The OIG and Therapy. A Case Study. ReDoc Customer Webinar August 27, Wednesday, September 4, 13

Transcription

1 The OIG and Therapy A Case Study ReDoc Customer Webinar August 27, 2013

2 Knock Knock It s the OIG! Rehab perception of investigations that led to Corporate Integrity Agreements (CIA) HealthSouth? Physio? Changing perception of investigations? Advanced Physical Therapy Carlson Therapy Network Audits v. Investigations Work Plan Referrals for investigation (RA, MAC, ZPIC, et al) Qui Tam Relators (Whistleblowers) 2

3 OIG Work Plan Independent Therapists High Utilization of Outpatient Physical Therapy Services We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable, medically necessary, or 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 , ch. 15, (OAS; W ;W ; W ; various reviews; expected issue date: FY 2013;work in progress and new start) 3

4 OIG Work Plan 2011 Questionable Billing for Medicare Outpatient Therapy Services We will review paid claims data for Medicare outpatient therapy services from 2009 and identify questionable billing patterns. We will identify counties with high utilization and compare utilization in these counties to national averages. We will also determine the extent to which billing characteristics in high-utilization counties, including questionable characteristics that may indicate fraud, differed from billing characteristics nationwide.. (OEI; ; expected issue date: FY 2011; work in progress) 4

5 There s Something About Medicare per-beneficiary spending on outpatient therapy services in Miami-Dade County was three times the national average in Miami-Dade County had at least three times the national levels for five of the six questionable billing characteristics. Recommend that CMS (1) target outpatient therapy claims in highutilization areas for further review, (2) target outpatient therapy claims with questionable billing characteristics for further review, (3) review geographic areas and providers with questionable billing and take appropriate action based on results, and (4) revise the current therapy cap exception process. CMS concurred with all four recommendations. 5 Report (OEI )

6 The Letter 6

7 Spectrum Rehabilitation We recommend that Spectrum: refund $3,112,501 to the Federal Government; strengthen its policies and procedures to ensure that outpatient therapy services are provided and documented in accordance with Medicare requirements; and obtain a better understanding of the Medicare reimbursement requirements related to outpatient therapy services, through such means as attending provider outreach and education seminars. 7 Report (A )

8 Spectrum OIG Alleged For 45 claims, Medicare physician certification requirements were not met. For 36 claims, the treatment notes maintained by Spectrum did not meet Medicare requirements. For 35 claims, the therapist who billed Medicare did not perform or supervise the service. For 21 claims, therapy services were not medically necessary. For 4 claims, the plan did not meet Medicare requirements. Note: Errors in 83 of 100 claims, 44 contained more than 1 deficiency 8

9 Spectrum Plan Did Not Meet For four claims, Spectrum received Medicare reimbursement for services that were not provided in accordance with a plan that met Medicare requirements. Specifically, for these four claims, the plan did not include the type of service provided and billed to Medicare. 9

10 Spectrum - Certification For 45 claims, Spectrum received Medicare reimbursement for services that did not meet physician certification requirements. Services were not certified in a timely manner. For 33 claims, services were not certified by a physician or non-physician practitioner when obtained or within 30 days of the first treatment (31 claims) or during the duration of the initial plan or within 90 days of the initial treatment under that plan (2 claims). Physician certifications of initial plans were not dated. For 11 claims, certifications were signed by a physician or non-physician practitioner but were not dated. Services were not certified. For one claim, services were not certified (i.e., there was no dated physician or non-physician signature on the plan). 10

11 Spectrum Daily Note For 36 claims, Spectrum received Medicare reimbursement for services for which the treatment note was missing or did not meet Medicare requirements. Specifically: Total treatment time not documented. For 31 claims, the total treatment time in minutes for timed procedures was not documented in the treatment note. No treatment note. For three claims, there was no treatment note for some services. Treatment note did not support the number of units billed. For three claims, the treatment note did not support the number of units billed for some services. 11

12 Spectrum Treating vs. Billing For 35 claims, Spectrum received Medicare reimbursement for outpatient therapy services provided by therapists that were not enrolled in Medicare and who did not have a provider identification number. These services were billed to Medicare using provider identification numbers assigned to other therapists in the practice. There was no evidence in the case records to indicate that these services were directly supervised by a therapist who was enrolled in Medicare. 12

13 Spectrum Medical Necessity For 21 claims, Spectrum received Medicare reimbursement for services that exceeded the therapy caps and for which the beneficiaries medical record did not support the medical necessity of services above the therapy caps. 13

14 Spectrum Plan Did Not Meet For four claims, Spectrum received Medicare reimbursement for services that were not provided in accordance with a plan that met Medicare requirements. Specifically, for these four claims, the plan did not include the type of service provided and billed to Medicare. 14

15 What Does This Mean for Your 15

16 Absolute Therapy Some Final Findings (Review of 20/100 sampled by PSC) services were rendered under unapproved or incomplete plans of care, documentation did not indicate that the plan of care was reviewed at least every 60 days, and documentation did not meet Medicare standards to support that services were actually provided. $5,928 in errors = $414,712 payback Medical reviewers determined that Absolute did not always follow Medicare requirements or fiscal intermediary (FI) guidance. Absolute had written policies and procedures that, if followed, would have precluded the errors the medical reviewers identified. 16 Report (A )

17 Speaker Information Nancy J. Beckley, MS, MBA, CHC President Nancy Beckley & Associates LLC Materials in this presentation are referenced from various HHS-OIG Reports and Work Plans that are readily available at the OIG website: Resources: 17