A quality assurance system should be implemented to ensure appropriate treatment, documentation, charges and billing for respiratory therapy services."

Sam Giordano, Executive Director. American Association of Respiratory Care (AARC), Texas: "The skilled nursing facility administrator has an obligation to document the competency of the respiratory therapists as a requirement for accreditation by the joint Commission on Accreditation of Healthcare Organizations. Therefore, it is necessary to employ or contract with professional respiratory care practitioners who utilize clinical practice guidelines. It is important to understand and be able to interpret respiratory care orders and provide continuing education to those staff members who interface with respiratory care patients."

The AARC, in conjunction with the American Health Care Association (AHCA), has developed a position paper entitled "Guidelines for Respiratory Care Services in Skilled Nursing Facilities." This, as well as protocols, standards of practice and other useful information, can be obtained by calling the AARC at [phone].

Parting note. If you have a post-acute management tip or would like to suggest a topic for this series, please write to Laura Hyatt, Hyatt & Associates, 2956 Kelton, Los Angeles, CA 90064. Please be sure to include your name, address and phone number in case more information is required.

Laura Hyatt is President of Hyatt & Associates, Los Angeles, CA.