CMS Targets Outpatient Therapy Providers That Stopped Therapy Just Under the Therapy Cap

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Original story posted on: August 14, 2013

More than 350 therapy providers are in the process of receiving letters that are not likely to be welcomed, as there is yet another Centers for Medicare & Medicaid Services (CMS) review contractor taking a look at outpatient therapy.  

Strategic Health Solutions, a CMS Supplemental Review Contractor, is requesting the targeted outpatient therapy providers to submit specified claims for post-payment review. The claims review period is from August 2012 through March 2013. Therapy providers are just getting accustomed to working with the Recovery Auditors (RACs) on manual medical review of therapy over the $3,700 thresholds after surviving manual medical review by the Medicare Administrative Contractors (MACs) in 2012. 

Outpatient therapy providers are receiving these letters as a result of CMS data mining and analysis intended to identify provision of therapy services that either stopped or was held up at just under the therapy cap. While a generic sample of the additional documentation request (ADR) letter is available on the CMS website, the specific text is not included. Here is how the letter reads:

“Analysis of Medicare claims data between August 2012 and March 2013 identified provision and billing for therapy services that either stopped or delayed just under the allowed therapy cap. This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.908(b). StrategicHealthSolutions LLC is requesting additional documentation for these claims for supplemental medical review of outpatient therapy services authorized by CMS.”

Until October 2012, outpatient therapy providers rarely came under review, despite the continued presence of outpatient physical therapy and CORFs in the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) work plans over the years. Beginning at that time, however, therapy over the $3,700 thresholds ($3,700 for physical and speech-language pathology combined, and $3700 for occupational therapy) was subject to manual medical review by the MACs. The process allowed therapy providers to submit documentation in advance to request additional therapy visits for pre-approval. If a therapy threshold was exceeded without prior approval, therapy claims were subject to manual medical review on a post-payment basis.

If you received an ADR request letter from Strategic Health Solutions, carefully review the letter and follow all their instructions for submitting data. A couple of tips to assist you in this endeavor:

  1. Ensure compliance with all CMS signature requirements, then double-check everything.
  2. Submit all requested documentation and additional documentation to support the claim.
  3. Prepare a summary cover letter detailing the key clinical findings: medical necessity for skilled care, previous level of function, and therapy outcomes (goals).
  4. Ensure timely certification of the plan of care (and ensure it is signed and dated) and submit a reason for late certification, per CMS guidelines, as needed.
  5. Submit your records using esMD rather than faxing (faxing only guarantees delays and problems).

Strategic has a number of other review projects underway, based upon a technical direction letter (TDL) from CMS, including review of power mobility devices, inpatient rehabilitation facilities, hyperbaric oxygen and E&M codes.

For this supplemental review, therapy providers have 45 days from the date of a letter to submit documentation in support of the identified claims. The supplemental review contractor has 60 days from the receipt of the medical records to provide a response. 

While it is still too early to render an opinion on the nature of this review, therapy providers who stopped therapy at or near the cap, then resumed during a new benefit period, now are subject to medical necessity review.

Therapy providers and beneficiaries alike may have thought that stopping therapy at the capped limit and waiting to roll over to a new benefit period was saving the beneficiary out-of-pocket money (the beneficiary was liable for therapy over the $1,880 therapy caps in 2012). 

Unfortunately, it is likely the cause for this review.

About the Author

Nancy Beckley, president of Nancy Beckley & Associates LLC, is certified in healthcare compliance and has extensive experience specializing in rehabilitation and compliance. Her work includes establishing auditing and monitoring protocols for outpatient providers; conducting pre-acquisition compliance risk audits; strategic market-based planning and analysis; operational analysis, including benchmarking, coding and staffing; CORF development and implementation; managed care analysis; facilitation of credentialing, and managed care contract technical review.

Contact the Author

nancy@nancybeckley.com

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Nancy J. Beckley, MB, MBA, CHC

Nancy Beckley is founder and president of Nancy Beckley & Associates LLC, providing compliance planning and outsourced compliance services to rehab providers in hospitals, rehab agencies, and private practices. Nancy is certified in healthcare compliance by the Healthcare Compliance Certification Board. She is on the board of the National Association of Rehabilitation Providers and Agencies. She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities. Nancy is a familiar voice on Monitor Mondays, where she serves as a senior national correspondent.

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