March 20, 2016

OIG Takes Aim at Therapy Services

By Marilyn Mines, Senior Manager, Advisory Services

OIG Takes Aim at Therapy Services

The Office of the Inspector General (OIG) publishes a work plan every year. As a result of the various in-depth studies OIG conducts, millions of dollars are recouped by the Medicare program, new regulations are developed, and greater oversight into the healthcare industry is established.

This year is no different. The OIG 2016 work plan includes a focus on therapy usage and misusage for post-acute care providers.

As publicized in January, one national therapy provider agreed to pay a $125 million settlement for allegations of overbilling therapy services. Four skilled nursing facilities that contracted with the therapy provider also paid $8.23 million in settlements. This brings home the importance of overseeing and ensuring that billing practices as they relate to therapy are compliant. Knowledge of Medicare eligibility and oversight of therapy is critical.

Although it may vary between provider types, documentation will either support or reject the medical necessity for skilled therapy services at the level being provided. Looking at patterns gives the OIG the needed ammunition to investigate therapy usage. Providers should be doing the same thing.

Here are some examples cited in the work plan:

  • Skilled nursing facilities (SNF) routinely bill for the highest level of therapy possible without significant change in beneficiary characteristics.
  • One in four home health agencies (HHA) were found to have questionable billing; almost $1 billion in improper Medicare payments/fraud was identified since 2010.
  • Independent physical therapists were found to provide services that were neither medically reasonable and necessary nor documented properly.

With those statistics, it is not hard to see why therapy is a focus for the OIG. But, what will the agency be looking for, and what can you do to avoid becoming one of the statistics?

No matter what provider type you are, the OIG will be delving into documentation to determine whether all federal requirements are met. This includes physician orders, a comprehensive assessment, and a comprehensive care plan developed by the interdisciplinary team, including the physician. In addition, questions such as: “does documentation support the amount of therapy being delivered?” “are the services of the skilled therapy medically reasonable and necessary?” “are the claims supported with documentation by the interdisciplinary team?” will be asked. 

To prevent being a statistic, ensure compliance by following these steps:

  • Ensure that staff knows the requirements.
  • Oversee documentation on all levels.
  • Review each resident’s goals, progress and participation in therapy services.

To accomplish this, develop strong quality assurance (QA) activities and quality assurance and performance improvement (QAPI) programs. Be sure they are fully and accurately completed. When possible, have an outside source review your documentation; a new set of eyes may see things differently.

To review the OIG work plan in its entirety, go to If you have any questions about the OIG work plan or would like to schedule education or a review of your clinical documentation with one of our clinical specialists, please contact your Marcum professional.

Information contained herein is accurate at the time of publication. We recommend that you consult with your Marcum advisor before implementing any action.

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