Outpatient Therapy Post-Payment Reviews Are Underway, Have You Been Invited?

By Nancy J Beckley, MS, MBA, CHC

Contact: nancy@nancybeckley.com

During the Public Health Emergency (PHE) and COVID-19 Pandemic therapy providers were relieved to find that the CMS Targeted Probe and Educate (TPE) audits were suspended. This came about when outpatient therapy providers, in both Part A and Part B settings, were struggling to keep the doors open, maintain a patient base, comply with various “stay at home” orders, understand the payroll protection program, and navigate the changing landscape of telehealth waivers and more!

CMS Medical Review Update

TPEs were suspended due to COVID effective March 26, 2020. It seems that just as therapy providers were settling into a “pandemic rhythm” CMS authorized the resumption of  RAC audits and other medical review activities on August 17, 2020  of items/services provided before March 1, 2020. This was to the dismay of all!

Outpatient therapy providers have been, and continue to be, “invited” to post-payment reviews.  MACs each posted the CMS obligatory language to their respective Medical Review pages that started with this missive…”to protect the Medicare Trust Fund against inappropriate payments, Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities.”

Step One in Getting Ready: Update Your Address with CMS

Now is a good time to make sure your contact address is updated with CMS system to ensure ADRs are directed in a timely manner, and to the right person.  Novitas provides standard instructional comments for Part A and Part B providers:

  Part A

In the Fiscal Intermediary Standard System (FISS), the address in the “other address” field is used for mailing medical review correspondence and ADR letters. Unfortunately Novitas is not able to update or change the designation for mailing correspondence and ADRs to a different address. However, it is important to note that providers can update the address listed in the “other address” field by completing a CMS-855 enrollment application.

Part B

The ADR letter is mailed to a provider’s practice address on file with Medicare. For individual providers rendering services in large facilities such as hospitals, the ADR letter may be misdirected and not received in time by the appropriate department and/or individual provider.

Providers in these situations may request Novitas to mail all correspondence (including ADRs) to the “pay-to” address listed on their PECOS file.

Therapy Post Payment Review Highlight: FCSO

First Coast Services Options (FCSO), the Florida MAC was first out-of-the-gate with active post-payment reviews for private practices and rehab agencies beginning in August. Providers reported receiving ADR “invitations” over the Labor Day weekend with most dates of therapy under review were dates in 2019, and some in December of 2018. FCSO has released 3 rounds of post-payment review for therapy providers.

Therapy providers in the first waves (August and September) were challenged by lack of certifications and recertifications on the Plan of Care. While CMS allows for delayed certifications, providers in Florida soon found out the complications of obtaining a valid delayed certification during the pandemic:

• Physician offices, particularly those of surgeons, were often closed as a result of the pandemic
• Physician offices that remained open, did not allow visitors, so an “in person” visit to hand deliver a POC was not a viable option
• Physicians, working remotely, were not getting faxes that therapy providers sent to a closed office (there always seems to be a reason a therapy POC fax is not received!)
• Some physicians were no longer in practice, and/or were no longer associated with their previous practice
• Some physicians did not want to certify a POC where therapy was provided 12-18 months ago
• In instances where the patient self-referred under direct-access, there was no documentation in the therapy record in support the “physician involvement” with the beneficiary, which could have been a mitigating factor for consideration in medical review

Getting Ready: Check Your MAC for Therapy Topics Under Review

The MACs have posted medical review topics at their Part A and Part B websites. Some MAC sites are easier to navigate to medical review topics than others. For example, Novitas has listed CMS approved topics under review, but has also provided summary updates of the review topics that include errors by topic and error rates. From a compliance perspective considering adding posted therapy topics to your Compliance Risk Assessment and as appropriate added to your Compliance Monitoring & Auditing Plan.

Table 1: Active Post Payment Therapy Reviews (February 15, 2021)

Final Thoughts

Have you received an invitation to a post-payment audit? Scrapbook your way to success by reviewing this article Local Coverage Determinations - Scrapbooking Your Way to Success in a RAC World that I wrote over 11 years ago…. Still good advice today.