Upcoming Seminars:
Documentation and Payment Issues in Outpatient Physical Therapy: Assuring Compliance & Avoiding Fraud and Abuse
October 16-17, 2008 — Great Wolf Lodge, Mason, Ohio
Payment & Policy Challenges in Outpatient Physical Therapy: Tools for Success in 2008 & Beyond!
October 24-25, 2008 — Raleigh-Durham, North Carolina
Audio Conference: The Advanced Beneficiary Notice: How to Legally Collect Cash from a Medicare Patient
September 9, 2008 — Partnership with APTA Chapters
Audio Conference: The OIG Self Disclosure Protocol: Should You Notify the Government if you suspect a Problem, and How to Minimize Your Risk of an Audit
October 7, 2008 — Partnership with APTA Chapters
Audio Conference (2 Part): Part 1: Establishing a Fee Schedule for your Facility: Using the Medicare Resource Based Relative Value Scale (RBRVS) as a Guide
November 11, 2008 — Partnership with APTA Chapters
Audio Conference (2 Part): Part 2: Determining Your Cost per Visit: Understanding Basic Financial Statements and Answering the Question: Should I Sign This Payer Contract?
November 18, 2008 — Partnership with APTA Chapters
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Expertise & Consulting Services — Overview
The Rehabilitation Consulting & Resource Institute (RCRI) offers expertise and consulting in the following areas:

Practice Management
The substantial time and money invested by a physical therapist to learn technical skills and patient management may be meaningless unless he or she also learns how to manage and control a business. Although in some cases practice management may only occupy a small portion of your daily activities, the efficient and effective management of these responsibilities will make the difference between success and failure in practice. Although successful practice management is so critical, most physical therapists and health care providers do not focus nearly as much attention on learning or staying current with these skills as they do with clinical management techniques. Whether in a small private practice, large multi-site facility, hospital physical therapy department, or any outpatient physical therapy provider, effective practice management is critical to overall practice success. In the process of managing the operations of any practice, it is important to maintain a “50,000 ft view”, that provides a more global perspective on daily operations while at the same time ensuring that the individual processes responsible for business success are managed efficiently and effectively. Providing an independent and objective analysis of operations can assist even the best manager in assuring that their operations are consistent with community and professional standards as well as applicable rules and regulations. RCRI can assist in assessing your facility’s areas of potential risk and need for improvement with regard to general administrative and clinical management processes, policies and procedures, data collection and management, critical practice statistics, assessment of efficiencies, productivity, staffing models and ratios, use of support personnel, patient outcomes, protocol development, budget development, contract negotiations, compensation models, selling/buying practices, exit strategies, and much more. For a more detailed list of specific areas of expertise and consultation in the area of practice management, click here.

Reimbursement Strategies

The reimbursement landscape is constantly changing, and managing a rehabilitation practice or department at any level is complicated. Navigating through the myriad of rules, policies, guidelines, and do’s & don’ts of outpatient payment systems is extremely time consuming but necessary, and can be treacherous to achieving a healthy bottom line if not done correctly. There is an inherent relationship between the ability to get paid for what you do and the ability to provide quality clinical services that lead to optimal functional outcomes. Practice owners, facility or department managers, or hospital administrators can be empowered by an awareness and understanding of reimbursement and fiscal management issues specific to physical therapy and rehabilitation, which are unique from most other health specialties. This understanding of current or potential payment challenges and an assessment of the reimbursement environment specific to your practice, along with development of a plan to address necessary issues, can prevent many problems and help respond proactively to others. RCRI has the nationally recognized expertise through years of involvement of its’ principals in the development, implementation, and application of CPT codes, relative values and fee schedules, and related payment policy. This expertise will provide the confidence you need when responding to a reimbursement landscape that will impact your financial viability. RCRI can assist is assessing your current reimbursement issues and potential risk through analysis of current billing and collection procedures, statistical analysis of practice costs, charges, and payment history, analysis of case mix, assistance with preventing and appealing claims denials, assessment of current facility/practice reimbursement challenges with development of a recommendation plan for implementation, and assessment of missed revenue opportunities. For a more detailed list of specific areas of expertise and consultation in the areas of reimbursement strategies, click here.

Documentation, Coding, and Billing Compliance

The pace of changing regulations and requirements is so rapid that even the best prepared private practitioner and well-staffed corporation or hospital department are hard pressed to establish and maintain the training, policies, and standards of documentation of and coding for clinical services. Despite the importance of adequate documentation and appropriate coding and billing for physical therapy services, most physical therapists did not receive adequate, if any, training to ensure that they comply with the ever-evolving requirements in these areas. Given recent studies from the Office of the Inspector General (OIG) and current government initiatives such as the Comprehensive Error Rate Testing (CERT) program and the Recovery Audit Contractor (RAC) initiative, Medicare and others have renewed and accelerated their efforts to reduce and recover overpayments for services. In addition, the issue of medical necessity has become the primary reason for payer and agency audits in an environment that requires documentation to justify clinically appropriate services. Although in the past the lack of adequate documentation of medical necessity would have resulted in the provider having to repay any monies collected from the insurer, today’s environment has made billing for services that are not adequately justified in the medical record an issue of potential fraud and abuse, carrying a much greater risk to the provider. The principals of RCRI are nationally recognized experts in the areas of CPT coding, the Resource Based Relative Value Scale (RBRVS) and its application to fee schedule development, physical therapy peer and utilization review, and documentation education and training. RCRI can assist in assessing your compliance with these issues as well as your potential risk through assessment of your current documentation content, methodology, and compliance, CPT coding and billing practices, assessment of your facility charge master and charge capture procedures, identification of potential audit review flags, assistance with minimizing your risk of Medicare audit and recovery, and assistance with payer relations in regards to contract negotiations and payment policy disputes. For a more detailed list of specific areas of expertise and consultation in the areas of documentation, coding and billing, click here.

Fraud & Abuse Issues

All too often physical therapists do not consider themselves at risk for penalties related to fraud and abuse, simply because they do not understand how their typical day to day behaviors may be viewed as fraudulent or abusive by today’s federal standards. Fraud involves intentional deception or misrepresentation intended to result in an unauthorized benefit, such as billing for services that are not rendered. Services that are billed but not documented are generally considered as not being rendered and therefore could constitute fraud. Abuse involves charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced. Abuse may be similar to fraud except that it is not possible to establish that the abusive acts were done with intent to deceive the insurer. For a variety of historical reasons, physical therapy and rehabilitation providers are at the center of many investigations and policy decisions regarding fraudulent and abusive practices. Most therapists and hospital administrators do not realize that the Health Insurance Portability and Accountability Act of 1996 included significant fraud and abuse provisions contained in the legislation. The Act makes "knowingly and willfully" defrauding any health care benefit program a federal crime. In fact, there are over 15 federal fraud laws that could be applied to health care providers, including physical therapists. Specifically, compliance issues that put physical therapy providers at risk include billing for services not documented, unbundling, upcoding, lack of documentation to support billing of timed codes, failure to properly use modifiers and waivers, submitting claims for medically unnecessary services, and care that is below the Standards of Care. RCRI can assist in assessing your risk associated with potential fraud and abuse practices through assessment of risk for key fraud and abuse areas in physical therapy and other rehabilitation services, assessment of risk related to the Federal False Claims Act, identification of potential Stark violations, staff education and training in justification of medical necessity in documentation, education and training to minimize the risk of potentially fraudulent or abusive practices, minimize your risk of federal or state audit and assist with developing a plan to minimize or eliminate risky practices. For a more detailed list of specific areas of expertise and consultation in the areas of fraud and abuse, click here.

Medicare Compliance

Medicare is the largest healthcare payer in the country, and the number of rules and regulations that govern the program is overwhelming. As a physical therapist or provider of physical therapy services, the amount of time and effort required to keep current with the ever-changing environment is equally daunting. Physical therapy services represent one of the fastest growing categories of costs under the Medicare program, and as a result, the federal government has been increasing its efforts to eliminate over utilization and potential fraud and abuse among providers who bill for physical therapy services. Although the Medicare Therapy Cap Exceptions Process has allowed beneficiaries who need these services to receive them when medically necessary, this process can be very confusing. What is more alarming is that accessing the Exceptions Process in the absence of documentation that justifies medical necessity will place the physical therapist and/or facility at risk for potentially committing fraud and abuse. However, Medicare compliance is not limited to the Therapy Cap and Exceptions Process. It is critical to ensure you are compliant with Medicare’s definition of skilled care, as well as the coverage limitations and “reasonable and necessary” requirements identified in the multiple Medicare regulations and manuals. Specifically, Medicare compliance issues that put physical therapy providers at risk include the requirement of qualified professionals to provide therapy services, appropriate use of waivers and modifiers, supervision of assistive personnel, the Correct Coding Initiative (CCI) program, certification requirements, adherence to minimal documentation requirements, and adherence to Local Carrier Determinations (LCDs). RCRI can assist in assessing your risk associated with Medicare Compliance issues through assessment of your practice/facility compliance with the rules related to outpatient therapy services, assessment of compliance with “skilled care” and the Medicare Benefit Policy Manual, assessment of appropriate use of modifiers and waivers, assistance with understanding and appropriate utilization of the Therapy Cap Exceptions Process, assessment of compliance with minimal documentation requirements, Assessment of potential Stark violations, and assessment of compliance with your local coverage determination for your region. For a more detailed list of specific areas of expertise and consultation in the areas of Medicare Compliance, click here.