Medicare Pre-payment Audit: SSI Physical Therapy Passes 100%

Although Medicare is supposed to make announcements of upcoming audits, most practices in South Carolina were not aware until they received notice. SSI Physical Therapy recently received nearly 40 notifications for pre-payment chart audit reviews in the mail in just one day. After a few phone calls to confirm, they learned many other clinics in both South Carolina and North Carolina were also receiving audit notifications.

This is  an interview with Darlene Pope, Co-owner and physical therapist at SSI of their recent experience with their recent pre-payment audit and how they achieved a 100% pass rate. Darlene is the clinical leader at SSI responsible for understanding, implementing and training staff on compliance requirements.

Was there anything unusual about this audit?

“Yes, there were a few things. This was an official pre-payment audit and we were a bit surprised, usually we are aware of audit activity in the area and there were no announcements, not even on the CMS website. In our case, almost all of our therapists were hit. While they were auditing across all codes, they seemed to pay close attention to any codes for aquatics and gait training. They also audited multiple codes for the same date of service.”

You mentioned these were pre-payment audits. How did that affect you?

“Medicare automatically put a 60 day hold on payments. However, in our case it took at 4 to 5 months before we received payment on some claims.”

That can have a serious impact on cash flow.

“Yes it can. We were lucky because we passed everything in the first round. We heard of other practices that received one strike and were then hit with 20 more audits per provider, and had all payments held. This can be devastating for private practices, which is why we have dedicated resources to understanding compliance regulations and requirements in our organization. As the clinical leader in charge of compliance, I am responsible for implementing policies and processes, and training our staff accordingly to minimize the impact an audit can have. In our case, it has paid off.”

Why did it take so many months to receive payment if you passed in the first round?

It appeared that although Medicare had no problem sending out so many audits, they didn’t have enough auditors to follow up. Some other practices that did not pass the initial round of audits experienced serious delays.  In some cases, the process was only expedited after a congressman advocated for them. Interestingly enough, many of the auditors were not familiar with the regulations or guidelines specific to physical therapy.

What were you required to provide?

For each date of service, we had to send a separate packet for each code billed. Each packet included the physician’s order, a copy of the initial evaluation, a signed plan of care and documentation for the visit in question. Of course, the documentation had to justify medical necessity. And the claim had to support the visit documentation. It was very time consuming, although I can’t imagine how much more difficult it would have been if we didn’t have everything in one system.

What lessons did you learn from this audit?

That it is critical to have a clinical leader who not only knows the Medicare guidelines, but who is responsible for training staff on the requirements and ensuring that the right systems are in place to empower them to be compliant, while enforcing adherence to your policies.

Can you give an example?

Demonstrating medical necessity was a critical element of this audit. We educate and coach our clinical staff how to document functional limitations, how to associate the functional limitations with reproducible clinical findings and self report scores, and develop and track both clinical and functional improvement. This has been one of my greatest challenges as a clinical leader. One of the reasons we chose Clinicient as our EMR system is because the goal tracker feature allows us to associate functional limitations with clinical findings, create goals based from those findings, then track them routinely visit to visit. This allows us to document progress easily, and produce compliant documentation. We spent a lot of time up front setting up the system and customizing it so that these guidelines and processes were adhered to, and it obviously has paid off.

What about matching the documentation to the claims?

“This part was easy with Clinicient and eliminated a lot of work on our part, and a lot of worry.  In Clinicient, the aggregation of charges and the clinical documentation for the visit are tightly linked.  The charges for a visit are built from the procedures documented during the visit, taking into account the Medicare rules for aggregating timed and untimed procedures for the visit.  Each visit is automatically audited as part of the sign off process and charges are not processed until the visit is signed off.  This way, the clinical documentation always supports the claim.”

What advice do you have for all the new therapists joining our profession?

There is a lot to grasp in understanding compliance, it is very serious and it impacts every one of us. My advice is to make sure they join an ethical practice that watches over compliance closely, enforces the right policies and provides the right systems to help make this easier.

It is vitally important that there is strong clinical leadership in any practice. Leadership should stay connected and network to be able to stay informed enough to train staff accordingly. Many therapists don’t understand that Medicare will not only audit a practice, but can go after the therapist directly so it behooves them to be informed and drill into this with prospective employers.