OASIS Alert

Beware of episodes with 10-12 therapy visits.

If you can't justify every therapy visit, you could be paying Medicare back more than $2,000 per episode.

Agencies responding to the financial incentive of extra payment for high-therapy-use episodes - "yes" answers to M0825 - probably are not surprised the feds are beginning to scrutinize episodes that just exceed the threshold. "Since PPS started ... and there was significantly more money for 10 or more therapy visits, audits have been on the horizon," says physical therapist Cindy Krafft, director of rehabilitation services for Peoria, IL-based OSF Home Care.

Don't Let This Happen To You

The HHS Office of Inspector General recently conducted an audit of Trumbull, CT-based Connecticut Home Health Care Inc. and downcoded nearly half of the high-therapy claims reviewed, according to an audit report released May 25.

Now the OIG is planning to conduct "a couple" more reviews of HHAs in this matter, an OIG spokesperson tells Eli.

The OIG had CHHC's intermediary, Associated Hospital Service, review 40 claims the agency billed with 10 to 12 therapy visits in fiscal year 2002. Of those, AHS found 19 had at least some therapy visits that were not reasonable or medically necessary, totaling an overpayment of nearly $42,000.

For seven of the claims, "medical review indicated that a brief period of physical therapy would have been reasonable to assess safety and to set up a home exercise program for reconditioning the patient," the OIG says in its audit report. "As a result, they reduced the allowed number of visits to less than the 10-visit threshold because the unique skills of a physical therapist were not necessary to assist the patient in performing the exercise program."

The result: CHHC already has repaid nearly $40,000 of the assessed overpayment. The OIG also instructed the agency to strengthen internal controls to eliminate unreasonable and medically unnecessary therapy visits and to "identify and submit adjusted claims for Medicare overpayments received subsequent to our audit period."

CHHC "stands behind the number of therapy visits provided as ordered by the physician," the agency says in its response to the report. "CHHC believes these patients would not have met their goals with less than the number of therapy visits provided."

AHS overturned one denied claim at the redetermination level, the OIG notes. CHHC is appealing the rest to the administrative law judge, the agency says.

The OIG will conduct "several" more reviews on this topic, but will not have one in every one of the agency's nine regions, the spokesperson says. After finishing its reviews, the OIG may roll them up into one report that identifies patterns across the audits.

Lesson learned: Involve rehab management in cases where you expect high therapy utilization to ensure that the services provided are reasonable and necessary, suggests the American Physical Therapy Association's Roger Herr.