Occupational Therapists, Physical Therapists, Speech Therapists and Rehabilitation Therapists Should Retain Legal Counsel for Medicare and Medicaid Audits

Wednesday, March 6, 2013

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Most Medicare and Medicaid auditors are cracking down on occupation therapists (OTs), physical therapists (PTs), speech therapists (STs) and rehabilitation therapists (RTs). We have recently been consulted by a number of large therapy groups and small therapy providers undergoing or who have recently undergone Medicare or Medicaid audits.  In too many circumstances the audit agency has come back with a 100 percent (100%) denial of all claims.

Common Errors Found in Medicare and Medicaid Audits.

There are number of different reasons why there have been these results.  Most of these relate to improper or incomplete documentation. Such errors include:

1.  Failure to obtain the physician's signature on the order or plan.
2.  Failure to have an order signed by a physician.
3.  Failure to have the care plan signed by the physician within 24 hours.
4.  Failure to document the start time and stop time of each procedure.
5.  Failure to have complete, unique notes for each patient (use of "cloned" notes).
6.  Failure to demonstrate if a client is progressing toward improvement or goal.
7.  Lack of medical necessity for procedures performed.

Therapists must insure that they are familiar with the local coverage determinations (LCDs) that are published by Medicare Administrative Contractors (MACs).  These are available on the MAC's website.  For Medicaid providers, therapists must be familiar with the documentation requirements provided in the Medicaid provider handbooks and guidelines published by the State Medicaid Agency.  Strict compliance on all such guidelines is required. 

Make Sure to Obtain the Physician’s Signature Prior to Treatment.

Therapists must insure that they obtain the proper physicians’ signatures before treating patients.  Make this an ironclad rule.  We have heard from some therapists that physicians often ignore their correspondence and documentation, or the physician sits on it for weeks at a time before signing it.  If you refuse to touch the patient without the required doctor's signature you cannot be faulted.  The responsibility is on the physician who fails to sign a plan in a timely manner. If you are unable to do this, then just plan on providing the services for free.  Guidance on documentation required for a therapist, as well as LCD, and therapy services required for Medicare can be found on the Centers for Medicare and Medicaid Services’ (CMS) website.

Challenge Overpayment Demands from Medicare and Medicaid Audits.

We have recently received numerous communications from health care professionals, including OTs, PTs, STs and RTs who have been placed on prepayment review after failing to challenge Medicare or Medicaid audit results.  The problem is that these providers, once placed on prepayment review, have their payments held up for many months and are often forced out of business.  Sometimes it appears that this may actually be the goal of the auditing contractor or agency. To read a blog I recently wrote on why you should challenge an overpayment demand from Medicare and Medicaid audits, click here.

Don't Wait Until It's Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. We also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals, occupation therapists (OTs), physical therapists (PTs), speech therapists (STs), rehabilitation therapists (RTs) and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid program.
For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.


Have you or has your business ever been audited? What was the process like? Did you retain legal counsel to help with the process? Was having legal assistance worth it? Please leave any thoughtful comments below.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Tag Words: Medicare, Medicare audit, Medicare auditor, Medicaid, Medicaid audit, Medicaid auditor, occupational therapist (OT), physical therapist (PT), speech therapist (ST), rehabilitation therapist (RT), therapy group, therapy provider, improper documentation, incomplete documentation, local coverage determination (LCDs), Medicare Administrative Contractor (MAC), Centers for Medicare and Medicaid Services (CMS), defense attorney, defense lawyer, Florida health law attorney, Florida health care lawyer

"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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