…. the contractor shall perform site visits in accordance with the following:

1. Initial application – If a physical therapist or physical therapist group submits an initial application, the contractor shall conduct a site visit prior to the contractor’s final decision regarding the application.
2. Revalidation – If a physical therapist or physical therapist group submits a revalidation application, the contractor shall conduct a site visit prior to making a final decision regarding the application.
3. New location – If a physical therapist or physical therapist group submits an application to add a new practice location, the contractor shall conduct a site visit of the new location prior to making a final decision.
4. Reactivation – If a physical therapist or physical therapist group submits a reactivation application, the contractor shall conduct a site visit prior to making a final decision.

In this transmittal, CMS also instructs the contractors to do the following during the site visit:

In section 2A of the Form CMS-855B application, physical and occupational therapy groups are denoted as “Physical/Occupational Therapy Group(s) in Private Practice.” If a supplier that checks this box in section 2A is exclusively an occupational therapy group in private practice – that is, there are no physical therapists in the group – the contractor shall process the application using the procedures in the “limited” screening category. No site visit is necessary. If there is at least one physical therapist in the group, the application shall be processed using the procedures in the “moderate” screening category. A site visit is required.

If an entity is enrolled as a physician practice and employs a physical therapist (PT) within the practice, the practice falls within the “limited” screening category. This is because the entity is enrolled as a physician practice, not a physical therapy group in private practice.

The site visit requirement applies to all physical therapists, including those who are reassigning their benefits to a physical therapy group practice or multi-specialty group practice. This may mean that the contractor will need to perform site visits at the same group practice as additional PTs join that group.

If a newly-enrolling physical therapist lists several practice locations, the contractor has the discretion to decide the location at which it will perform the required site visit.

A site visit will be required when a physical therapist submits an application for initial enrollment and reassignment of benefits (Form CMS-855I and Form CMS-855R). However, a site visit is not required for an enrolled physical therapist who is reassigning his or her benefits only (Form CMS-855R).

If the physical therapist’s practice location is his or her home address and it exclusively performs services in patients’ homes, nursing homes, etc., no site visit is necessary.

Do you have a policy to handle site visits and investigations?

1. Recovery Audit Prepayment Review: The Recovery Audit Prepayment Review demonstration will allow Medicare Recovery Auditors (RACs) to review claims before they are paid to ensure that the provider complied with all Medicare payment rules.  The RACs will conduct prepayment reviews on certain types of claims that historically result in high rates of improper payments.   These reviews will focus on   seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states. This demonstration will also help lower the error rate by preventing improper payments rather than the traditional “pay and chase” methods of looking for improper payments after they have been made.  
2.  Prior Authorization for Certain Medical Equipment: this will require Prior Authorization for certain medical equipment for all people with Medicare who reside in seven states with high populations of fraud- and error-prone providers (CA, FL, IL, MI, NY, NC and TX).   This demonstration will help ensure that a beneficiary’s medical condition warrants their medical equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary’s right to receive quality products from accredited suppliers.   The Prior Authorization demonstration will be implemented in two phases. During the first phase (the first three to nine months), the Medicare Administrative Contractors will conduct    prepayment reviews on certain medical equipment claims. The second phase, for the remainder of this three-year demonstration, will implement prior authorization, a tool utilized by private-sector health care payers to prevent improper payments and deter the fraudulent provision of items or services. 
3. Part A to Part B Rebilling: The third initiative will allow hospitals to rebill for 90 percent of the Part B payment when a Medicare contractor denies a Part A inpatient short stay claim as not reasonable and necessary due to the hospital billing for the wrong setting.  Currently, when outpatient services are billed as inpatient services, the entire claim is denied in full.   This demonstration will be limited to a representative sample of 380 hospitals nationwide that volunteer to be part of the program. This demonstration will allow hospitals to resubmit claims for 90 percent of the allowable Part B payment when a Medicare Administrative Contractor, Recovery Auditor, or the Comprehensive Error Rate Testing Contractor finds that a Medicare patient met the requirements for Part B services but did not meet the requirements for a Part A inpatient stay.  In addition, this demonstration is expected to lower the appeals rate which will protect the trust fund and reduce hospital burden.   Beneficiaries will be held harmless with respect to changes in hospital coinsurance liability.

While there doesn’t appear to be an issue looming large for rehab facilities, whether inpatient or outpatient, Florida is indeed a wild care due to the high level of sham therapy operators who billed for services never provided.  Additionally there have been instances of therapy fraudent billing, based upon DOJ press releases citing arrests, convictions, pleadings and sentencing in several of the other states noted.  The take away on all of this is the continued necesstiy to have an effective compliance progam in place that adequatly assesses risks and conducts auditing and monitoring based on those risks.

CMS has provided a sample revalidation letter so that providers can begin to review and assemble documents.  While the push is toward the PECOS system, the letter states that enrollment may also take place via the old fashion method:  the applicable 855 form  If you are on the list, and did not recieve a “colored” envelope in the mail, CMS is instructing you to contact your contractor.

The gaming of Medicare represents serious abuse of the home health program, said Baucus.  Elderly patients in the Medicare system should not be used as pawns to increase a company’s profits. Especially in these tough economic times, taxpayers simply cannot afford for their dollars to be wasted on unnecessary care. We are going to continue to crack down on these companies to ensure taxpayer dollars are used efficiently and Medicare patients are protected.   The reimbursement policy encourages gaming, and gaming is what’s occurred. Companies are doing everything they can to make as much money as possible, whether the patients need the care or not. The federal government needs to fix the policy that lets Medicare money flow down the drain. This can’t wait until tomorrow. It should have been done yesterday. The longer this kind of policy continues, the more Medicare’s budget balloons, and the bigger the burden on taxpayers,” Grassley said.

According to the press release  Baucus and Grassley began their investigation into home health therapy practices at Amedisys, LHC Group, Gentiva, and Almost Family in May of 2010 in response to a media report that these home health companies took advantage of the Medicare therapy payment system by providing medically-unnecessary patient care.

The Committee staff report released today examines documents provided by the companies which show how therapists were encouraged to target the most profitable number of therapy visits, even when patient need may not have required such visits. In addition, therapy visit records for each company showed concentrated numbers of therapy visits at or just above the point at which a “bonus” payment was triggered by the Medicare program.

 

CMS has provided further information regarding this pilot project at the esMD website.

While the electronic submission sounds simple at first glance, CMS learning a number of lession in a pre-pilot project and is attempting to utilize provider feedback to make this process user friendly. 

Accoding to Carol Spencer, in her article at RACMonitor.com:

To send medical documentation electronically, providers must obtain access to a CONNECT-compatible gateway. Those that want to electronically submit documentation to a RAC or other contractor must either build this gateway or procure gateway services from the health information handler (HIH) of choice.  Although some large providers, such as hospital chains, may choose to build their own gateways, CMS anticipates that many providers will choose to obtain services by entering into contract or other arrangement with a HIH. This could be achieved by contacting the HIHs that have already built an esMD gateway (available on the CMS web site) or contacting HIHs with whom providers already have relationships (such as their claims clearinghouses).

Rehab providers will be able to take advante of this new method when submitting requested documentation for medical review to their MACs, for RAC medical record submissions, as well as for CERT contrator requests.

Important changes have taken place in the landscape for rehab providers in the compliance arena. Compliance Update for Rehab Providers and Rehab Clinics helps you understand how a new enrollment initiative and fraud initiative under the Affordable Care Act affect will affect rehab providers, and explains what makes a provider “high risk” in the eyes of CMS and Medicare.  According to the description:

This podcast offers an opportunity to hear Nancy Beckley share the top compliance initiatives outpatient therapy providers can implement to protect their practices. Learn about key thrusts behind these initiatives, and the benefits of a compliance plan that uses a three-tiered risk assessment to assure Medicare rules and regulations are followed, and billing and documentation are correct.

You’ll also find out how hospital outpatient therapy departments and other rehab venues are challenged separately by compliance issues, and why comprehensive outpatient rehab facilities (CORFs) face a particular set of compliance concerns.

The 2010 podcast, Compliance in Rehab Practice – Risks and Rewards,  is also available for listening.  Nancy Beckley will be at the Rehab Management Booth at the APTA Private Practice Section’s meeting in Seattle on Friday (Nov 4th).

According to SGS the purpose of the Comparative Billing Report (CBR) is

to help prevent improper payments by educating physical therapy providers using billing data for selected therapy services billed to Medicare.  The CBR provide comparative billing data on how individuals health care providers compare to their peers by looking at utilization patterns for billed services.

According to the CBR, this was prompted in part by the Office of the Inspector General (OIG) December 2010 report on Questionable Billing for Medicare Outpatient Therapy Services:

The OIG has indicated that outpatient therapy expenditures have increased by 133% over the past 10 years which represents an increase of $2.8 billion.  The OIG report also indicated that the KX modifier was over-utilized and exceeded annual therapy caps at levels much higher than the national average.

The analysis for the second PT CBR encompassed all final Medicare Part B paid claims retrieved from the Integrated Data Repository on 6/24/2011 with service dates from 1/1/2010 through 12/31/2010, with “office” as the place of service.  The highest billed codes that were analyzed:  97110, 97140, 97112, G0283 and 97530.

Hospital outpatient therapy departments, rehab agencies, CORFs and SNF Part B providers did not receive reports as institutional providers.  The CBR reports were individual in nature and released to the billing physical therapist.  The data collected during the SGS analysis of physical therapy billing with the KX modifier in the 2010 and 2011 reports will not be aggregated or released as a report, only individual providers will receive a report on their billing activity.

It should not go without stating that Safeguard Services is a Medicare Program Safeguard Contractor, and is also the Zone Program Integrity Contractor (ZPIC) for the State of Florida.  Who’s to know how that collective information might be utilized in the future?