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Managing Physical/Occupational/Speech Therapy & Rehabilitation Care, 7th Edition (2009)
Apollo Managed Care Consultants, Jan 2009, Pages: 630
575 page 2-volume compendium of detailed review criteria policies and guidelines for outpatient (adult and pediatric) Occupational, Physical and Speech Therapy + inpatient rehabilitation services. The number of visits (and time per visit for modalities) commonly required to treat specific conditions by body region or therapy are listed as well as review criteria guidelines for rehabilitation care admission, continued stay and discharge for common disorders. Example protocols and other tools to improve care are located throughout the manual. Resources include the Oregon pediatric rehabilitation guidelines and example home exercise handouts to give to patients; authoritative references; web links.
Volume I
This manual has been compiled in recognition of the need for a construct of objective guidelines, policies and procedures for the management of acute inpatient, skilled nursing facility and rehabilitation hospital care as well as outpatient integrated rehabilitation medicine programs providing physical, occupational and speech therapy. Standards for the authorization review of requests for services are an integral part of the management of these services.
This information is provided as a general reference and is not intended to address every aspect of a clinical situation that may exist now, or in the future. Physicians and health care professionals must exercise clinical discretion in interpreting and applying this information to individual patients.
“These guidelines are an educational tool designed to assist practitioners in providing appropriate care for patients. They are not inflexible rules or requirements of practice and are not intended, no should they be used, to establish a legal standard of care. … The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician” (or other care provider) “in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations on available resources or advances in knowledge or technology subsequent to publication of the guidelines. However, a practitioner who employs an approach substantially different from” nationally accepted “guidelines is advised to document in the patient record information sufficient to explain the approach taken. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. It should be recognized; therefore, that adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care.”
The manual is written/edited by a physician who has served as a consultant to various managed care entities and served as a Medical Director for an IPA and a medical group. The information has been used or critiqued by others who are actively engaged in delivering therapy and rehabilitation services. Whenever possible, literature references are used to support the written materials. It is not a guide to practice, but rather a compilation of policies, procedures, guidelines and related information with extensive references and resources. ‘Physical medicine’ is used throughout the text in the broadest sense and does not imply that the provider of care has any given degree, training or certification, although all providers must be practicing within their sphere of expertise and licensure.
This manual has been developed to provide a model for common, acceptable, customary, reasonable and medically necessary managed care contract benefit interpretations and objective evidence-based review for authorization (or denial) of services. One of the most common reasons for denial by any payer is that a service is not a covered benefit in the beneficiaries contract. Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.
This manual provides examples (some abstracted from Medicare policies) of common, customary, reasonable and necessary care benefit interpretations and objective evidence-based review guidelines for authorization (or denial) of services. A ‘benefit interpretation’ is a document that describes an issue as it relates to insurance coverage (read source of payment). Coverage may vary from one company to another, and from contract to contract within a given company. Coverage provides payment for services. It has no other function related to the care of a patient.
Volume II
This ‘single topic’ medical guideline and review criteria has been developed to provide a representative model for common, acceptable, customary, reasonable and necessary managed care contract benefit interpretations and objective evidence-based review for authorization (or denial) of services. Each guideline must be reviewed by the medical policy committee of the HMO or contracted/delegated medical group, modified and adapted as appropriate. It is strongly recommended that all applicable documents that will be used to manage medical care in the organization be sent to affected providers for review and comment prior to implementation. This will always promote an understanding of the guideline, avoid compliance issues, and frequently improve the document by additional input. Cost effective health care is quality driven (true quality, that is; not excessive care) and attention must always be focused on the issues that will result in optimal medical/surgical outcomes in a specific local medical environment.
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