Compliance programs encourage employees to report potential problems and permit the provider / supplier to conduct an internal investigation and take corrective action. An effective compliance program should increase the likelihood of preventing, identifying, and correcting unlawful, abusive or wasteful conduct at an early stage, minimizing financial loss to the government, to taxpayers, and to the provider / supplier.

Compliance programs must encompass billings, payments, medical necessity, quality of care, governance, credentialing and other risk areas that a provider / supplier, with due diligence, identifies. Specifically, an effective compliance plan should include the following elements:

1. Designation of a compliance officer responsible for the day-to-day operation of the compliance program; this employee should report directly to the provider's / supplier's chief executive and periodically report to the governing body (Board of Directors or Board of Trustees) on the activities of the compliance program;

2. Training and education of all affected employees and persons associated with the provider / supplier, including executives and governing body members, on compliance issues, expectations, and the operation of the compliance program; such training should occur periodically and should be made a part of the orientation of new employees and governing body members;

3. A communication process, such as a hotline, accessible to all employees, outside vendors, governing body members, patients or other users of the provider's / supplier's services, for the reporting of compliance issues; the lines of communication should allow for anonymous and good faith reporting of potential compliance issues as they are identified;

4. Disciplinary policies and standards that are distributed to all employees, which are fairly, evenly, and firmly applied, and encourage good faith participation in the compliance process, including policies that articulate expectations for reporting compliance issues and assist in their resolution and outline sanctions for:
a. failing to report suspected problems;
b. engaging in non-compliant behavior;
c. encouraging, directing, facilitating or permitting either actively or passively non-compliant behavior.

5. A system for routine identification of compliance risk areas specific to the particular provider / supplier, for self-evaluation of such risks areas, including but not limited to internal audits and as appropriate, external audits, and for evaluation of potential or actual non-compliance as a result of such self-evaluations and audits, credentialing of providers / suppliers and persons associated with providers / suppliers, reporting, governance, and quality of care to patients.

6. A system for responding to compliance issues as they are raised; for investigating potential compliance problems; responding to compliance problems as identified in the course of self-evaluations, external evaluations and audits, correcting such problems promptly and thoroughly and implementing procedures, policies and systems as necessary to reduce the potential for recurrence; identifying and reporting compliance issues to federal and state officials, (Office of Inspector General, Medicaid Fraud Units, etc.); and refunding overpayments.

We suggest you review your own listing for accuracy!

The links below will take you to the recently revised and updated Physician Compare website operated by The Centers for Medicare & Medicaid Services (CMS).  This searchable database includes Physical Therapists, and is intended to provide information about your Medicare enrollment.  We strongly encourage you to review your own listing for accuracy.  You may be surprised at what you find.

To locate physical therapists listing, after clicking on link, select "Other Healthcare Professionals".

Link to Physician Compare website:

http://www.medicare.gov/find-a-doctor/provider-search.aspx?AspxAutoDetectCookieSupport=1

or

http://tinyurl.com/247u839

Question:

I have a Medicare billing question. If I was to bill Medicare:

1 unit of gait training

1 unit of therapeutic exercise

1 unit of Manual therapy

Am I saying that I was one-on-one with the patient for 39+ minutes, or that I spent the greater than 8 minutes doing each of the defined modalities with the patient?

Response:

Actually, you are saying both. In order to justify the billing of 3 timed CPT codes to Medicare, your total time spent in one-to-one treatment must be at least 38 minutes, and may last as long as 52. If the time devoted to one of these timed codes was less than 8 minutes, you could bill 2 units of one of the other 2 services for which you spent more time than the other.

Question:

When a person has Medicare as their secondary insurance (meaning they are over 65 and still employed), is there a requirement for a signed plan of care along with the rest of the Medicare guidelines if Medicare is only being billed for the co-insurance of the primary? Not sure I'm asking the question correctly!

Response:

Keep in mind that whether Medicare is the primary or secondary payer on a claim, the same coverage criteria apply. When you are submitting a claim where Medicare will be the secondary payer (MSP), you are not submitting a dollar amount, you are submitting a claim for services (or portions of those services) not covered by the primary. Therefore the same coverage criteria would apply to that claim, including the need for physician certification, in order for Medicare to cover that claim as the secondary payer.

Please also note that the fact that a patient is over 65 and still employed does not automatically mean that they have Medicare as their secondary insurance.