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Rehab Compliance: Nancy Beckley
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CMS issued a State Medicaid Director Letter (SMDL)  in 2009 recommending that States require providers to screen all employees and contractors monthly.  However in 2011, CMS issued final regulations mandating States to screen all enrolled providers monthly.   Furthermore Section 6501 of PPACA requires States to terminate individuals or entities from their Medicaid programs if the individuals or entities were terminated from Medicare or another States Medicaid program.  This becomes the “excluded in one, excluded in all” principle.

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Checking exclusions is a key component of any viable compliance program.  The Office of the Inspector General (OIG) of the US Department of Health and Human Services maintains a list of excluded individuals and entities (LEIE).   Anyone who hires an individual or entity named on the LEIE may be subject to civil monetary penalties (CMP). 

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Problems come up all the time in the therapy world and people look to their peers for help, support and resources, whether at hospitals, private practice, nursing home or home health agencies.  It is fantastic to be able to look to peers when you are seeking advice on a Medicare policy (does Medicare pay for aquatic therapy?), or unbiased reviews of new equipment (do you find that this treadmill is really better for therapy patients?). 

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There are 9 occupational therapy PQRS measures in 2014 for claims-based reporting (free).  Many are the same measure for physical therapy reporting, however there are some different options for occupational therapy.  Before we get to the measures, it’s important to clear up some misunderstanding about the minimum number of measure that must be successfully reported (via claims based reporting). 

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PQRS measures and reporting have changed for 2014, and if you are not aware of the changes, your reporting could cost you 2% of your 2016 payments from Medicare!  For physical therapists doing claims based reporting there are 8 eligible measures, and for occupational therapists there a 9 eligible measures. 

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The CMS RAC Work pause of the Recovery Auditor (RAC) program will provide some work load relief for outpatient therapy providers in the short run, but in the long run 100% of therapy claims over the $3700 thresholds will be reviewed.  So what does this mean for therapy providers? 

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CMS announced this week that the Recovery Audit program (RACs) would pause for a period of time so that the current ADR requests can process through the RAC reviews.  RAC audit stoppage is not likely to affect therapy ADRs.  In what might have been a false sense of “freedom” rehab providers reading RAC Monitor’s special article today were jumping for joy.  A Chicago provider invited me to come on down and pop the bubbly with them!  Don’t throw the confetti just yet!  CMS explains the pause is this fashion:

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Tricare does not reimburse for therapy provided by therapy assistants, and in fact excludes from reimbursement outpatient physical therapy that is performed by physical therapist assistants.  This may be a surprise to many providers, in that Tricare, like Medicare is a federal healthcare program, and of course we all know that Medicare allows therapy to be provided by a qualified physical therapist assistant.

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Appealing Therapy Medicare denials is likely to be a reality for all outpatient therapy providers this year. Therapy over the $3700 cap is subject to 100% mandatory medical review by the Recovery Auditors (RACs) through 3/31/2013.  In fact those reviews, if not favorable, will first frustrate you, then possible anger you, then compel you to file an appeal. 

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The therapy $3700 cap (alternatively called threshold) is still in place for Medicare through 3/31/2014.  Claims over the therapy $3700 threshold will be reviewed by the Recovery Auditors (RACs) on either a prepayment or post-payment review basis.  Many providers use a quick estimate of $100 in Medicare allowable reimbursement per date of service, and then can finger count to 37 visits when the therapy threshold will trigger manual medical review by the RACs. #$3700TherapyCap
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