The Medicare Fraud Strike Force arrested eight individuals in October 2008, including two doctors, charging them with conspiracy and fraud in a scheme to bill Medicare for HIV infusion treatments that were never performed.
Similar schemes involving compounding pharmacies in 2007 cost the Medicare program $20 million dollars.
In May 2007 a Miami medical billing company was convicted of fraudulently collecting $56 million from Medicare.
Medicare payments to home health agencies in Miami have increased 1300% since 2003.
"focusing on home health agencies that send nurses to give homebound diabetics insulin injections. Some patients are neither homebound nor unable to give themselves the injections...Some don't even have diabetes."
So, how does this affect physical therapists?
All health care providers are suspect when these kinds of abuses occur.
Medicare must enact tougher controls to manage the system.
Better control of 'outlier' payments is first on Medicare's list.
From the October 10, 2008 USA Today -If you are a legitimate outlier, for instance a manual physical therapist who charges a lot of Manual Therapy (CPT 97140) you need to make sure that your notes support your billed charges.
"Randall Culp, an FBI agent who oversees a team that investigates Medicare fraud, says Medicare should move faster to revoke Medicare status for questionable home health agencies and crack down on outlier payment abuses."
You need to show...
- Medical necessity for physical therapy (measurable, treatable findings)
- Expected improvement in a reasonable time frame (progress)
- Skilled physical therapy (decisions)
A legitimate outlier would have a patient population that requires above-average amounts of a particular intervention, for instance chronic low back pain.
Documented pain diagrams or patient-reported functional scales, such as the OPTIMAL can help demonstrate medical necessity for physical therapy for this patient population.
Validated outcomes measure such as OPTIMAL or AM-PAC can show progress.
Skilled therapy is demonstrated by your decisions.
Get training for improved physical therapy decision making at BulletproofPT.com.