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OIG 2016 Work Plan and Physical Therapists in Private Practice

November 14, 2015 3 Comments

The 2016 OIG Work Plan once again includes a review of physical therapists in private practice and is captioned as “Physical therapists—2016 written on rural roadhigh use of outpatient physical therapy services”.  Per the OIG Work Plan and physical therapists in private practice:

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 or were not properly documented or that the therapy services were not medically necessary. 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.

The OIG notes reference to therapy documentation requirements for therapy services in CMS’s Medicare Benefit Policy Manual, Pub. No. 100-02, Ch. 15, § 220.3.  Of note OIG Office of Audit Services (OAS) also included physical therapists in private practice in the 2011, 2012, 2013, 2014, and 2015 Work Plans.  In addition to audits under the various Work Plans the OIG initiated a widespread audit of 400 physical therapy claims nationwide in 2014 out of the OIG Chicago office.  An audit report has not been published on this initiative.

The OIG has published several reports on physical therapists in private practice pursuant to the OAS initiatives under previous years’ Work Plan.  A report on a New Jersey provider was released in 2013, followed by an Illinois provider in 2014. Reports regarding providers from New York and Puerto Rico were released in 2015.  Additional audits are underway so expect to see further OIG-OAS audit reports in 2016.

OIG 2016 Work Plan and Physical Therapists in Private Practice – What You Need to Know.

Before breathing a sigh of relief (because you haven’t been audited) it is important to know that in a recent report the OIG disallowed delayed certifications that were obtained per the statutory guidance and CMS manual instructions.   The OIG also provided different interpretation to  elements required in the plan of care than CMS manual guidance.  When OIG audit findings are presented to CMS for recommended actions (contained in the report recommendations) there is an opportunity for the provider to plead their case with the CMS official assigned to the case.  Following that, the provider has a chance to stave off the “extrapolated” payment with timely filing of the first level of appeals.  If unsuccessful at redetermination, timely filing at the second level of appeals (reconsideration) can stave off recoupment once again.  Unfortunately, recoupment begins if the reconsideration is unsuccessful even if an appeal to the third level (ALJ) is initiated.

So what’s the message for private practices?  If the above mentioned providers have taken their OIG audit findings through the appeals process on OIG findings, and their rationale and are unsuccessful, there will be “new policy” that other contractors can use with respect to plan of care elements, delayed certification, and provider supervision.  Note to readers:  none of this had to do with medical necessity!  In fact, the New York provider with the $1.3 million extrapolation payment demand had a an extremely low 4% error rate on medical necessity.  Stay tuned for further updates.  And by the way, ensure compliance with timely certifications!

Reference: 2016 OIG Work Plan:

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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  1. OIG 2016 Work Plan and Physical Therapists in Private Practice | HealthBACON | November 14, 2015
  1. Pam Wood says:

    We are a small, low volume independent PT practice and just received an audit request for progress notes from CareFirst for a patient’s services rendered during the year 2015. It stated that it was a Valuation Audit mandated by HHS for both independent and health exchange insured. While I understand audits, this is extremely time consuming for my staff and will be very costly should we receive requests for many patients. Can we bill for copying costs??

    We are not a high volume clinic, with this patient receiving less than 15 visits over a one year period. That said, we are faxing our e-notes one at a time, but it is ridiculously slow. There has got to be a better way than this. Can we expect this trend to increase in number of chart requests over the upcoming year?? At the very least, they should shoulder the administrative costs. Thanks. Pam

  2. Hi Pam – The request that you received from the Medicare Advantage Plan (Part C) was a request in compliance with their contract requirements. I have heard from a number of other providers receiving similar requests from their Medicare Advantage contracts. It is likely when you signed the contract that somewhere in the small print you agreed to cooperate and assist the plan in meeting reporting requirements. This trend will likely continue, and as with every contract you have to weight the participation costs against the merits of the contract. It is not likely that you will be able to receive compensation for copying costs. You may be able to electronically transport the records, and that may be a more affordable option. Thank you for your question.

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