The Office of the Inspector General (OIG) published their 2014 Work Plan in the end of January. The OIG 2014 Work Plan includes physical therapy. Physical therapists in private practice have once again been identified as part of the work scope.
This topic has been ongoing for the past several years so it comes as no surprise that physical therapy will be in the cross hairs yet again. The reviews will be ongoing and this work is already in progress from the 2013 Work Plan (which also represented a continuance from the 2012 Work Plan). The 2014 Plan also indicate a new start. The reviews will be conducted by the OIG Office of Audit Services. Breathe a sigh of relief – it is the auditors, not the investigators! The OIG audits for physical therapists in private practice will target billing and payment to determine if they are in compliance with Medicare reimbursement regulations.
Physical therapists—High utilization of outpatient physical therapy services
Billing and Payments. We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. Context—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. Our focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).) Documentation requirements for therapy services are in CMS’s, Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15, § 220.3. (OAS; W-00-11-35220;W-00-12-35220; W-00-13-35220; various reviews; expected issue date: FY 2014; work in progress and new start.)
Cross your fingers and hope that your number is not pulled. Well, that is something we all want to do, but the better idea is to be prepared, starting with having a active compliance program in place that not only provides insight into Medicare billing and payments for all employees, but more importantly oversight to ensure that everything was done as planned. This includes an active compliance cycle of: DETECT, CORRECT and PREVENT.
OIG 2014 Work Plan Includes Physical Therapy – What do I do?
The good news (if you can call it that) is that the OIG has published a report last year regarding Spectrum Rehabilitation. This report contains some tell-tale information about how the OIG approaches and audit, and details findings related to outpatient rehabilitation. This review comprised audit personnel from the OIG and well as medical reviewers from the provider’s MAC.
If you are a physical therapist in private practice these are the things that should be at the top of your to do list:
- Have an effective and active compliance program in place. A compliance program is based on a compliance plan. If you don’t have a compliance plan – quickly scale the implementation of a plan to the size of your practice and begin with a risk assessment, a code of conduct and an employee education program, so that everyone understands expected behavior and knows Medicare billing, coding and documentation rules. The presence of an active compliance program demonstrates a commitment to do the right thing, and is required under the ACA (although regulations have not been published). Best practice is to follow the guidance of the OIG Compliance Guidance for Physicians and Small Practices.
- Review the OIG Spectrum Rehabilitation Report. After you have finished the report select a few of audit categories and do a replica audit in your own practice. Keep in mind this is not quality assurance, but regulatory compliance, as much of the requirements noted related to the “Statute” (that being the Social Security Statute – or the “Law”). My suggestions would be to address the plan of care certification, ensure the billing provider is the rendering provider, and that therapy minutes are calculated correctly two way (time codes and total treatment time).
It is the Super Bowl Weekend – so take time to enjoy to root for your team, or to enjoy the commercials and half-time show. But come Monday morning, join me on Monitor Monday, as we have the pleasure of having the Erin Bills, the Director of External Affairs for the OIG as our special guest to talk about the 2014 Work Plan.
Nancy J. Beckley is the president of Nancy Beckley & Associates LLC, a firm specializing in outpatient therapy compliance. The firm offers compliance outsourcing, risk assessment, compliance plan development, annual compliance training, and external auditing, due diligence and investigation support. Clients include providers under Medicare probe review, progressive corrective action plans, corporate integrity agreements, ZPIC investigations and RAC audits.
Nancy’s background includes 15 years hospital experience serving in management capacities at two large inpatient rehabilitation facilities with extensive managed care contracting and program management expertise. A therapist by background and training, Nancy has served as program director, facility director and administrator in both inpatient and outpatient rehabilitation facilities.
She is a nationally known speaker in the area of rehab compliance, and has presented at the Provider Practice Compliance Conference, Florida Compliance Conference, and the Healthcare Compliance Association Compliance Institute. She was featured in a Healthcare Compliance Association webinar on Hospital Risks in Outpatient Therapy, and has authored three articles for Compliance Today and written over 20 articles on the RAC program.
Ms. Beckley’s area of expertise includes:
• Compliance program development, consulting, training, and external auditor
• Medicare regulatory requirements for outpatient therapy providers, including extensive experience in Medicare survey and certification for outpatient therapy providers
• Audit and consulting engagements under attorney-client privilege for risk assessment and potential payback liability analysis
• Medicare program integrity initiatives: MACs, RACs, CERT, ZPIC, probe reviews, pre and post payment reviews
• Nationally recognized expert on CORFs, served on the Medicare CORF Technical Expert Panel
• Hospital outpatient compliance consulting, auditing & training
• Compliance due diligence activities in acquisition and portfolio development to assess Medicare compliance risk
EDUCATION: University of South Florida, M.B.A.; Harvard University School of Public Health Course for Managed Care Executives; University of Illinois, M.S.; University of Wisconsin, B.S.
PROFESSIONAL ASSOCIATIONS: Board of Directors, National Association of Rehab Agencies (NARA); Member, Healthcare Compliance Association; Senior Contributing Editor, RAC Monitor + Monitor Mondays; Compliance Columnist for APTA’s IMPACT Journal
PROFESSIONALCERTIFICATIONS: CHC, Certified, Healthcare Compliance by the Healthcare Compliance Certification Board
PUBLICATIONS & PRESENTATIONS: Available upon request
CONTACT: 414-748-4376; [email protected];