In this blog I attempt to summarize the recommendations from a recent article found on https://www.lexology.com/. The article highlights enforcement in Physical Therapy.
The Department of Health and Human Services and The Department of Justice have started to focus on “lower-cost” services such as PT providers that bill Medicare and Medicaid. A few examples:
· A whistleblower alleged their former employer submitted claims for services provided to multiple patients simultaneously, as though those services were provided to one patient at a time.
· Claims submitted to Medicare for Physical Therapy services were supervised by non-credentialed personnel
· “Upcoding” resulted in increased Medicare reimbursement for patients in skilled nursing facilities. This was done by changing “Resource Utilization Group” scores, thereby providing skilled therapy to those who did not need it or could not benefit from it.
· Medicare and TRICARE were billed for PT services performed by athletic trainers, exercise physiologists and other unauthorized providers.
· There was a $15 million Medicare fraud scheme in which claims by a chiropractor were submitted for PT services (that either were not provided or were provided by unlicensed staff.)
· There have been fines based on allegations that a company provided unreasonable, unnecessary, or unskilled PT services.
The author's “key takeaways”:
Accurately report the duration of services provided.
For example, allegations of fraudulent billing arose when an audit revealed four simultaneous, hour-long, one-on-one appointments that were scheduled within the same time frame.
There were also healthcare fraud claims due to “rounding up” appointment times to maximize reimbursement, providing unnecessary services to increase the time, or engaging patients in unskilled exercises that were not in line with plan-of-care goals, in order to obtain additional minutes.
To avoid this, ensure that claims submitted reflect actual PT services provided and that the procedures are supported by the documentation.
The False Claims Act (FCA) provides financial incentive for whistleblowers aka “qui tam relators” to report suspect fraud on their current or former employers.
Taking proactive measures that demonstrate that a company takes compliance seriously can diminish qui tam actions. For example, incorporate compliance plans and policies, address concerns related to compliance or billing, conduct internal audits, and take corrective actions. Additionally, the authors suggest companies conduct exit interviews, which may help them discover issues that an employee could raise as a “whistleblower”.
Be mindful that Medicare and other payers only cover services personally rendered by a licensed PT or PTA.
Aides may provide unskilled services, however those services are not covered by Medicare. In several enforcement actions, PT’s, in violation of billing requirements, submitted reimbursement for care provided by unsupervised and unauthorized personnel. In addition, a whistleblower reported on their employer for routinely billing PT services performed by unqualified and unauthorized providers.
“Performing auditing and monitoring can help identify billing errors and correct improper documentation or billing practices before causing devastating amounts of liability under the FCA."
In addition to civil liability under the FCA, improper billing of PT services can result in exclusion from participation in federal healthcare programs, corporate integrity agreements (CIAs) with the OIG, and potential criminal liability for healthcare fraud”.
The above enforcement actions have resulted in significant financial settlements, exclusions from participation in federal healthcare programs up to 5 years, and imprisonment. The authors conclude that “although most enforcement actions will not involve enormous settlements or lengthy prison sentences, providers should adopt compliance plans to safeguard their practices from auditors and regulators.” For best practice, familiarize yourself with your company compliance plan and as well as billing and coding rules. If your company does not already monitor billing and documentation, suggest they incorporate peer to peer reviews and or complete internal audits of documentation and billing, and to compare the schedule to the billing and supporting documentation.