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

RACs Exploit Technology to Reveal Potential Audits
9/2/2011 1:38:00 PM

The Centers for Medicare & Medicaid Services (CMS) are focused on preventing and detecting Medicare fraud and abuse.  The methods employed to accomplish this goal have become increasingly more organized and targeted. The screenings use technology to increase efficiency  and more easily discover improper claims submitted to Medicare. The most prevalent method used by RACs is data mining (allowing software to screen records enables many more audits to be performed).

CMS has an extensive database of services billed to Medicare by all providers, including physical therapy. This database is employed by RACs, ZPICs and other audit contractors to analyze coding, billing, and volume of claims.  The RAC contractors identify  the most frequently billed codes, practice locations, number of visits per diagnosis, etc. and use this information to create physical therapy profiles.  

The  PT profiles are  compared against your coding and billing submissions in an attempt to identify unusual  patterns and identify you as an outlier.  If billing abnormalities or outliers are discovered the auditors take action and request an audit of your services, the purpose of which is to retrieve an overpayments issued by Medicare.   When an offense is discovered auditors will send an overpayment demand letter.   Once they find an error, like a shark drawn to blood in the water,  they request a complex review of medical records and further reviews of other claims are requested.   The auditors, who only are compensated when they extract a refund from you, naturally assume that ''Where there''s smoke there''s fire''.  If one record is bad, other records must be also be bad.  Unfortunately the RACs assume correctly, which is why they are scheduled to retrieve more than $1Billion dollars in 2011.

If and when an audit occurs, you are may be faced with significant overpayment return demands.  If you decide to appeal, the appeal  is a five-step Medicare appeals process. This is an ominous, time-consuming, and expensive process (lawyers fees).   It is imperative that we PTs proactively prepare to prevent these audits.  By having supportive documentation that defends clinical behavior, an audit can be prevented  If you are forced to defend claims without proper clinical documentation you have no defense.

All the tools you need to support your clinical actions are in MediGraph.  Outcome instruments (OPTIMAL, Oswestry, etc.) and tests that establish impairments, disablements, and medically necessary are in the program.  Please use them. 

Be well,

Tom Kane, PT