Audits & Investigations
Until recently outpatient therapy providers had a low expectation of an audit, much less an expectation of an investigation. Therapists in private practice have been on the radar of the Office of the Inspector General (OIG) for the past several years. In general most providers have felt immune from review, and most reports of therapy misdeeds involved either sham operators, or the occasional legitimate therapy provider who upon review failed to meet Medicare documentation, coding and billing requirements. This is the current landscape for outpatient therapy providers:
- The Florida Zone Program Integrity Contractor (ZPIC) has conducted special investigations on outpatient therapy providers in southeast Florida. The ZPICs are fraud investigators, and act with determination to find wrong doing, even with legitimate providers.
- Therapy “sham operators” are routinely caught up in Medicare Strike Force initiatives and dragnets.
- The OIG 2013 Work Plan initiative to review private practice therapy providers in active and legitimate providers are finding that being “almost” right with Medicare rules is likely to lead to a finding of “always” wrong.
- The Recovery Auditors (RACs) are reviewing 100% of outpatient therapy claims over the $3700 therapy thresholds – opening therapy documentation to Medicare program integrity contractors who are paid a percentage of the claims that find that were submitted in error.
- The “Medicare Mini-Me” crowd of commercial and Medicare Advantage plans are replicating Medicare rules and regulations and have increased their prospective and retrospective utilization review.
Providers should seeks expert advice for audits, particularly if they have never had experienced a formal review of their Medicare claims. Providers, both owners and staff, should also be prepared in advance of a potential investigation, and understand the steps to implement should an investigator appear on the door step requesting documents and/or touring the facility with cameras in hand. Nancy Beckley & Associates provides compliance consultation and audit support, and assists clients in investigation response (which is recommended under attorney-client privilege).
Our Red Envelope Policy will assist you to frame, in advance of any knock on the door, your response to an investigator during an unannounced visit.