Outpatient physical therapists under scrutiny by Office of the Inspector General

The OIG 2009 Work Plan has several areas that address outpatient physical therapists directly.

• Outpatient Physical Therapy Services Provided by Independent Therapists

"We will review outpatient physical therapy services provided by independent therapists to determine if they are in compliance with Medicare reimbursement regulations. The Social Security Act, § 1862(a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 15, § 220.3, contains documentation requirements for therapy services. Previous OIG work has identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented. Focusing on independent therapists who have a high utilization rate for outpatient physical therapy services, we will determine whether the services that they billed to Medicare were in accordance with Federal requirements.
(OAS; W-00-09-35220; various reviews; expected issue date: FY 2009; new start)"

• Physicians’ Medicare Services Performed by Nonphysicians

"We will review services physicians bill to Medicare but do not perform personally. Such services, called “incident to,” are typically performed by nonphysician staff members in physicians’ offices. The Social Security Act, § 18610(s)(2)(A), provides for Medicare coverage of services and supplies performed “incident to” the professional services of a physician. However, these services may be vulnerable to overutilization or put beneficiaries at risk of receiving services that do not meet professionally recognized standards of care. We will
FY 2009 OIG Work Plan 15 Centers for Medicare and Medicaid Services
examine the qualifications of nonphysician staff that perform “incident to” services and assess whether these qualifications are consistent with professionally recognized standards of care.
(OEI; 09-06-00430; expected issue date: FY 2009; work in progress)"

Outpatient physical therapists with high, unexplained utilization rates will have to show good documentation for their charges.

Physician-owned physical therapists will also have to demonstrate the following:

• Medical necessity for physical therapy (treatable findings)
• Expectation of significant improvement in a reasonable time frame (progress)
• Skilled physical therapy (PT decisions or PTA clinical judgment)

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