RACs Get Complex

Up until now, Recovery Audit Contractors (RACs) have only been approved to issue demand letters for multiple, untimed codes:

• evaluation (97001)
• re-eval (97002)
• e-stim (G0283)
• traction (97012)
• etc

...per day per patient.

The RACs would review your billing profile using computerized, 'data drilling robots' that spot these un-listed Common Procedural Terminology (CPT) code edits and send you a demand letter.

The demand letter would arrive, automatically generated, with days, patients and dollar amounts listed.

Since multiple untimed codes are 'technical denials' there is no appeal.

Now, RACs are approved for complex review - that means they can request and review copies of your charts. They will attempt to find issues that would give basis for a medical necessity denial.

You can appeal medical necessity denials - and you should.

There is evidence that RACs inappropriately interpret published Medicare guidelines in making their denials.

For my state, Florida, Connolly Healthcare is the CMS-approved RAC. Connolly also administers the RAC program for Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas.

Private Practice Physical Therapists will get RAC data from Belinda Holmes

Belinda Holmes, BS, CPC, CCP-P will share her physical therapy RAC 'war stories' and tips to protect yourself from physical therapy automated claims review for 'untimed codes' in 2010.

Belinda will present

"Medicare Defense Strategies"

in Palmetto at Medical Arts Rehabilitation, Inc from 9am to 3pm - Belinda's part begins at 10:30am -11:30am on Saturday, November 7th, 2009.

Belinda works for Kerkering Barberio, a large Sarasota accounting firm with expertise in defending physical therapy clinic owners from Medicare audits.

Belinda is usually called in after the audit letter is received by the physical therapist and by then her job is usually 'damage control'.

At her seminar, Belinda would like to share with you ways to prevent that audit letter from ever reaching you.

Belinda's talk will focus on real-world, 'boots-on-the-ground' tactics you can use in your daily practice to prevent and defend your notes and charts from a Medicare audit.

1. RACs: What are they and how to avoid them
2. OIG 2010 Work Plan
3. Real life accounts of physical therapy audits
4. The new focus on medical necessity

Recent RAC missteps

RACs have not been putting up the kind of stellar numbers recently that earned their Demonstration Project permanent status in 2008.

The latest update of the three year Demonstration project in Florida, California and New York reveals that providers are right to have concerns about RAC improper application of Medicare guidelines.

Type of Reviewer	% of improper payment denials appealed by provider	% of appealed claims overturned in favor of provider	% of all improper payment denials overturned in favor of provider
Claims Processing Contractors	4%	59%	2.3%
Recovery Audit Contractors	22.5%	34%	7.6%

Since the percent of all 'improper payment denials' for RACs is almost three times the rate of MACs the data lend credence to the belief that RACs are not correctly interpreting Medicare guidelines.

Since RACs return overpayments successfully overturned at any level of the appeals process what can providers do to create a strong disincentive for RACs to incorrectly deny your claim?

Appeal!

Call 941.729.1800 to RSVP for Saturday's seminar.

You can get more information at www.BulletproofPT.com

Physical Therapy, Silver Coins and Green Eyeshades

We need a common coin of the realm.

After Napoleon's final defeat at the Battle of Waterloo on June 18, 1815 the British bond market rallied as investors predicted lower government borrowing for future wars. Nathan Rothschild arrived in London just hours ahead of the news of the battle's outcome and began buying up British war bonds at bargain basement prices.

Bond prices rose as yields fell and Rothschild sold at a huge profit. Rothschild's future was made in those months following Waterloo. Many sources credit Rothschild as the pre-eminent banker, speculator and, some say, the most powerful financier of the nineteenth century.

After securing his fortune Nathan Rothschild went on to become famous and also managed to create a standard that still affects our lives today. He demanded, and got, due to his money and influence, a uniform system for paying bond holders in sterling silver - no matter which country they were from. Investors no longer had to go to London to receive their bond coupon payments and sterling silver became the coin of the European investing realm.

Improvements in payments made bonds more attractive to investors and, ultimately, easier for Rothschild to sell. Bond holders were better off, governments gained access to new funding and Rothschild got richer.

I see a parallel here.

Couldn't physical therapists demand a uniform measurement system for rehabilitation outcomes? If all rehabilitation professionals had a common measurement system (eg: standardized performance, self-report, impairment or classification measures) then physical therapist outcomes could be compared with other rehab professionals. Right now, the only available comparisons are based on setting (eg: POPTS, PTPP, hospitals, etc.) and the only available measure is cost.

What if physical therapists could compete with physicians on outcomes?

Physician owned physical therapy clinics (POPTs) are slightly lower in annual Medicare, per beneficiary costs ($522) than their Physical Therapist in Private Practice (PTPP) peers ($871) but that may be due to the 'Flying Below the Radar' effect.

Unfortunately, cost is not the best measure of competitiveness. Not if you believe that quality service is a better measure. WalMart competes on cost - would you buy healthcare from WalMart?

Physical Therapists under Automated Review

Right now, in America, powerful computer algorithms are sifting your claims data and looking for patterns outside the 'bell curve' - do you do a lot of manual therapy?

Four manual therapy units (1 hour) per visit? You are outside the curve.

Automated reviews, conducted by Recovery Audit Contractors (men in green eyeshades), are looking for duplicate payments like two spinal tractions in one day. Spinal traction is a 'supervised modality' - you set it and go treat another patient. Totally legal - however you can't charge more than one per day per patient.

Recovery Audit Contractors (RACs) made some good money in Florida, California and New York from 2005 to 2008 during the RAC Demonstration Audit with automated reviews.

	RECOVERED AMOUNT	NUMBER OF PROVIDERS	TOTAL PHYSICIANS AUDITED BY RACS: 2005-2008
My experience: 2005-2008	~$80/year	7
Average Florida Provider: 2006	$135	21,927
Average California Provider: 2006	$216		50,054

I posted this chart originally on June 8, 2009 from my own clinic data as well as US government published data from the RAC Demonstration Audit Report (June 2008)

I define 'good money' as the piddling amount RACs 'recovered' from me because cost/investment = $0 and return = $80. To the men in green eyeshades the calculated ROI is infinite.

Michael Apolski's Medicare Update blog is quoted in the September 2009 issue of Orthopaedic Practice Management - he discusses automated reviews on page 99.

"RACs can analyze claims using two methods. During “automated” review, they attempt to find “the low-hanging fruit” by making a claim determination at the system level without even reviewing the medical record, Apolskis says."

Alternative Physical Therapy Payments

The current lead contender for a 'common coin of the realm' is a tool being developed by a private-public partnership, Research Triangle Institute (RTI).

I have a couple of concerns with RTI's Developing Outpatient Therapy Payment Alternatives (DOTPA) project:

1. Despite their attempts at outreach they still have a government mandate - they can ram it down our throats, if they want to.
   
   
2. Their assessment tool is expected to take 15-30 minutes per patient! No time left for patient-therapist collaboration or establishing rapport.
   
   
3. Is RTI re-inventing the wheel? Physical therapists already know how to assess our patients - do we need a new setting-specific tool? Couldn't we do better with a set of condition-specific measures for common, high-volume conditions like the Oswesty for lower back pain or the SPADI for shoulder pain? Let the clinician choose.
   
   
4. How many physicians could manage the transition from profit-driven POPTs to outcomes-driven care? Would running a PT clinic under those circumstances (ie: when you're not a PT) be worth the 'hassle"?

Nathan Rothschild seized a singular moment in world history and used it to shape the future of finance - could physical therapists seize healthcare reform as a springboard to position evidence based physical therapy as the universal standard by which all rehabilitation professionals are judged?

Could we 'sell' physical therapy to a skeptical public of payers and government policymakers when we are all better off with outcomes?