How to Avoid Landing in Medicare Hot Water

Avoid these Medicare red flagsWe’ve all heard the stories about sleazy providers scamming the system—and their patients—out of more money than they can count—like the “Rock Doc” in South Beach. But sensational stories aside, most practitioners who get into trouble with Medicare do so as a result of documentation and billing errors rather than flat out fraud or abuse.

Regardless of the reason, though, being in Medicare hot water isn’t good for you, your practice, or your patients, so it’s critical to keep your clinic compliant, on point, and far, far away from these major red flags that can easily trigger a full-fledged audit:

  • Frequent KX modifier use (divergent from the norm)
  • Billing under one PT provider number rather than each separate enrolled PT
  • Billing excessive number of codes per session

What else can you do to keep the Medicare auditors at bay? Ensure you documentation is picture perfect by:

  • Including certifications on plan of care
  • Providing adequate PTA supervision
  • Complying with the 8-minute rule and/or CCI edits
  • Ensuring legible signatures (whether its the physician’s on the plan of care or the PT’s)
  • Physically signing documents (stamped signatures are a no-no)
  • Having the physician sign the plan of care in a timely manner
  • Re-certifying the plan of care
  • Ensuring duration/frequency are compliant with Local Coverage Decision
  • Documenting comprehensively

Plus, never—and I mean never—modify your documentation after you receive a denial. And, if Medicare requests your records, supply them, without delay.

In terms of billing, don’t:

  • Bill for services furnished by aides or techs, one‐on‐one codes instead of group therapy, or co‐treatment when co-treatment hasn’t occured
  • Submit claims for services that you know aren’t reasonable and necessary
  • Code game, like unbundling (hot pack, dressings) and upcoding (E‐Stim)
  • Bill for non-covered services without an Advanced Beneficiary Notice (ABN)
  • Bill for maintenance care; excessive duration and frequency of services; services not furnished; or student services

Want even more security? Here’s a few more tips:

Get Educated. Keep a copy of Medicare’s Local and National Coverage Policies on hand and make sure that you—and your staff—understand the coverage criteria that applies to your practice. Not a visual learner? Check out what Medicare CEU opportunities are available for a more hands-on or audio learning experience.

Get Online. While I can think of plenty of other online activities that might be more fun, you should really get to know Medicare’s website. Specifically, learn how to access key Medicare reference documents, like their Benefits Policy and Claims Processing manuals. I also recommend checking out the PT Compliance Group and Gawenda Seminars for great online compliance resources.

Get Your Team. Now that you’ve got all things Medicare down cold, it’s time to get your team onboard. After all, you’re only as a compliant as your least compliant team member. Okay, that may not be how the saying goes, but that doesn’t mean it’s any less true. Everyone in your clinic needs to understand the importance of compliance and how to behave in a manner that reflect this understanding. Once everyone’s got a grasp of the basics, it might be time to introduce self audits and appoint a compliance officer.

Get Organized. So, you and your team know how to document and bill to meet Medicare’s standards. Just one more step to keep your clinic out of hot water: institute—and document—a compliance plan. Along with a series of checks and balances to ensure your clinic stays compliant as it grows, your plan should include:

  • Clinic standards of conduct
    • New (and current) employee training (and retraining)
    • Disciplinary actions for misconduct or non-compliance
  • Compliance officer responsibilities
  • Internal audit processes
    • Procedures for reporting violations
    • Corrective action for confirmed violation

This might seem like a hefty list of tips, but keeping on Medicare’s good side can mean the difference between getting paid and, well, not. Not to mention that staying out of hot water means you avoid the stress of cumbersome audits and potential legal issues. Getting educated, getting online, getting your team onboard, and putting together a plan will not only ensure that you know how to stay compliant but also help you prepare for what to do if something goes wrong—mistakes happen, after all. And that’s okay. As long as you know how to handle them properly from both Medicare’s point of view and in a way that aligns with your and your clinic’s principles.

About the Author

Heidi Jannenga, PT, MPT, ATC/L
Heidi was a basketball athlete at the University of California, Davis. Following a knee injury and subsequent successful rehabilitation, Heidi developed a passion for physical therapy. She started her 16-year physical therapy career after graduating with her Masters from the Institute of Physical Therapy in St. Augustine, Florida.

In 2008, Heidi and her husband Brad launched WebPT, the leading web-based Electronic Medical Record (EMR) and comprehensive practice management service for physical therapists. As the company’s COO, Heidi is responsible for product development/management, billing services, and customer support.

She now resides in Phoenix with Brad and their daughter Ava.

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