More than 60% of outpatient physical therapy claims audited over a six-month period did not comply with Medicare’s requirements, according to a report from the Office of Inspector General (OIG). With an estimated $367 million paid out by Medicare for services that should not have been covered, OIG has recommended that CMS increase its oversight of outpatient PT claims.
It’s important to note, however, that OIG only reviewed a total of 300 claims and extrapolated their results to the entire universe of outpatient therapy claims. However, if you’re providing therapy in an outpatient setting, it may be time to take a closer look. How can you minimize improper payments and boost reimbursement with clean claims?
Consider the following tips from Ellen Strunk, owner of Rehab Resources & Consulting. In our Keys to Successful Claims Submission webinar, Ellen highlighted three areas to focus on as you evaluate your claims process:
1 – Intake: Take time to double-check that your patient information is correct, such as the spelling of the patient’s name, date of birth and insurance card ID number. Not getting it right can lead to rejected claims, lower reimbursement and unhappy patients. It’s also important to ask clarifying questions, such as the examples provided below. Depending on how patients answer, their eligibility, the primary payer or type of benefit may change.
- Has the patient already been treated by another outpatient provider?
- Is the patient being treated in other settings, such as home health?
- Is a Medicare secondary payer form required?
- Are the proper consents and authorizations in place?
2 – Validation: Proper validation of the following areas will keep your patient operations on track and ensure that everyone knows from the start who’s financially responsible for the service.
- The therapist – Check that your therapist is licensed, credentialed and has not been excluded from the Medicare/Medicaid program, which you can do via OIG’s online list of excluded individuals. While you may have checked licensing during the hiring process, many compliance officers recommend doing it monthly to keep your records up to date. If the therapist is not properly credentialed, your scheduling will quickly get complicated.
- The referral source – Check the referral source’s status in the same OIG online list. This is important because if you accept a referral and provide services based on an exclusive provider’s referral, it puts you at liability for those services.
- The insurance – Check what the insurance will cover. Benefits vary across Medicare Administrative Contractors (MACs) and commercial payers, so it’s best not to assume anything. For example, even if you believe Medicare is the primary payer, make sure to fill out a Medicare secondary payer form. This will help clarify whether Medicare is the primary or secondary payer for the service. Not doing so could result in having to pay back Medicare if auditors determine that another insurer should have paid for the service instead.
3- Filing the claim: Whether this is done manually in your office or via your EMR, the same checks and balances need to occur. Make sure you know what forms you need and how you’re going to submit them. Commercial payers may not require the same forms as Medicare, and there may be special requirements for special services. Understand the policies and procedures for each.
Look to your therapy software provider
Filing your claims correctly depends on tracking a multitude of details. The good news is that with the right therapy software, many of these claims processes are managed for you—eliminating the burden on billing staff and therapists. At a minimum, therapy software should allow you to:
- Electronically verify the insurance benefit
- Alert you if a therapist’s licensing status and credentials have expired prior to scheduling
- Automatically transmit all charges and codes to the billing software
- Scrub and validate claims prior to submission
- Submit electronic claims, including CMS1500 and UB04 claims
To learn more about the claims process and how to submit clean claims, watch our webinar with Ellen Strunk or request a demo to find out how Optima Therapy for Clinics can support your therapy practice.