Medicare is among the largest healthcare payers in the country, and is the most influential in terms of the formulation of private and federal payment policy. As a physical therapist or provider of physical therapy services, the amount of time and effort required to keep current with the ever-changing environment of payer regulations is especially daunting. Physical therapy services represent one of the fastest growing categories of costs under the Medicare program, and as a result, the federal government has been increasing its efforts to eliminate over-utilization and potential fraud and abuse among providers who bill for physical therapy services. Moreover, efforts toward health care reform are focusing further emphasis on reducing fraud, waste, and abuse in government run programs to help pay for necessary services.

Although the Medicare Therapy Cap Exceptions Process has allowed beneficiaries who need these services to receive them when medically necessary, this process can be very confusing. What is more alarming is that accessing the Medicare Programs "Exceptions Process" in the absence of documentation that justifies medical necessity will place the physical therapist and/or facility at risk for potentially committing fraud and abuse. However, Medicare compliance is not limited to the Therapy Cap and Exceptions Process. It is critical to ensure providers are compliant with Medicare's definition of skilled care, as well as the coverage limitations and "reasonable and necessary" requirements identified in the multiple Medicare regulations and manuals. Specifically, Medicare compliance issues that put physical therapy providers at risk include the requirement of qualified professionals to provide therapy services, appropriate use of waivers and modifiers, supervision of assistive personnel, the Correct Coding Initiative (CCI) program and other claim edit programs, certification requirements, adherence to Medicare's Minimal Documentation Requirements, and adherence to Local Carrier Determinations (LCDs).

Fearon & Levine can assist in assessing a provider's supplier's risk associated with Medicare compliance issues and supporting compliance efforts through:

• Assessment of compliance with Medicare rules and regulations relating to outpatient physical therapy and other rehabilitation services
  
  
• Assessment of compliance with Medicare's "skilled care" requirements
  
  
• Assessment of compliance with the Medicare Benefit Policy Manual
  
  
• Assessment of appropriate applications of waivers (i.e. Advanced Beneficiary Notification (ABN), Notice of Exclusion from Medicare Benefits (NEMB))
  
  
• Assessment of appropriate use of modifiers and review of documentation to support their use
  
  
• Assessment of risk related to Correct Coding Initiative (CCI) and other edit initiatives that effect payment
  
  
• Assistance with Therapy Cap issues and compliance
  
  
• Assistance with understanding and compliance of the Therapy Cap Exceptions Process
  
  
• Assessment of compliance with Medicare's Minimal Documentation Requirements
  
  
• Development of documentation templates that incorporate Medicare's Minimal Documentation Requirements
  
  
• Assessment of supervision compliance regarding assistive personnel
  
  
• Assessment of compliance with certification requirements and other components of technical compliance under the Medicare program
  
  
• Provision of recommendations regarding the use of attorney/client privilege during audit or investigation that may provide greater protection of the provider in these circumstances
  
  
• Identification of areas of risk related to potential Stark ramifications in the areas of ownership, joint ventures, fee splitting, kickbacks, or inducements
  
  
• Education and training in criteria for documenting medical necessity and skilled care
  
  
• Assistance in understanding specific local Carrier and Intermediary coverage determinations
  
  
• Staff education and training in the area of Medicare compliance
  
  
• Provide non-punitive audits to assess statutory compliance with Medicare regulations and other third-party payer requirements
  
  
• Provide resources to facilitate legal consultation with expert Medicare attorneys in any of the following areas: reimbursement issues, compliance, contacts, joint ventures, other federal law issues (including fraud and abuse concerns), Stark issues, and the new privacy laws
  
  
• Provide resources to facilitate legal representation in matters pertaining to Medicare/third party reimbursement