The 2016 OIG Work Plan once again includes a review of physical therapists in private practice and is captioned as “Physical therapists—high 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: http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf