Each year the Office of Inspector General releases their action plan for the following 12 months. Â It is the ultimate To Do List; giving us insight into where they will be dedicating resources. Â Not surprisingly, the OIG is looking at areas of high utilization, improper or incomplete documentation, and providers and suppliers billing for services that are not medially necessary. Â They have targeted individual providers, practices and facilities across many medical specialty areas. Â It is foolhardy to believe that anyone can fly below their radar.
Physical therapistsâ€”High utilization of outpatient physical therapy services
Billing and Payments: Â We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations.
Contextâ€”Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable or medically necessary or were not properly documented. Â
Our focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Â Medicare will not pay for items or services that are not â€œreasonable and necessary.â€
Their text states that the â€œDocumentation requirements for therapy services are in CMS’s, Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15, Â§ 220.3.â€ Â Could they be any more explicit? Â We donâ€™t see how.
If the OIG report alone has not captured your attention, letâ€™s consider the implications of the settlement reached in Jimmo v. Sebelius. Â Â The settlement of this recent Vermont case clarifies the coverage parameters for Maintenance Therapy under Medicare. Â CMS revised parts of Sections 220 & 230 of Chapt. 15 to address the documentation required to support claims for Maintenance Therapy. Â These changes took effect on January 7, 2014 and indicate that:
Skilled therapy services require the specialized skill, knowledge and judgement of a qualified therapist to establish or design a maintenance program. . . . The specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.
The determining factor in these cases is whether the skills of a therapist are required. Â This also indicates that these maintenance services will not be covered by Medicare if they are performed by a PTA or other staff member. Â We anticipate that this will be another fertile area for Medicare to audit. Â Consequently it is critical that your staff is properly documenting these cases.
Genco Healthcare helps practices achieve and maintain a culture of compliance. Â They also assist Healthcare Attorneys in defending their clients who have been audited or subject to pre-payment review. Â Consequently, Genco Healthcare has their finger on the pulse of precisely what Medicareâ€™s expectations are when it comes to medical documentation. Â You can reach them at 914-713-3606 or Â email David Alben atÂ David@Gencohealthcare.net.