Home Health & Hospice Week

Medical reviewers have strong incentives to deny your therapy visits.

Expect medical reviewers to scour your high-therapy claims like never before, thanks to a recent HHS Office of Inspector General audit - and that could take a big bite out of your rightful reimbursement.

"Targeting therapy episodes with 10, 11 or 12 therapy visits provides a good return on investment for Medicare," observes physical therapist Linda Krulish, consultant with Redmond, WA-based Home Therapy Services. A recent OIG audit report denied half of the 40 high-therapy claims reviewed at a cost of more than $40,000.

"Catching" therapy visits that are not reasonable and medically necessary yields "a big payoff back to Medicare," agrees PT Cindy Krafft, director of rehabilitation services for OSF Home Care based in Peoria,IL. "The incentive is to find a reason to deny some or all of the therapy visits."

Medical reviewers can find plenty of traction for therapy denials due to reasonableness and medical necessity, because the criteria for the requirements are "not very specific and can be open to interpretation," Krafft notes.

To protect your therapy reimbursement, check out these steps:

1. Focus on clinical needs. Your number-one priority should be the patient's clinical needs, not the number of visits you furnish, Krafft stresses. Clinical care and patient outcomes should be your focus, and you should "cross the 10-visit line as a by-product of a clinical focus," she maintains.

2. Create airtight documentation. Therapists' zeal to streamline home health documentation requirements may result in insufficient documentation and claims denials or downcodes, Krafft worries. "Each therapy visit, regardless of the total number provided, has to clearly reflect the skill required," she urges.

"Each therapy visit must be medically reasonable and necessary," Krulish instructs. "And the documentation for each visit must substantiate the need and coverage."

3. Zero in on quality. You'll have a hard time convincing medical reviewers that you are furnishing above-average numbers of therapy services to improve patient outcomes if your actual outcomes numbers are sub-par. The agency audited by the OIG, Connecticut Home Health Services Inc. in Trumbull, CT, has a hospitalization rate of 55 percent, according to Medicare's Home Health Compare Web site. That's nearly twice the national average, Krulish points out.

CHHC's ambulation/locomotion improvement rate is 25 percent compared with 37 percent nationally and transferring improvement is 31 percent compared with 51 percent nationally. HHAs with such statistics "need to better support and manage their therapy services to protect both their quality outcomes and their reimbursement," Krulish advises.

4. Don't have your PT go it alone. Smaller agencies with only one therapist run a risk in assuming that their single therapist is competent with clinical and administrative functions - particularly documentation, Krulish warns. "Often they don't have anyone to supervise or question or support the therapist's practice," she says. That could lead to visits that aren't reasonable and medically necessary, or documentation that makes them appear that way.

5. Safeguard risk areas. While all your documentation and supervision should pass muster, you may want to go above and beyond usual record-keeping for episodes with known risk areas. Those include episodes that just meet or barely exceed the 10-visit therapy threshold, as the OIG's audit shows.

Another target may be cases that have only therapy visits, but those visits meet or exceed the threshold, Krafft suggests. "With one discipline involved to break 10, concerns grow about what justified that many visits clinically," she notes.

OSF often exceeds the threshold on therapy-only cases because both PTs and occupational therapists work with the patients to achieve better clinical care and outcomes. Thanks to good clinical practices and documentation, "we have yet to have any therapy claims denied in the two-and-a-half years I have been here, despite dramatic increases in therapy utilization," Krafft tells Eli.