Practices of all ages and sizes can apply these tips to avoid audit triggers
By Lynn Steffes, PT, DPT
In my experience, most private practice owners like to sleep soundly at night. They like to believe they are serving their community, which benefits from their services, without fear of having a commercial or government payer auditing them and recovering funds or pursuing practice sanctions.
In order to proactively limit your risk of audit, identify the charts of your frequent flyer patients and determine whether their episode of care might appear prolonged by the payer. It should not be a surprise to anyone that prolonged episodes of care are often selected for audit!
STEP 1: TAKE A SNAPSHOT OF YOUR PATIENT CHARTS/DATA
What percent of your Medicare patients in the past 12 months exceeded the $3,000 Therapy Threshold for Medical Review? What percent of your Medicare patients in the past 12 months exceeded the $2,080 Initial Therapy Threshold Therapy Threshold for Medical Review?
If the percent exceeding $2,080/beneficiary in the past year is >23% and or the percent exceeding the $3,000 Medical Review Threshold is >10%, you may appear to be a ripe target for Medicare audits!
What is the average number of timed and billed procedure codes your practice provided per visit in 2021? Do you have multiple, non-surgical, musculoskeletal patients that have had continuous episodes of care that exceed 6 months? Or 24+ continuous visits?
If your average units/visit is greater than 4 you may be at risk for audit. If your practice has continuous episodes of care that exceed 6 months or 24-plus continuous visits you may be at risk for audit.
STEP 2: GATHER SAMPLES OF AT-RISK CHARTS FROM YOUR PRACTICE IN THE PAST 24 MONTHS.
STEP 3: REVISIT BOTH MEDICARE & COMMERCIAL DEFINITIONS FOR MEDICALLY NECESSARY CARE IN YOUR AREA.
Identify payer language as it relates to coverage for Maintenance Care.
STEP 4: PERFORM AN INTERNAL CHART AUDIT ON AT-RISK CHARTS.
Perform a thorough chart a to audit determine whether that chart reflects standards for skilled care and measurable functional progress.
If the chart is for a commercial patient whose plan does NOT cover Maintenance Care, consider transitioning your patient to cash or putting them on a pause with a strong home exercise and management program. Plan to recheck them in 90 days or less if needed to determine if additional episodes of care might be appropriate instead of continuous care.
If the chart is for a Medicare patient—which does cover Maintenance Care—review the requirements of a restorative versus a maintenance plan of care. Determine if your patient might qualify for Maintenance Care and execute your transition to a maintenance plan of care for those patients.
Lynn Steffes, PT, DPT, is president and consultant of Steffes & Associates, a national rehabilitation consulting group focused on marketing and program development for private practices nationwide. She is an instructor in five physical therapy programs and has actively presented, consulted, and taught in 40 states. She can be reached at email@example.com.