Recovery Audit Contractors

October 14, 2008

The RAC program is coming to a state year you . . . of particular concern to

me personally is North Carolina (proposed start January 1st 2009 and

retro-dated to October 2007). Working in an outpatient setting, of

particular concern is (as I read it) the fact that the report found that

some of the highest overpayments of the nearly 700million identified, were

related to insufficient documentation for therex and manual therapy (read as

EEEEK!). Maybe I'm looking in the wrong place, but I am not seeing or

hearing much from the state association or the APTA on the subject beyond

" be prepared, " and hear a lot of very different approaches from a variety of

therapists at different clinics regard what they are (or are not) doing to

prepare. I don't mean to be alarmist (but among those PT's aware, fear is

in the air), but this has the potential to impact the profession in a more

dramatic way than managed care, the balanced budget amendment, or therapy

caps. Specifically, I'd like to know how those PT's that have or are about

to be impact by RACs, have obtained their information. What

seminars/webinars would you recommend? Are therapists simply trusting the

information they're getting from their employer? Is (and I'd hope not) this

the first that most rank-and-file clinicians are hearing about the program?

Also, what are we as a profession doing with respect to " beyond functional "

goal writing, and " why were YOU as a skilled professional " needed for

execution of the therapy session (as opposed to a trainer or HEP)

explanations in the objective section of every note (e.g. using the

buzzwords " facilitate " " inhibit " " verbal cue required " and " tactile cue

required)? Given the potential impact that this may have on the profession,

this seems to me to be something of an under-response.

Any suggestions would be greatly appreciated,

Dr. M. Ball, PT, DPT, PhD, MBA

Charlotte, NC

October 15, 2008

Dear Dr. Bell,

Thank you for opening dialogue on this very alarming and critical matter.

I am also not hearing much or reading much regarding the Recovery Audit

Contract (RAC) Program from the state association or the APTA on this subject

matter either (we are in Louisiana). However, you can hear a great deal more

about this and other Medicare and Medicaid audit programs (Comprehensive Error

Rate Testing-CERT-Program) by attending a Healthcare Financial Management

Association Conference. Most states have a local chapter of the HFMA you can

join. You can also read about this and similar programs by visiting their

website at _http://www.hmfa.org_ (http://www.hmfa.org) . Additionally, this

information can be found by visiting the CMS website at _http://cms.gov_

(http://cms.gov) .

In short, both the RAC Program and CERT Program have been enormously

successful. As a result of the tens of millions of dollars of

fraudulent/abusive

billing uncovered by MACs (Medicare Administrative Contractors) over the past

two years alone, CMS and HHS now have the resources they need to ramp up their

efforts. Prior to this time, CMS, HHS and OIG was limited to focusing

their efforts on the " big " or " high dollar " offenders, e.g., hospitals, DME

Suppliers, home health agencies, large group practices, etc. That time has

come

and gone. Now CMS and HHS have the resources to focus on all healthcare

providers and suppliers, big and small.

In the past, it took CMS, HHS, OIG months and months to gather all the data

it required to investigate and prosecute cases of fraud and abuse. Those

days are gone. CMS, HHS and OIG have partnered with the CIA. Highly

sophisticated software programs developed by the CIA to track terrorist

activity are

now being used by CMS and HHS to track specific billing and upcoding patterns

or " spikes " in real time. This software also allows CMS and HHS to combine

Medicare and Medicaid claims data--a problem CMS, HHS and OIG considered when

implementing these new programs.

Prior to this time, Medicare claim data and Medicaid claim data were not

stored on the same database. According, Dr. Joe Schmoe could be billing

Medicare for 40 visits per day, and billing Medicaid for 40 visits a day during

the

same 8 hour workday without ever raising a " red flag. " Combining Medicare

and Medicaid claim data will now allow CMS and HHS to more effectively track

fraudulent and abusive billing practices before they get out of hand.

I too, do not want to come across as an alarmist. However, when CMS and HHS

is reduced to using software developed by the CIA to track terrorist

activity in order to track and curtail rampant Medicare and Medicaid fraud and

abuse, we should all be alarmed.

If your practice does not have a Corporate Compliance Plan in place, hire an

attorney or consultant to create one for your practice and ensure that you

have appointed a Compliance Officer to oversee and implement these policies

and procedures.

If your practice therapists and billing staff members have not recently

attended a Medicare and/or Medicaid sponsored coding, billing and documentation

workshop that specifically addresses previous and upcoming changes being

implemented by CMS and HHS, find one and send them.

And finally, document, document, document! Documentation to support medical

necessity, as well as level of service charge is the area that CMS will

focus their attention on in 2009, as this has been proven to be a problematic

area for outpatient therapy and rehab.

As always, wishing you all the best of luck and prosperity in the future.

Vickie

D. Cavitt, President

Medical Legal Alliance, L.L.C.

600 Guilbeau Road, Suite A

Lafayette, LA 70506

In a message dated 10/14/2008 6:08:06 P.M. Central Daylight Time,

DrDrewpt@... writes: