By Direct Care Training & Resource Center, Inc. & Electronic Medical Services, LLC
Providers delivering care in Michigan’s Personal Injury Protection (PIP) system must be aware of an often-overlooked financial adjustment that can impact reimbursement for attendant care services. When a foster care resident receiving 24-hour attendant care also participates in outpatient therapy sessions, insurers commonly reduce billed attendant care hours for the time spent in therapy—even when a physician order prescribes continuous care.
Understanding Insurer Adjustments
A claim specialist from the Michigan Auto Club Group recently noted: “It is reasonable to expect that attendants are not actively engaged with the resident while the resident is being attended to by therapists, therapy assistants, and other staff in outpatient clinics. Therefore, attendant care is subject to adjustment.”
This means that if a resident undergoes therapy for three hours in a clinic setting, an insurer may deduct those three hours from the attendant care bill, assuming no additional supervision is required. While this adjustment is standard practice, it can significantly impact a provider’s financial projections if not anticipated.
In a scenario like this, the work of the therapist would be deemed sufficient with no additional support.
Challenging Attendant Care Reductions:
Providers who believe attendant care should continue during outpatient therapies must be prepared to justify the necessity with strong documentation. Specifically, providers should:
- Obtain physician agreement stating that the resident requires dedicated supervision even while in outpatient therapy.
- Demonstrate behavioral concerns such as elopement risk, aggression, or an inability to remain safe in a clinic setting.
- Highlight instances where outpatient therapy staff are unable to provide necessary one-on-one support beyond therapy-specific needs.
A physician with knowledge of the patient’s needs and behaviors should be on board when justifying added attendant care during outpatient therapies.
It is important to note that additional personal care tasks performed during outpatient sessions, such as assisting with toileting or positioning, are typically expected to be managed by the clinic’s staff. Simply arguing that the resident needs help with basic personal care functions is unlikely to meet the standard for maintaining full attendant care reimbursement during therapy hours.
Compliance with Billing Regulations
Providers must also be mindful of compliance risks. If attendant care is billed for a resident during outpatient therapy hours when no dedicated care is actually being provided, this could be considered fraudulent under the False Claims Act. Ensuring that billing accurately reflects the services rendered is not just a matter of financial prudence, it is a legal requirement.
Financial Planning Considerations:
For providers operating in Michigan’s PIP system, understanding and anticipating these insurer deductions is critical. Adjusting financial projections to account for these reductions and proactively addressing necessary documentation can help providers maintain compliance while advocating for appropriate resident care.
Those seeking to bill for attendant care during therapy hours should ensure they have proper medical justification and insurer understanding of the need to avoid disputes and potential legal concerns.
Another Blog Post by Direct Care Training & Resource Center, Inc. Photos used are designed to complement the written content. They do not imply a relationship with or endorsement by any individual nor entity and may belong to their respective copyright holders.
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