Let's Help Each Other

Physical therapy is changing rapidly. As a PT with more than thirty years of experience, the changes observed in the last ten years triple those of the first twenty years. The pace of change is not slowing down. The Medigraph Blog will serve as a forum that will enable us to exchange ideas and assist each other. This blog will be used to share billing, documentation, and any other ideas to improve any aspects of our profession. If we share what we have learned, we can develop a resource that enables our collective understanding to advance our careers.

As profit margins grow smaller and expenses grow larger, we need to assist each other to survive and prosper. If we share our experiences we can help each other to grow professionally, administratively, and financially. Our professional lives, our livelihood, and our personal lives are intertwined. Our resources individually are limited. Together we can accomplish more than we can individually. Let's help each other


Tom Kane, PT
MediGraph Software

Medicare Anti-Fraud Act Denies Medicare Providers Future Access
8/19/2011 4:10:00 PM
A recent bill introduced to Congress under the name of the "Strengthening Medicare Anti-Fraud Measures Act of 2011 (the "Act"), increases DHHS'' existing powers.  (Reminder;  coding errors can be treated the same as fraud).   Instead of paying a fine (prior restitution for fraud), the bill allows DHHS to exclude owners, officers, and mangers of companies that are convicted of health care fraud from participating in federal healthcare programs.  According to the DOJ (Department of Justice) and HHS, new aggressive initiatives to combat health care fraud also allows for the criminal prosecution of owners and executives.  According to the Act, the exclusion and/or prosecution may proceed even if the owners and executives were not complicit in the fraud, but could have stopped the fraud if they had known that fraud was occurring.   Stated more colloquially, if you did not know that fraud was occurring, but you were in a position to stop the fraud if you did know, you will be prosecuted as though you committed the fraud.  To avoid criminal prosecution (and the legal costs to defend yourself),  you could just surrender your ability to accept Federal insurance, and agree not to work in a facility that accepts federal insurance. (Where could you work?). You may be thinking, "Are we talking about the USA?"  Sadly,  our run amok government considers us criminals even if we did not commit the fraud, but would have prevented the fraud if we did know about it.  (Sounds like ''''Minority Report'''' starring Tom Cruise!).  Therefore, if your billing clerk or agency submits an improper code by mistake (and this code is repeated multiple times), you committed Medicare Fraud.  If your documentation clearly identifies the content and context of your treatment, your documentation may serve as mitigating factors that weigh in your favor.  However, improper documentation could be used against you to substantiate the fraudulent intent (though none existed).  Please understand that having proper documentation is not a guarantee that your error will be dismissed.  But having improper documentation almost guaranties that you will be prey for a government bureaucrat that understands you can be excluded from all Federal healthcare programs or undergo prosecution.   As mentioned previously on this blog, CMS has re-characterized physical therapists in the Moderate risk category for fraud.   Has fraud occurred?  Yes it has.  Are the vast majority of our colleagues honest?  Yes they are.  These overreaching rules and classification of PT in the Moderate fraud risk categories should serve as a warning. Everyone is vulnerable.   
Be well,
Tom Kane, PT
MediGraph Software
New Medicare Enrollment Requirements
8/12/2011 5:53:00 PM

The April 1, 2011 post on this blog presented a preview of things to come from Medicare.  That post addressed the prospect of unannounced on site visits from Medicare.  Final rules regarding eligible enrollment of PT have been established by CMS. 

Physical therapists that were enrolled in the Medicare prior to March 25, 2011 must revalidate their enrollment as required by the Affordable Care Act (ACA, commonly referred to as Obamacare). Part of the reason for this new enrollment is the classification of the new risk (fraud) screening criteria.  As was addressed in the aforementioned April 1, 20111 blog post, PT has been assigned to the Moderate risk category for fraud. The risk categories (low, moderate, high) determine the degree of screening that will be performed by MACs (Medicare Administrative Contractors).  As stated in the April posting, the moderate risk classification means that PTs are subject to unannounced on site inspections from Medicare Administrative Contractors.   

Starting from today through March 2013, MACs will be notifying practitioners of the need to re-enroll in Medicare.   CMS has advised providers to begin the revalidation process as soon as they hear from their MACs.  You only have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges. 


Tom Kane,  PT




Medicare Legal Documentation Questions
7/27/2011 10:38:00 PM
Dear Subscribers:

New MediGraph subscribers often ask questions that are related to Medicare standards and the legality of specific functions that relate to documentation.  Three of the most frequently asked questions are presented below.

Question:  Can I edit my notes after the day of treatment?

Answer:  Section 220.3 states, “Dictated Documentation. For Medicare purposes, dictated therapy documentation is considered completed on the day it was dictated. The qualified professional may edit and electronically sign the documentation at a later date.

Question:  Is it legal to write a progress note at a later date?

Answer:  Section 220.3 states, “Dates for Documentation. The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan. However, contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the Progress Report or Treatment Note refers.”
Question:  How do I prove that a skilled professional care was required?

Answer:  "To determine whether a service is skilled, and therefore coverable, the new regulations direct decision-makers to review accepted standards of clinical practice and to consider whether a professional is needed for the service to be safe and effective for the particular beneficiary.”

If we interpret this last answer with a most literal perspective, the ability to improve the patient’s condition becomes secondary to proving that skilled care was required.   If we are honest, we will admit that these perfunctory tasks are not designed to improve patient care or outcomes.  They are designed to reduce the care rendered in an attempt to save money.  A few software vendors present the documentation changes that are taking place in Medicare as though they are desirable.  If we were accountants, not therapist, I would agree.  We at MediGraph choose not to sugar coat this issue.  We comply with the documentation standards because we are forced to comply.  We address this matter openly, with the direct attention that it deserves.  In the near future, an upgrade of the program will take evidence based medicine to the next level, automatically providing intervention references that are diagnosis specific.  For example, if you choose to provide transverse friction massage for lateral epicondylitis, a peer reviewed reference will accompany the intervention.  We will guide through the Medicare requirement maze so that you can do what you do best; treat the patient.


Tom Kane, PT
Unannounced Medicare On Site Visits Effective March 25, 2011
4/1/2011 3:24:00 PM

CMS (The Centers for Medicare and Medicaid Services released information on  new provider enrollment screening regulations.   In these new regulations physical therapists in private practice are not required to undergo site visits before they enroll in  Medicare.  However, PTs are subject to unannounced  on-site visits after they are enrolled.  Theses new measures are intended to curb fraud and abuse.  Physical therapy practices are characterized as moderate risks for fraud (the other categories are Limited and High Risk).  However, physical therapist that bill for DME will be placed in the High Risk category, and will be subject to the on site unnanounced visit standards in this category.

An unannounced site visit will include the date and time of the visit,  observations made at the facility,  and photographs will be taken of the therapists.  Obviously, unannounced visit contractors must enter the office or facility.  If any of the basic elements are not met, the provider's Medicare billing privileges can be revoked.  The changes can be viewed at: http://www.cms.gov/transmittals/downloads/R371PI.pdf.

The long term effect of these Draconian government actions are undetermined.  As overreaching these rules may be, my greater concerns are those that involve human behavior.  Medicare and RAC contractors are subject to the human frailties that unbridled authority can have on behavior, where ordinary people can become monsters because of they are placed in an authoritative position.  Bullying by government officials is not an unusual occurrence, and at the first sign of weakness, many government enforcers will jump at the opportunity to wield their prowess.   Is there fraud in PT?  Of course there is.  Is it rampant?  I do not believe fraud is rampant within our ranks.  I do believe that the incidents of fraud that are severe become sensationalized and ridiculous regulations to address the few inconvenience the rest of us. 

Personal feelings aside, the best defense in these situations are a good offense.  Are you using MediGraph in a way that helps to serve you in these uncertain times?   Are you employing the objective outcome based documentation that defeats audits and prevents them from occurring?  I have sent emails and provided many posts on the importance of objective documentation and outcomes.  Both impairment measurement and functional outcomes tests (including OPTIMAL) are in MediGraph.  Please use them.  Also, prior to this recent CMS ruling, we at MediGraph were working on an electronic Medicare Manual.  We should have this product completed in a few weeks.  When the unannounced on site Medicare examiner visits your facility and asks for your Medicare Manual, you will be able to produce an up to date document at the click of a button.  

Our desire and actions that demonstrate our clinical competence and concern for our patients is not a defense against RACs and unannounced agency examiners.   The auditors’ job has nothing to do with quality care.  Use MediGraph to beat them at their own game while simultaneously elevating your clinical intervention.

Best regards,

Tom Kane, PT
MediGraph Software

Medicare as a Secondary Payer
3/27/2011 12:59:00 PM

The current financial climate is causing more Medicare beneficiaries to remain employed.  A major motivation for not retiring is because pension plans and home values (typical retirement  nest eggs) have been eroded.  As the level of economic uncertainty continues, the number of Medicare beneficiaries that remain employed is growing.  Therefore, we PTs must recognize that our payment may depend on the collection and coordination of health insurance  coverage from the patient.  Medicare can be a secondary payer when beneficiaries are covered by other insurance, including group health plans offered by employers (GHP).  Physical therapists must be certain to obtain all of the patients’ insurance information instead of assuming that Medicare is always primary.  If the primary payer is not Medicare, physical therapist must bill the primary payer before billing Medicare as required by the Social Security Act.



Primary Payers

Primary payers are those that are responsible for the first payment of a claim. Examples are unending but include the aforementioned group health plan (GHP) provided by the employer of a Medicare beneficiary.   Medicare remains the primary payer for beneficiaries who are not covered by other types of health insurance or coverage. Medicare may also be the primary payer in some other instances.   For additional information, CMS provides  guidance at http://www.cms.gov/MLNProducts/downloads/MSP_Fact_Sheet.pdf. You may also verify Medicare's primary/secondary status by contacting the COBC at 800-999-1118.


Other Important Points of Interest

  1. Medicare sometimes pays for benefits that GHP denies or if the GHP has been exhausted.
  2. A signed plan of care remains a requirement if Medicare is not the primary.
  3. Medicare documentation requirements are required when Medicare is not the primary.
  4. The therapy cap remains in place.   If PT services exceed the cap, an exception must be obtained.
  5. When Medicare is not the primary your records remain vulnerable to RAC audits.


Best regards,

Tom Kane, PT

MediGraph Software
Medicare Audits: Prevention is Better Than Cure
7/27/2010 4:08:00 PM
Ben Franklin stated, “An ounce of prevention is better than a pound of cure.” This universal principle applies to everything from diet to automobile maintenance.  Medicare audits are no exception to this rule. With forethought (prevention), the new Medicare RAC audit system can work for you instead of against you.

The new RAC (random audit contracting) auditing methods have totally changed Medicare audit methodology. The prior auditing system permitted the auditor to be paid to review records regardless of the outcome. For example, if your documentation was acceptable, and there was no demand for refunds of previous payments, the auditor got paid. In the new RAC system auditors only get paid if they obtain a refund from you. Those that have endured the RAC audit have described the experience with colorful adjectives and adverbs. However,  as with most crises, opportunity may lie therein.

We PTs are patient driven. Our instincts are to provide documentation that is employed to  advance the goal of patient recovery.  Unfortuntely a "patient only" approach to documentation will not satisfy a RAC.  Preventing RAC audits  must also become  one of our documentation goals or we may shoot ourselves in the foot. Medical documentation is the primary leverage employed by auditors to reduce fees for services. Documentation must now satisfy our clinical needs while simultaneous serving as a document that facilitates reimbursement by preventing a RAC audit. If we do not act proactively  reimbursement for services rendered can be denied, or we can be forced to surrender a refund of prior reimbursements.  

 Auditors are paper pushers with limited knowledge of physical therapy. To the hired-gun RAQ auditor patient strength improvement is meaningless unless we can demonstrate increased functional ability.  A functional increase must be displayed in an easy to understand format that does not require PT knowledge.  This approach to documentation prevents an audit. When documentation is more function oriented, and standardized test are employed to reveal functional improvement, the RAC auditor''''s thinking changes to, “These records are not worth reviewing.  If I audit this facility and do not obtain  a refund, I won’t be paid.” As sad as this state of affairs may be, it is reality.  Recent RAC audits of PT facilities in the NJ, NY, PA garnished $9 billion dollars in refunds.  Despite our best clinical intentions, we must learn to produce documentation that prevents our being mugged by RAC reality. Many of us are unwilling to discuss this topic openly fearing that such a discussion is unprofessional  Nothing could be further from the truth than such shallow of a perspective.  Future blog postings will continue to offer more insight into this area.

Be well,
Tom Kane, PT
MediGraph Software