Heads Up! Physical Therapists in Private Practice (PTPP)

The annual issuance of the Office of the Inspector General's (OIG) 2010 Work Plan sets the tempo for all subsequent Medicare audits - since the OIG is the agency that actually audits Medicare (CMS).

Here is what the Work Plan actually says about physical therapists in private practice:

"Outpatient Physical Therapy Services Provided by Independent Therapists

We will review outpatient physical therapy services provided by independent therapists to determine whether 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-00-10-35220; various reviews; expected issue date: FY 2010; new start)"
(page 29)

Physical therapists in Private practice should focus their attention on two areas to make sure that their compliance plan meets Medicare requirements:

Process Measures such as the following:

• 8-minute rule
  
  
• -kx modifiers and the arbitrary PT caps
  
  
• PT/PTA supervision requirements
  
  
• Medicare Minimal Documentation requirements
  
  
• ‘Skilled physical therapy’
  
  
• One-on-one procedure codes
  
  
• Untimed modality codes
  
  
• -59 modifiers and CPT code edits
  
  
• Physician certification of the physical therapy plan of care

Evidence-based physical therapists who truly care about their patients and about the job we do will also want to direct their attention to Outcome Measures such as the following:

• Patient self-report outcomes and questionnaires (eg: OPTIMAL, LEFS, etc.)
  
  
• Therapist-administered performance tests (eg: Gait Velocity, TUG Test, etc.)
  
  
• Impairment-level tests and measures (eg: SLR, neck rotation, etc.)

Finally, one self-administered process measure is Treatment Based Classification (TBC), which has the potential to...

• save costs,
  
  
• improve outcomes and
  
  
• elevate physical therapist decision making

TBC can show Medical Necessity and Skilled Therapy - two important areas of Medicare Minimal Documentation requirements.

To learn more about TBC and Medicare compliance you can attend one of the Classification Seminars in Palmetto, Florida on November 7th or 21st at the Medical Arts Rehabilitation physical therapy clinic from 9am to 4pm.

You can sign-up online at BulletproofPT.com

Medicare Recovery Audit Contractors (RACs) have, in 2009, begun their work auditing the charts and notes of hospitals, physicians and physical therapists.

Their activities have, as they impact physical therapists, have been discussed in this blog, also here, and here.

During the Medicare RAC Demonstration Project inpatient hospitals were the primary target, accounting for over 84% of the recovered amounts.

Physicians (and physical therapists) accounted for less than $19 million of almost a billion dollars recovered.

Will the same experience prevail with the Permanent RAC Program?

The American Association of Family Practices has prepared this Questions and Answers page that may help private practice physical therapists calculate their risk and answer their questions.

The Medicare Taxonomy for Physical Therapists

I am not a doctor.

I don't even play one on T.V.

I don't have a Ph.D.

I don't have a Doctor of Physical Therapy (DPT).

I'm a physical therapist (PT).

That's it.

And, I present material in this blog that some people may associate with post-graduate instruction, legal advice or consulting on Medicare compliance.

That would be a mistake.

All I do is treat patients with physical therapy, write my notes and try to understand our nation's Medicare program as it applies to outpatient physical therapy services.

To help the process of Medicare compliance I created my alternate website, Bulletproof Physical Therapy Notes and Charts with free government and professional resources on making a do-it-yourself Medicare compliance program.

Isn't that the way most physical therapists are?

Resourceful?

Ultimately, I intend to create a taxonomy that students and non-professionals can use to understand the work we physical therapists do for our Medicare patients.

It's crazy that I can describe Medicare with taxonomy, a word originally used to describe the complexity of living organisms.

Now, Medicare compliance is completely the jurisdiction of "Medicare auditors"

• un-elected


• un-licensed (as auditors)


• non-peer reviewed

..."experts" that get paid to look at your notes.

Don't get me wrong - everybody deserves a chance to make a living - even Medicare auditors.

The $3 billion Medicare program needs auditors - to catch the bad guys.

That $3 billion attracts a lot of bad guys.

But, physical therapists usually aren't bad guys (or girls).

What physical therapists need is a simpler, less intimidating process to...

• document our findings
  
• show medical necessity
  
• show progress
  
• show skilled decisions
  
• help patients without taking ridiculous risks
  

Am I the only one who thinks this way?

What will replace the OPTIMAL?

I get a lot of feedback on this blog from physical therapists who don't much like the OPTIMAL scale.

Some say they use it because it's 'recommended' by Medicare, not because it's a good outcomes scale.

Some of the problems with the OPTIMAL scale that physical therapists relate to me are:

• Too general
• No descriptors of the activities (eg: long distance walking)
• Inappropriate for elderly persons (eg: running, hopping and jumping)
• Too long (21 activities)
  

This is just a short list...

Additionally, the American Physical Therapy Association has gone on record saying the OPTIMAL has not fulfilled its intended mission:

...to be the single, disease-specific treatment planning and goal-setting tool for outpatient physical therapy Medicare compliance and outcomes measurement. (my emphasis)

Nevertheless, the APTA maintains the OPTIMAL page on its website and offers free licensing for clinical physical therapy use until a superior alternative is found.

What are the alternatives?

Now, be aware that these are commercial (NOT free) alternatives that offer some enhancement over a pen-and-paper tool like the OPTIMAL.

CARE tool (May 2009)

AM-PAC (required by 2012?)

FOTO

There may be others, like the following:

• Neck and Back Index
  
• Oswestry scale
  
• Lower Extremity Functional Scale
  
• Patient-Specific Functional Scale

...and others, that are acceptable overall outcomes measures but are not recommended by Medicare.

Acceptable outcome measures have usually gone through the peer review process and are published in a professional journal and are accepted by a consensus.

What is the trade-off?

The trade-off for comprehensiveness is time.

A tool that is disease-specific requires multiple templates for different body parts or regions (eg: Neck and Back Index).

A tool that is more comprehensive is longer and harder for the patient to complete.

A longer tool may be more difficult for the clinician to score.

A commercial tool, today, offer few benefits over the free tool.

The OPTIMAL is brief and simple to score.

My own recommendation, today, is for the clinician to use the OPTIMAL.

What is the time frame?

In May 2009, Research Triangle International (RTI) will begin a pilot project to develop a new measurement tool to find

"...better information tied to patient need and the effectiveness of outpatient therapy services."

Between 2012 and 2014 the pilot project will wrap up and, presumably, physical therapists will have a needs-based, risk-adjusted tool to assess their patients, in acute, hospital-based and outpatient clinics.

What if you do nothing?

Even if you don't adopt a commercial tool today that, realistically, will segue into the recommended tool by 2012 you should be using the free tool.

Doing nothing is not an option.

A Medicare auditor looking at your files may consider the absence of any outcomes tool as 'blatant disregard' of published recommendations.

Get your systems in place now.

The easiest, simplest system today is the OPTIMAL baseline and follow-up scale.

Use outcomes measures to measure your effectiveness because it's good physical therapy.

Use outcomes measures to improve your Medicare compliance because you can't afford not to do so.

How much do RACs cost private practice physicians and physical therapists?

I've been living under the gun for three and a half years.

The RAC gun.

The Medicare Recovery Audit Contractor (RAC) program is a new permanent federal program expected to 'go live' in February 2009.

The initial roll-out is mainly in the northeast and in the RAC demonstration states.

I live in Florida, a demonstration state since 2005.

Recent conversations I've had with my peers and professional organizations indicate that there is a lot of additional anxiety regarding the RACs.

While I never want to downplay the severity or the possibility of a Medicare audit, MAC or RAC, I want to present some information that can help private practice physical therapists assess the risk of and the damage from the RACs.

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

Data for this table is available in this report.

Note that physical therapists are lumped in with physicians in the RAC report from which this data is drawn.

$992.7 million dollars in overpayments were recovered from providers, mainly (85%) inpatient hospitals.

Of the $992.7 million only $19 million came from physician practices (which include physical therapists).

40% ($391.3 million) of the overpayments were for medically unnecessary services.

Services are medically unnecessary when the clinician failed to justify why the services were performed.

For physical therapists this usually means measurements of ROM or strength deficits.

Also, measurements of activity limitations.

Finally, link deficits to activity limitations in the physical therapists' diagnosis.

Bulletproof Compliance

Your current Medicare compliance plan should be sufficient to respond to a RAC audit.

If you have a current Medicare compliance plan.

Mine used to be a dusty manila file folder sitting up on a shelf.

Not anymore.

I got busy and got some basic education - available in this blog and at Bulletproof PT.

Get your own compliance program.

Get Bulletproof.

I live under the gun...

But, I sleep well.

Is Ultrasound Medically Necessary for Physical Therapy?

Do you use ultrasound on your patients?

Why?

How often or how much?

When do you stop ultrasound treatments?

What are the bases for your decisions?

Do you go with the flow?

Many physical therapists choose to use ultrasound for their patients.

Patients often demand ultrasound and physicians often request ultrasound.

Ultrasound is often criticized for its poor evidence base despite widespread anecdotal reports of it's benefit.

Show your work

Here'e the easy way to demonstrate medical necessity (need) for ultrasound.

Create a simple checklist or chart template that you or your staff could fill out every time you or they select ultrasound.

Copy the template or checklist and make it part of the initial evaluation.

Have extra copies ready for those patients who request ultrasound mid-way through their treatment.

Use the checklist to describe the findings that indicate ultrasound is necessary.

Findings: Inflammation

For example, pulsed ultrasound may be used as an anti-inflammatory modality.

This chart checklist, filled out at the initial evaluation, may support the medical necessity (need) for ultrasound when used as an anti-inflammatory modality.

You may also create a template to check off the findings that support ultrasound's thermal effects for scar tissue, etc.

(YES/NO)	CONDITION	Dimensions
	Swelling
	Redness
	Tenderness
	Palpable heat
	Loss of Function

One or more of these conditions present, with the dimensions noted, could provide a basis for ultrasound.

Properly filled out initially, and at subsequent intervals for Progress Notes, this chart checklist is a decision-making tool that can help the therapist understand when certain interventions are, and are not, indicated.

As a physical therapy clinical manager it is your responsibility to provide these tools to your clinical staff to ensure a Medicare compliant chart.

When it is so easy to do - why not?

Good for the patient, the therapist and the Medicare auditor

A Medicare auditor could look at this checklist to clearly and quickly see why the physical therapist had charged for sessions of ultrasound in the physical therapy plan of care.

Some therapists have used this pen-and paper tool to explain to their patients when ultrasound, a modality with a strong placebo effect, may no longer be indicated.

Bottom line, simple tools that demonstrate your skilled physical therapy decisions and show the need for your valuable treatments are essential in today's clinical environment.

For more free tools, templates and tips on physical therapy Medicare compliance go to www.BulletproofPT.com . 

Can Physical Therapists go over the PT Cap with an X-Ray?

Does an X-ray demonstrate medical necessity for physical therapy?


...or does an axial CT myelogram?


These images are examples that have in common a clear pathology that many patients and physical therapists confuse with medical necessity for physical therapy.

Right now (November 17th 2008) I have several physical therapy patients who have exceeded their $1,810 Medicare benefit and are asking me for continued physical therapy services in my outpatient clinic.

Many of these patients have chronic conditions such as the following:

• degenerative spinal stenosis
  
• massive rotator cuff tears
  
• knee osteoarthritis

These conditions show up well on sophisticated imaging scans such as X-ray, CT scans and MRI.

These conditions often require extended courses of physical therapy or multiple episodes of physical therapy in the course of a calendar year.

In my clinic, the $1,810 Medicare cap is usually reached by 16-18 visits.

It would not be unusual for degenerative spinal stenosis to take 20 visits. I'm pretty sure my experience is typical.

Who needs PT?

For an exception to the Medicare cap the physical therapist would have to show three criteria:

• Need
  
• Progress
  
• Skill

Need is often shown with physical findings.

The above X-ray and CT myelogram show physical findings based on anatomy.

Physical therapists should show physical findings based on function.

Diagnosis: Process or Label?

An epiphany in own my practice has been the use of disablement models: most recently the International Classification of Function (ICF Model) that describes the link between Body Structure and Function and Activity Limitations.

The ICF classification framework is to physical therapists what the ICD-9 diagnostic labels are to physicians.

Note the ICF model describes any health condition - for instance, your patient with degenerative spinal stenosis who has 'run out' of Medicare physical therapy benefits but asks you to append the -KX modifier to continue their care.

What do you do?

Do you ask the doctor for another script?

Perhaps you consider using another diagnosis from the old 'diagnosis list' from 2006.

Don't.

The Therapy Cap

The purpose of the therapy cap is to cut costs without limiting patient access to necessary care.

There is a large POPTs in my town that automatically cuts off therapy to every patient approaching the $1,810 Medicare Cap - regardless of need or progress.

They perceive that, as a POPTs, they are in the Medicare audit crosshairs and they refuse to add 'risk' to their caseload by appending the -KX modifier.

They are limiting care to their patients.

The Caps Work

Data for this table comes from the Outpatient Therapy Alternative Payment Study 2 (OTAPS 2) Task Order - Utilization Report.

Outpatient Physical Therapy
	2004	2006	Per cent change
Mean dollars paid per user	$864	$788.06	-8.8%
Mean dollars paid per episode	$748	$682	-8.9%
Standard deviation paid per episode	$1,047	$782	-25.4%

"The Balanced Budget Act of 1997 enacted financial limitations (therapy caps) on outpatient physical therapy (PT) and speech-language pathology (SLP) combined... In 2006 the Automatic Exceptions Process to the caps began, enacted by the Deficit Reduction Act of 2005." (OTAPS 2)

The result of the caps has been the observed decrease in per user and per episode dollars paid.

Read the full blog entry here.

Note that cost reductions occurred from 2004 to 2006.

There was no cap in 2004. The cap exceptions process began in 2006.

The Caps work - so, work with the Caps

Get better at showing need.

Show that your patients have Activity Limitations using a functional scale.

I recommend the OPTIMAL scale (free) or the AM-PAC (small $$).

Show Progress.

I've designed a neat pen-and-paper graph that easily and quickly shows functional progress over 1, 2 or 3 months.

No more discharges after 20 visits whether the patient is better or not.

Now, patients come back to me because they know I can 'go to bat' for them.

If they are getting better I can prove it.

Get a copy of the Functional Progress Graph here.

Make skilled decisions.

Use the ICF model to link impairments in Body Structure and Function with the measured Activity Limitations.

The link is your Physical Therapist's Diagnosis.

What do YOU need to go to bat for your patients?

Not fancy x-rays or 'alphabet soup' imaging.

Get better at describing your own skills using simple tools.

Get the free tools I've described in this post.

Also, get a free tutorial called Bulletproof PT to learn more.

Medicare Fraud Strike Force Indicts Eight in Miami

So far this and other Medicare actions in the South Florida area do not appear to have involved physical therapists.

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.

Medicare is...

"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 -

"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."

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.

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.

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)

For a step-by-step program that a PT manager can implement without becoming a 'Medicare expert' go to BulletproofPT.com to protect yourself and to sleep well.

Physical Therapy Diagnosis: Label or Process?

The new International Classification of Functioning, Disability and Health (ICF) speaks to the central decision physical therapists make in clinical practice:

What is wrong with the patient?

The ICF model seems to avoid the use of descriptors, or labels, that can be used to describe conditions related to human movement.

Fine with me.

The ICF Browser has descriptors of the following:

• Body Functions
• Body Structures
• Activity and Participation
• Environmental Factors

...that affect human movement and function.

Using ICF, I could make a diagnosis on a patient with neck pain that would look something like this...

"Patient has difficulty Bending, Sitting and Pushing (all measured by OPTIMAL scale) due to the following:

1. Stiff upper cervical sidebending (C0-C2).


2. Weak deep cervical flexors (DCF) muscles (measured by flexor muscle endurance test).


3. Decreased cervical rotation ROM, bilateral.
   

...to be treated with the following...

1. Therapeutic Exercise (97110) for endurance of DCF muscles.
2. Manual therapy (97140) for ROM, PROM, massage.
3. Neuromuscular Reeducation (97112) to distinguish cervical sidebending from cervical rotation.
4. Therapeutic Activities (97530) for Pushing with a stabilized cervical spine."

The descriptors used in ICF all have to do with measured findings.

The descriptors for the above diagnosis are the following:

Body Function:

• Mobility of several joints (b7101)
• Endurance of isolated muscles (b7400)

Body Structure

• Ligaments and Fasciae of the Head and Neck (s7105)

Activities

• Bending (d4105)
• Sitting (d4103)
• Pushing (d4451)

Without inventing a nomenclature or supposing the existence of any mechanism or model the physical therapist is able to accurately identify the structure at fault, the proposed treatment and the effect on the patient.

I make this diagnosis about 5-6 times per week.

Most of my patients (60%) are Medicare beneficiaries with typical, routine presentations that require a typical, routine evaluation.

I don't try to 're-invent the wheel' for each new patient I see.

I do take measurements for each descriptor listed above.

I should be able to describe to anybody the patients I treat, the intervention I use and the outcomes I expect.

'Anybody' includes the following...

• the patient
• the physician
• my physical therapist and physical therapist assistant peers
• third party payers
• federal policymakers
• national and international health researchers
• rehabilitation professionals from related professions
• the man on the street (?)

If you still want to use physical therapy diagnostic labels you will have to answer Dr. Andrew Guccione's question...

"What concepts are necessary to structure clinical observations into a recognizable pattern that also suggests physical therapy intervention?"

Generally, I recommend the ICF model to any physical therapist who wants to do a good job of treating function.

Specifically, I recommend the ICF model to any private practice physical therapist who wants to generate Bulletproof Physical Therapy Notes and Charts for Medicare compliance purposes.

Physical Therapists in Florida included in the RAC Rollout

Physical therapists in Florida are in the first round of states receiving provider education beginning October 1, 2008 according to an article in the September 11 AHA News.

The Medicare RAC Program is designed to augment exiting Medicare audit capacity and, in the words of former CMS Administrator Mark McClellan, M.D., Ph.D...

“There are two parts to making certain that Medicare dollars go to their intended purposes,” said CMS Administrator Mark McClellan, M.D., Ph.D. “First, we need clear and straightforward rules to assure that fair payments are made for services to Medicare beneficiaries and second we need effective mechanisms in place to detect and respond to inappropriate billing. In conjunction with new steps to ensure Medicare’s billing rules are clear, this demonstration will let us test a new approach to ensure that payments made to providers are accurate.”

This RAC expansion map shows the states affected on October 11.

My experience in Medicare Part B outpatient physical therapy is that the RAC audits affected PT's in Florida very little..

We had less than $100 in post-pay audits in the four-year scope of the three-year demonstration project.

Overall, Physician Groups had about $19 million seized as part of the RAC demonstration project.

Most of the money came from inpatient hospitals.

Get the full RAC demonstration report here.

Physical therapists and doctors: Get ready to hand over more documentation

Much in the news lately is the Office of the Inspector General Investigation of the Comprehensive Error Rate Testing Program.

As I blogged on Sunday, August 24, 2008 you-know-what will run downhill on this one.

Here is the OIG report for your reading.

In summary the report states the following:

"We recommend that CMS:

• require the CERT contractor to review all available supplier documentation;
• establish a written policy to address the appropriate use of clinical inference;
• require the CERT contractor to review all medical records (including, but not limited to, physicians’ records) necessary to determine compliance with applicable requirements on medical necessity;
• document oral guidance that conflicts with written policies, such as guidance on the need for proof-of-delivery documentation in making medical review determinations;
• instruct its Medicare contractors to provide additional training to physicians that focuses on improving their medical record documentation to support ordered DME items; and
• require the CERT contractor to contact the beneficiaries named on high-risk claims, such as claims for power mobility devices, to help determine whether the beneficiaries received these items and the items were medically necessary."

I've highlighted in red the requirement that I believe will lead to tougher audit standards on physical therapists and physicians - already overburdened with declining reimbursements and rising costs.

Medicare Auditors Get Spanked

Health care providers can expect this one to flow downhill like you-know-what.

All across the blogosphere, reports of the draft report from the HHS Office of the Inspector General are streaming in...

Miami Herald Aug. 21

ProPublica Aug. 22

Tampa Tribune Aug. 21

Judicial Watch Aug. 22

Looking for the Outliers Aug. 23

Who Will Audit the Auditors? Aug. 22

Medicare claims $700 million in fraudulent savings to the federal health care program for elderly and disabled persons.

The New York Times (Aug. 20) claims the amount should be over 4 times that amount - almost $3.2 billion - that may have been swindled by unscrupulous medical device providers like wheelchairs and motorized carts.

Medicare failed to follow its own internal accounting controls in estimating the amount of fraud.

Congress and Senator Charles Grassley
are mad.

"I want to know what happened, who's responsible, who will be held accountable and what the [Human Services] secretary will do about it," said the senator, who was briefed on the draft report. "If people cooked the books, manipulated the methodology or told the contractor to ignore the rules, those individuals need to take the heat."

If Congress spanks Medicare you can expect Medicare to spank providers with tougher audits.

All providers will suffer for the actions of a few - and for the actions of a watchdog agency that tried to cut a few corners.

Medicare Messed Up

Physical therapists should pay attention to this new Office of the Inspector General (OIG) Report that claims the Centers for Medicare and Medicaid Services (CMS) under reported fraud in durable medical equipment (DME).

"The report found that in fiscal year 2006, CMS failed to detect that more than one-third of spending on DME was fraudulent."

More than one blog picked up the story from the New York Times today based on a draft report obtained by the Times.

The full report should be out this week or next.

Medicare fraud was under reported by CMs when they claimed the false claims error rate for DME was 7.5% for 2006 when actually, according to the OIG, the true error rate was 31.5%.

“This is outrageous,” said Senator Charles E. Grassley of Iowa, the top-ranking Republican on the Senate Finance Committee, who has repeatedly credited the Centers for Medicare and Medicaid Services with reducing improper expenditures. “If heads don’t roll, you can’t change the culture of this organization,” he added." (source - NYT)

Honest, hardworking physical therapists may now have to put up with increasingly burdensome audit and regulatory measures.

Physical Therapists Watch out for auditors in U-haul trailers at your office!

Did you work all day treating patients?

Tired?

Ready to relax?

But wait, don't you have to update your Medicare compliance plan?

Remember the one sitting on the shelf? Or, the one you've been meaning to work on?

Well, take heart...

I've assembled some resources that will help get you started or further along to completion.

The first is this recent article...

Altering Medical Records: What Not To Do When Being Audited By Medicare : Physician Law

The article is published on the blog of attorney Todd Rodriguez, who specializes in Medicare fraud.

This next resource is a recent post from the Physical Therapy Manager (PT Manager) list-serve at Yahoo Groups. You may be required to join the group.

The list is moderated but most physical therapists, administrators and some medical doctors and chiropractors have managed to get on.

Look for Victoria Cavitt's post from July 30, 2008 (she is replying to Jim Hall, CPA) and she talks about 'U-haul trailers with copiers' - here is a sample...

"They show up at your practice with U-haul trucks that house their own
copiers and OIG agents serve you a subpoena to access ALL your medical
records.

Medicaid and OIG employees randomly pull patient charts off your shelf, copy
these charts in their U-haul trailers, and look for patterns of inaccurate
billing and insufficient documentation. They don't give you advance notice of their arrival..."

That post got my attention - I kept thinking about those U-haul trailer all day at work! And I have a great Medicare compliance plan that meets all of Victoria's criteria.

I got my plan from the source documents - I'll tell you where to get those in just a minute - but first you should take a look at the basis for any Medicare compliance plan.

The DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Inspector General Compliance Program for Individual and Small Group Physician Practices is the authorizing document for any small practice tying to 'do-it-yourself' when it comes to compliance.

"We believe that the development and issuance of this voluntary compliance program guidance for individual and small group physician practices will serve as a positive step towards assisting providers in preventing the submission of erroneous claims or engaging in unlawful conduct involving the Federal health care programs."

Finally, I have this OIG document, the Medicare Manuals, an many more physical therapy specific resources all available for download at BulletproofPT.com.

You can get a free compliance tutorial that gives you 13 tips and strategies to 'bulletproof' your physical therapy practice.

Don't let the U-hauls get you.

Get Bulletproof PT today.

Physical therapists take note of Medicare audit process

The MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) Program: An Evaluation of the 3-Year Demonstration June 2008
report is available here (downloadable PDF).

Interpretations differ but most call the program a success citing the high amount recovered and the low amount recovered on appeal.

The Recovery Audit Contractors have recovered more than one billion dollars.

Amounts overturned on appeal were low...

"As of March 27, 2008, providers had chosen to
appeal 14.0 percent of the RAC determinations.
Of all the RAC overpayment determinations, only
4.6 percent were overturned on appeal."

Overpayments by provider type showed that physicians (which include outpatient physical therapists) accounted for only 2.5% of the total overpayments collected.

While some feel that the RAC program is on a 'bounty hunt' the results of this report that, not only are RACs here to stay but that soon they will be in all 50 states.

New Physical Therapy Paradigm

There is a new game in town.

Physical therapists may have to hit the hit the books again to learn the new disability paradigm...

APTA Endorses World Health Organization International Classification of Function Model

In school (I graduated in 1992 from the University of Florida), we learned about impairments in range-of-motion and strength.

We learned about disability and how physical therapists can help people.

We learned that physical therapists link impairments to disability via the physical therapy diagnosis.

Now, the link is the same.

Physical therapists still do the same thing.

The names have changed.

The new ICF model uses new terms.

The terms are important because words direct thinking.

Words are powerful. Words are labels.

Words like Disablement = Participation.

Words like Functional Limitation = Activities.

Words like Impairment = Body Structure and Function.

The American Physical Therapy Association has gotten behind the new paradigm.

Soon, educational programs will get on board.

Then, your students and new graduate physical therapists will arrive...

...talking the new language of Participation, Activities, Body Structure and Function.

Then Medicare will get on board.

Then, you will have to get the new paradigm.

Get it now. Get the new paradigm. Because it's good for your patients.

Because it can help your clinical decision-making.

Learn how you can work this new paradigm into your clinical practice.

Get Bulletproof Physical Therapy Charts and Notes.

Get it.

20% Medicare Physical Therapy cuts in 2009

The US Senate, on July 9, 2008, overwhelmingly passed their version of HR 6331, designed to prevent the 10.6% cut in the Physicans' Fee Schedule and reinstate the Automatic Exceptions Process to the Physical Therapy $1,810 benefits cap.

The physical therapy benefits caps arbitrarily imposes the cap once outpatient physical therapy charges reach $1,810. Thus, those patients who need physical therapy care the most are harmed the most.

One of my patients, an elderly grandmother had her left knee replaced on June 1. For four weeks she had to use a walker to get from her bed to her bathroom and caused her right elbow to hurt.

June 20th she saw her orthopedic surgeon who said she now has developed osteoarthritis in her left shoulder and needs the shoulder replaced.

On June 29th the "regularly-scheduled hostage crisis" in the US Senate had Americans and their health care providers anxiously waiting to see which way the budget ax would fall.

So far the ax hasn't fallen on my elderly grandmother - she has been able to get her physical therapy at the hospital. Hospital outpatient physical therapy departments are exempt from the cap.

Ironically, the passage of HR 6331 sets the stage for a 20% Medicare cut in December 2009.

Pete Sepp of the Shreveport Times says the following:

"The outcome of this drama depends on whether politicians enact modest reforms sooner to avoid catastrophe later."

As I posted before the Senate vote I recommended an annual 2% cut to the Physicians' (and physical therapists') Fee Schedule.

The American Medical Association (and the APTA)would be unable to register sufficient voter and constituent indignation to counter the cut.

I don't want a 2% to my practice revenues but I, just like all Americans, can see the writing on the wall.

We've made the diagnosis.

Diagnosis is necessary for prognosis.

Now is time for some bitter medicine, before it' too late.

Destroy Healthcare in order to save it

Medicare wants to save healthcare providers by changing the system.

Ironically, Medicare and Congress are trying to save Medicare by making adjustments that threaten to destroy the health care system.

In order to give congress more time to act to prevent the 10.6% cut in the Physicians' Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) will pinch the cash-flow pipeline until at least July 15th.

Cash flow is the lifeblood of any business and represents the majority of payments to medical practices in retirement areas, such as Florida.

Kevin Schweers, a spokesman for the Department of Health and Human Services, said Monday the Centers for Medicare and Medicaid Services will hold doctors' Medicare claims for services delivered on or after July 1. Claims for services received on before June 30 will be processed as usual, he said. By holding claims for health care services that are delivered on or after July 1, CMS will not be making any payments on the 10.6 percent reduction until July 15 at the earliest," Schweers said.

The CMS action seems reminiscent of a statement attributed to an American major during the Vietnam war...

"After the village of Ben Tre was virtually destroyed, an American Major said to journalist Peter Arnett (who would become famous for his work on CNN during the Gulf War),

"It became necessary to destroy the village in order to save it."

The CMS freeze is designed to prevent providers' accounting workload from going up since retroactive changes to the fee schedule necessitate billing small amounts that increase billing volume without increasing provider revenues proportionally.

Local groups across the nation, such as the Manatee Medical Society, are mobilizing support to encourage the Senate to get behind HR 6331 the Medicare Improvements for Patients and Providers Act of 2008.

When the Senate re-convenes on July 7th the Senators will have another chance to vote to prevent the 10.6% cut to the Physicans' Fee Schedule.

Everyone knows the direction Medicare and social security must go down in order to supply the Baby Boomers with pension and health care services and funds.

Why not a 2% cut every year, scheduled and anticipated, rather than a draconian 10% that prompts a PAC funding and lobbying bonanza every six months?

As a physical therapist, I make a physical therapy diagnosis on every patient I treat.

A healthcare policymaker would diagnose the financing of the Medicare system as broken.

Medicare recovery audit contractors

Physical therapists are another healthcare provider that will get caught in Medicare RAC audits, as I posted on June 20th.

Medicare recovery audit contractors (RAC) draws criticism from stakeholders - 06/25/08.

The article states the following...

"The RAC, which, according to Smith, acted in an aggressive manner, also cited a lack of documentation regarding documents that the practice had provided in electronic format."

Once again, the problem stems from a lack of documentation.

Physical therapists need a simple way to document the services they provide.

Physical therapists need to quickly and accurately show the following:

1) Medical Necessity for Physical Therapy

2) Skilled Physical Therapy Services

3) Expected Improvement in a Reasonable Time Frame

How can a Physical Therapy manager do this consistently?

Get Bulletproof Physical Therapy Charts and Notes

Go to Bulletproof-PT-Charts.com

Sleep Well.