You're under medical review: Do you know what to do?

Rehab Regs, September 8, 2003

You're under medical review: Do you know what to do?
A guide to the process and tips for success

As a therapist who practices in an outpatient rehab setting, you're busy treating patients on a Monday afternoon when a biller from your business office walks in and drops off a letter for you.

When you finally find five minutes to read the letter, it contains unwelcome news: Your fiscal intermediary (FI) or carrier is placing some of your claims for services furnished to Medicare recipients under medical review.

Worse yet, it's the first time that any of your claims have come under medical review. You have limited knowledge of the process and several questions-the trigger for the medical review, the type of information and criteria the payer will look for when scrutinizing the claim, and the looming possibility that the payer may demand more claims and place the practice under a larger, more focused medical review.

The experience outlined here is not unique. Many outpatient rehab providers will find themselves placed under medical review at one time or another. In order to successfully meet the challenge of a medical review, providers should become familiar with the medical review process and take a few proactive steps that will help if they are ever placed under review.

What can trigger a review?
As a general rule of thumb, FIs or carriers may randomly decide to select claims for review or the payer may suspect after a review of claims that a pattern indicates larger problems, industry experts say.

"Many of the carriers will look for items [in claims] that fall outside of the norm," says David Perry, PT, MS, director of Gentiva Orthopedic Services in Southfield, MI, and owner of Perry Therapeutics, a consulting company in Grosse Pointe Woods, MI.

For example, FIs or carriers may set regional norms when it comes to the type and frequency of certain codes. An outpatient rehab provider may submit claims that fall outside these norms-and trigger a review.

"An example is a facility that may always bill [CPT code] 97110-therapeutic exercise-and never 97140, which is manual therapy," Perry says. "This may place that facility outside of the norm for the clinics in that area. That's usually one trigger that [payers] will look for-billing patterns that fall outside the norm."

Providers should remember that although the codes contained within claims may fall outside their payer's norms and trigger a review, this does not necessarily indicate that they're billing incorrectly. A particular outpatient facility or clinic may concentrate on delivering a specific type or set of services, resulting in the coding discrepancy, Perry says.

CMS also instructs carriers to implement common working file (CWF) edits on a periodic basis, says Mary Foto, OT, CCM, FAOTA, chief executive officer of the Foto Group, Inc., rehabilitation consultants in Montecito, CA.

Depending on the edits, claims submitted by outpatient rehab providers can trigger a review.

"Edits change all the time," Foto says. "For example, you could come under review based on the fact that you're a provider who falls into the top 10% of billed units, or the top 10% of billed charges, depending on the edit. You might then receive a request for medical review on a random sample of claims. That is merely the [FI or carrier] scanning the terrain."

If a payer selects a rehab provider for random review, it may submit the requested documentation and-provided that everything is in order-sail through the review. In other cases, however, the FI or carrier may discover a potential pattern of errors within the claims based on the random review.

"These may be either technical problems or medical necessity problems," Foto says. "Then there will be an increase in the percentage of the sample claims they study. All of a sudden, providers are going to start getting more requests [for additional documentation] and there is an increased possibility of denials."

That's when the scope of the medical review shifts -they are now under focused medical review, and their FIs or carriers may request copies of all of a provider's claims that fall into a certain type.

"If there is a large number of claims [that exceeds a certain percentage] that have problems, then [providers] can go on a focused medical review," Perry says. "This is a time-consuming process. They will have to copy everything in the records and submit it with their claims. It slows down the billing process."
What are the FIs and carriers searching for when they conduct claim reviews? Their search is twofold: they want to ascertain that providers meet the technical requirements of the program and deliver services that are considered medically necessary.

"They'll look at claims from a technical point of
view--i.e., that your physician prescription is correct, or your documentation of services delivered matches with those services included in the treatment plan," Foto says. "But once those technical items are considered, then you have the whole issue of medical necessity. If it meets the test of medical necessity as well, then you should get paid."

What should you do when under medical review?
Outpatient rehab providers who do receive notices from their FIs or carriers that they're being placed on focused medical review should keep in mind the following items, Perry and Foto say:

Read the request for information carefully and submit it in a timely manner. An outpatient rehab practice's business office will receive a letter from the FI or carrier that says the facility is being placed under medical review. Pay attention to the details, Perry says.

"They need to read that letter very carefully," he says. "It will outline very specifically the information that [the FI or carrier] wants. If in doubt, call and clarify what types of documentation you should submit."

The other thing to remember when it comes to medical reviews is to abide by the time frames. FIs and carriers will give you very specific and limited time frames.

In some cases-whether it's due to volume or other issues-FIs or carriers may misplace some of the information that providers send in response to the review request.

Outpatient rehab providers can afford themselves a measure of protection by sending all requested documentation via certified mail, Perry says. While it may create a small expense for the facility, it gives the provider proof that it did send the information requested to the payer.

Focus on documentation. All outpatient rehab providers should act in a proactive manner and carefully document services, as this will head off issues should they ever come under medical review.

"This all goes back to the question of whether you have good documentation of services and whether you're following the rules," Perry says.

"If so, then being placed under medical review becomes an annoyance, and you should not only be able to survive the process, but come out a winner. If you've got poor documentation, it will shoot you in the foot every time."

Focus on communication between departments. Outpatient rehab practices should set up a system to alert the necessary departments once a medical review request comes in the door, Foto says.

In some practices, the business office, which first receives the request, may act alone or involve only the medical records department as it gathers the requested documentation to send to the payer. However, everyone in the practice needs to be in the loop.

"Sometimes, it's not until a high percentage of provider claims are under review that [providers fully] notice," Foto says. "Obviously from a provider standpoint you need to have a good relationship between the business office and medical records, and when the additional record request comes in, the therapy department is notified. Its antenna should go up, and if they're starting to receive more [documentation] requests, their antenna should go way up."

Although this sounds simple, many outpatient rehab providers fail to implement such a notification process-and often, therapists discover the problem with service delivery and documentation only after an FI or carrier places it on a focused medical review and audits a high percentage of claims.

The keys to documentation and medical review

You're an outpatient rehab provider who just received notice from your fiscal intermediary (FI) or carrier that you're under a medical review. You want to submit documentation that shows the services that you provided on the claims in question were medically necessary. How should you go about doing this?

When it comes to therapies and medical necessity, outpatient rehab providers should focus on showing the delivery of services from the start of care-even if the patient has been treated for some time, says Mary Foto, OT, CCM, FAOTA, chief executive officer of the Foto Group Inc., rehabilitation consultants in Camarillo, CA.

"While there are some differentiations within each request, they'll likely ask for documentation from the start of care," she says. "It's sequential. You can't look at it as a snapshot for one particular bill period."

The Medicare guidelines related to medical necessity outline specific standards for reasonable and necessary, Foto says. Consequently, the documentation must show that this patient really has the potential to respond to the treatment that the therapist is offering. Therefore, FIs and carriers will read the record from the start of care in order to determine whether the services-and not just for the period that the claim covers-are medically necessary.

Therefore, outpatient rehab providers should remember to include the following:

 The history and physical performed by the physician so that the FI or carrier may validate the patient's diagnosis
 The physician's order for therapy and recertifications, when applicable
 Documentation of therapy services delivered, including those from the start of care

CMS issues guidelines for medical reviews

If you're an outpatient rehab provider looking for further clarification on the medical review process, check out CMS Program Memorandum (PM) AB-00-72, released in August 2000.

In this PM, CMS released guidance for fiscal intermediaries (FIs) and carriers when it came to implementing medical review. Although much of the material is outlined in the appropriate program manuals, some highlights from the PM include the following:

1. Data analysis should drive medical review. FIs and carriers should analyze data as "an essential first step" to determine whether there's a pattern of claim submission and payment that may indicate potential problems.

2. Probe reviews. Before undertaking a large-scale analysis of provider claims, FIs and carriers should perform the "interim step" of a probe review, in which they select a small sample of claims for review. CMS established a general rule of thumb that says such samples should not exceed 20-40 claims in order to ensure whether the problem exists for a specific provider, or 100 claims for a larger number of providers, which may occur should the FI or carrier suspect there is a systemic billing problem.

3. Time frames exist on additional documentation requests. FIs and carriers should set this limit for any additional documentation they need in order to complete the review. If the documentation is not received within 45 days, the FI or carrier should make its determination based upon the documentation it has.

Quick tip: Put a tracking system in place

Has your rehab facility had claims denied because its fiscal intermediary (FI) says it has not received the medical review documentation you sent?

David Ross, CPA, director of reimbursement and internal auditing at the Kessler Rehabilitation Corporation in West Orange, NJ, says one of the issues his company has been dealing with is the failure of FIs to track the medical review documentation that is sent to them. "We received quite a few denials because the FI claims not to have received the documents when we have sent them," he says. When his company did a check, in about two-thirds of those cases, personnel mailed the needed documents. "That's frustrating," he says.

Because of this problem, it's important that facilities use some kind of tracking system to prove that they sent the documents and the FI received them, he says. Facilities should use a delivery system that tracks mailings, for instance, where someone must provide a signature that he or she received the delivery. It's also a good idea to put a patient's account number on the return receipt-requested card so the facility knows specifically what claim and documentation was mailed.

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