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OIG Sample Finds that More than 60% of Therapy Claims Don’t Meet Medicare Requirements

Posted by David Fong on Jun 8, 2018 6:00:00 AM

A recent article in Skilled Nursing News reported that more than 60% of outpatient therapy claims filed over a six-month period didn’t meet Medicare’s requirements — a figure that has a key government watchdog agency concerned.

 

TherapyThe Department of Health and Human Services (HHS) Office of the Inspector General (OIG) looked at a representative sample of 300 Medicare therapy claims filed in the final six months of 2013, and found that only 116 — or about 38.7% — actually met the requirements for reimbursement. The other 61.3% represented medically unnecessary therapy services, as well as those with coding and documentation errors.

 

Based on that sample, the OIG determined that the government spent more than $367 million on therapy services that didn’t comply with Centers for Medicare & Medicaid Services (CMS) rules between July and December 2013, which the HHS enforcement arm blames squarely on CMS.

 

Of the 184 offending claims, 145 had coding errors, including mismatches between reported and recommended services and simple coding errors. In addition, 112 lacked supporting documentation, while 91 were deemed medically unnecessary; the numbers do not add up to 184 because individual claims could have multiple issues.

 

 “CMS does not concur with the determination made by the OIG’s independent medical review contractor that the sample of physical therapy claims reviewed did not comply with Medicare coverage and payment requirements,” CMS administrator Seema Verma wrote in a memo to the OIG about a draft version of the report in October.

 

The administrator also noted that the deficient claims “are likely attributable to” human errors and not fraud.

 

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Topics: Medical Coding, Outsourcing, Coding Denial Management