Outpatient Therapy Claims


Medical review and audits.

By Nancy J. Beckley, MS, MBA, CHC

It is no secret that Medicare review of therapy records and claims have increased this past year. While largely due to the mandated manual medical review of therapy over the $3,700 threshold (physical therapy and speech/language pathology combined) by the Recovery Auditors, other initiatives have resulted in therapy chart reviews. The Office of the Inspector General (OIG) continues with audits of private practice physical therapists with published reports from the Office of Audit Services (OAS) in 2013 and in 2014. Therapy audits continue to take place under the recent OIG Annual Work Plans under the auspices of the Office of Audit Services. This past October, the OIG-OAS initiated a nationwide review of physical therapists in private practice. The sampling of private practice therapists’ compliance with Medicare requirements for outpatient therapy by the OIG-OAS does is not constitute an audit of any private practice, but rather a statistical sampling of therapists throughout the country.

The Comprehensive Error Rate Testing Program (CERT) publishes its findings on a quarterly basis of the paid claims error rate for CMS Medicare Administrative Contractors (MAC). Each year, CERT evaluates a statistically valid random sample of fee-for-service claims submitted to the MACs to determine if they were paid properly under Medicare coverage, coding, and billing rules. The Zone Program Integrity Contractors (ZPICs) investigate allegations of suspected fraud and abuse by referrals from other agencies and/or claims and providers selected based on data mining and statistical analysis. Most state Medicaid programs now have mandated recovery audit programs in place, but reviews can also be conducted by a state Medicaid office of Inspector General or the Medicaid Fraud Control Units.

While most claim audits involve review of the medical records that correspond to a submitted claim, the review at hand may not necessarily be related to a review of medical necessity, but rather to compliance with technical and statutory requirements.

Q: We were under review by Strategic Health Solutions resulting in having claims denied retroactively. What is their authority for conducting a review?

A: Strategic Health Solutions has a contract with the Centers for Medicare and Medicaid Services (CMS) as a “supplemental review contractor.” In that capacity, CMS has referred a variety of audits to them. Strategic has conducted two outpatient therapy audits, and the findings of both reviews have been reported on their website. The first report (Y1P5) was based on a 2013 review of charts for “Analysis of Medicare claims data between August 2012 to March 2013 identified provision and billing of therapy services that either stopped or delayed just under the allowed therapy cap….. The purpose of the project was to determine whether the Medicare Part B Medicare Part B Outpatient Rehabilitation Therapy Services claim was appropriately adjudicated according to Medicare regulations and guidelines.”1

Strategic requested 7,080 claims from 357 unique providers (10 claims were not reviewed as the parameters for the review were not met), of which 2,580 were denied because the provider did not respond to the request for records. Another 1,437 were denied after review, leaving 3,063 claims that were paid. The error rate for providers on this audit was 57 percent. The advice offered to providers included:

  • Sending records on time per the ADR request
  • Submitting all documentation in support of the medical necessity of the services that were billed
  • Correctly report the number of units based on procedure or service

Strategic also conducted another audit of therapy providers who billed for therapy services during the summer of 2012’s Superstorm Sandy: “Analysis of Medicare claims data for October and November 2012 identified a continuation in billing and payment for Outpatient Therapy Services during a period of time that health care facilities were inaccessible to the public as a result of power outages and flooding caused by Hurricane Sandy. The purpose of the project was to determine whether the Medicare Part B Outpatient Therapy service claim was appropriately adjudicated according to Medicare regulations and guidelines.”2

The sample of providers in this review was largely confined to providers in the path of Superstorm Sandy; however, many providers throughout New York not affected by Superstorm Sandy had record requests. Claims were with dates of service October 29, 30, or 31 and November 1 of 2012 for specific areas defined by zip code regions. Many providers in the path of Superstorm Sandy were able to maintain operations in spite of widespread power outages. Providers wondered if the real issue was providing “evidence of power,” why didn’t providers have to submit their electric bill or an attestation from staff and patients that the clinic was operating on a dates that CMS believed to be “dark” for all providers? CMS authorized this audit as they felt it constituted new and material evidence establishing good cause for reopening.3

Strategic requested 7,018 claims—of which 1,134 were denied for no response. Another 2,309 were denied after review, leaving 3,575 claims that were paid. The error rate for providers on this audit was 49 percent. Strategic offered the same advice to providers as in the previous audit, and additional insight or guidance was given from which providers could glean any insight—other than to promptly respond to requests and to ensure compliance with properly reporting the number of units for both timed and untimed codes.

Under both audits by Strategic, they noted that in the absence of compliance with CMS signature requirements the review would be conducted without “considering the documentation with the missing or illegible signature” if the provider had failed to respond to a request to submit a signature attestation log within 20 calendar days.

Q: There was an August 2014 OIG Report about a physical therapist in private practice in Illinois. Why was the practice not identified? Was there anything new to learn from this report?

A: The OIG published “An Illinois Physical Therapist Claimed Unallowable Medicare Part B Reimbursement for Outpatient Therapy Services”4 in August, noting a 99 percent error rate, stating that only one claim was properly reimbursed. It is the Health and Human Services (HHS)-OIG Office of Audit Services’ policy not to include the name of a sole health care practitioner in publically available audit reports that are posted to the HHS-OIG internet.5

Screen Shot 2014-12-29 at 4.46.19 PM

Figure 1 indicates the error-by-error type including error related to the Plan of Care, Treatment Notes, Progress Reports, Medical Necessity, and Physician Certification. The overall error rate included overlapped errors as noted in the charts related to the specific types of errors for plan of care, treatment notes, and physician certification. The OIG report includes a detailed rebuttal by the physical therapist including reasons for the OIG to maintain their original position, and recommending that $634,837 be paid back to the Federal Government. The OIG noted in the report that “these deficiencies occurred because the therapist did not have adequate policies and procedures in place to ensure that the therapist billed services met certain Medicare requirements.” The second recommendation was that adequate policies and procedures be established to ensure services billed to Medicare are medically necessary, coded correctly, and adequately documented.

Any provider involved in an OIG recommendation to repay will have the opportunity to refute the OIG findings through with CMS using the established appeals process. Therapists in private practice should ensure that reports by the OIG regarding therapy are viewed in the context of current risks in your practice.

Screen Shot 2014-12-29 at 4.49.39 PM

Q: How is a practice notified of a CERT request? Is there anything that a practice can do to be prepared to respond to a request by the CERT contractor?

A: According to CMS6 the CERT program selects a stratified random sample of approximately 40,000 claims submitted to Part A/B and DME Medicare Administrative Contractors during each reporting period. The CERT program allows CMS to calculate a national improper payment rate as well as contractor-specific and service-specific improper payment rates.

A therapy provider will receive a request for medical records, either via mail or fax from the CERT Documentation Contractor, that is responsible for collecting the records to be reviewed by the CERT Review Contractor. The contact will come to your practice based on the information that you have on file with CMS. If you do not have updated information on file with CMS, it can be updated via the 855i and 855b forms (keep in mind that CMS has time limits on reporting certain items, including change of practice location). A provider has 75 days in which to provide the request medical records. The CERT contractor will make a second and likely third attempt to obtain medical records if you do not respond. Signatures for records must be in accordance with CMS Signature Requirements, and if they are not, the CERT contractor may follow up to request a signature attestation form. Best practice would be to comply with CMS signature requirements, and if your review of records prior to submission indicates noncompliance it is best to provide the proper signature attestation with submission of the requested records. CMS signature requirement can be found in MedLearn Matters MM6698.

The medical review by the CERT Contractor is done in order to determine if the claims were paid correctly under Medicare coverage, coding, and billing rules. If these criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped. On a positive note, if an underpayment has been found, that will also be sent to the MAC for correction.

Error in the CERT program may be utilized by other CMS Program Integrity Contractors, the MAC, as well as the OIG to identify issues for review and audit.

Q: Has the CERT program found specific issues related to outpatient therapy? If the findings are adverse can we file an appeal?

A: The CERT reports are published to the CMS website. Additionally providers should query their MAC’s website to find specific CERT information, training, and results. A CERT A-B MAC Outreach & Education Task Force (made up of the various MACs) is in place to coordinate communication, understanding, and compliance with the CERT program. The first provider-specific educational tool developed this year was targeted to outpatient therapy.

The CERT Task Force noted that “insufficient” documentation in the medical records was the leading cause for CERT therapy errors. Each MAC provided information on their website linking to their respective local coverage determinations (LCD) as well as therapy documentation requirement noted in the Medicare Benefits Policy Manual. Also noted as a therapy error are missing or illegible signatures on the plan of care.

Additional widespread issues that result in “insufficient” documentation errors for outpatient therapy include: missing or illegible signature on the plan of care, missing or illegible signature for physician’s certification, and missing legible signature and required treatment minutes in narrative or on flow sheet.7


1. Strategic Health Solutions Report Y1P5 Medicare Part B Outpatient Rehabilitation Therapy Services. Website www.strategichs.com/wpcms/project-y1p5-medicare-part-b-outpatient-rehabilitation-therapy-services/ Accessed November 2014.

2. Strategic Health Solutions Report Y1P9 Medicare Part B Outpatient Rehabilitation Therapy Services: www.strategichs.com/wpcms/project-y1p9-medicare-part-b-outpatient-therapy-services-2. Accessed November 2014.

3. Good cause for reopening found at: 42CFR 405.980(b).

4. OIG, August 2014, A-05-13-00010.

5. Email response to from HHS-OIG OAS to Nancy Beckley.

6. www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Background.html Accessed November 2014.

7. CERT A/B MAC Outreach & Education Task Force Scenario: Documenting Therapy and Rehabilitation Services, 2014. Link to information at WPS: www.wpsmedicare.com/j5macpartb/departments/cert/cert-ab-task-force.shtml Accessed November 2014.


Nancy J. Beckley, MS, MBA, CHC, is certified in health care compliance by the Compliance Certification Board, and is a frequent speaker and author on outpatient therapy compliance topics. She advises practices on compliance plan development and audit response. Questions and comments can be directed to nancy@nancybeckley.com.

Copyright © 2018, Private Practice Section of the American Physical Therapy Association. All Rights Reserved.

Are you a PPS Member?
Please sign in to access site.
Enter Site!