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Case Studies

Client Case Studies

Privileged External Audit – A provider determined that therapy provided to Medicare beneficiaries was not properly billed according to Medicare 1:1 requirements.  The audit included a review of claims in mutliple stratas from a statistically valid sampling of therapy claims in order for the provider to assess payback liabilities.

Compliance Guidance for OIG Site Visit– A provider under a CIA (Corporate Integrity Agreement) with the Office of the Inspector General requested onsite assistance during the OIG’s site review of the facility.  The provider felt that an outside set of expert eyes would provide valuable insight duing the two day visit.   The OIG positively noted the use of a consultant in both their exit interveiw and subsequent follow-up report.

Compliance Program Development – A small private practice asked for assistance in developing policies and procedures to be compliant with Medicare. We provided a template policy and procedure manual that we assisted the provider in customizing and updating during several years of rapid growth consistent with the OIG Compliance Guidance for Physicians and Small Practices.

Medicare Documentation Training – A hospital outpatient department requested a Medicare documentation training for therapy staff based upon the Local Coverage Determination of their new fiscal intermediary.  Seasoned therapy staff wanted to ensure best practices in the use of procedure and diagnosis codes, and wanted recommendations on documentation format and efficiency.

Monitoring and Auditing A medium sized therapy network, with clinics in several states, requested development of an annual monitoring and auditng plan that took into account not only Medicare documentation requirements, but the differences in the local coverage determiniations for the different Medicare carriers they billed.  Based upon findings from these activities they asked us to develop a training program for clinical staff, billing staff and front office staff to ensure full compliance.

Mandated Compliance Training Under Corrective Action Plan – A small rehab agency was cited by their fiscal intermediary for not complying with intermediary requests.  The corrective action plan called for specific training to be conducted by an outside rehab expert to include documentation requirements and full compliance with Rehab Agency Conditions of Participation.

Managed Care Contract Review – A group therapy practice requested review of managed care contracts where the renewal agreement terms changed from the original signed contract.  We reviewed the contract, pointed out inconsistencies, lack of explanation of contract terms, and recommended the exclusion of certain contract terms automatically extending discounted pricing to future products.  The managed care plan accepted the terms, and the provider was saved from automatically discounting a higher paying book of business when the managed care plan brought this product to market.

Managed Care Negotiation Strategy Development – A hosptial outpatient therapy system was renewing a capitated managed care contract with a physician IPA where the hospital was losing money.  They requested financial analysis of the past two years performance under the contract and recommendations for establishing a negotiating position that would bring profitability to the contract.  A completed financial analysis was done, as well as a selected review of patients clinical and financial records.  We assisted the provider in developing a negotiating strategy that was based on quality care indicators, patient education, and restructured a reimbursement paradigm for outlier cases that was accepted by the IPA.

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