There are many in our profession that believe that fraud in physical therapy is common-I am not one of them. Outpatient PT in medicare is roughly a 4 billion dollar industry that is hardly low hanging fruit for widespread fraud. The recent newsworthy items that mention PT fraud are really reporting malicious criminal acts-not someone unwittingly miscoding because they received two different instructions at 2 different courses and 20 different opinions on a bulletin board regarding group therapy. There are 300 agents from OIG out in full force and they aren’t exactly busting jaywalkers. While DME seems to be rooted in most if not all of them, any of the involved PT “operations” were various criminals billing under impostors including recruiting patients to take part in their false billings. The irony here is that CMS has pre-existing rules that require PT’s to have licenses-obviously they need to tighten that one up a little bit. One of our PT listserves actually wanted to know if any of these “PT’s” were part of APTA so that ethics charges can be started (not sure under old or our new ethics 2.0). I don’t think APTA has an impostor category at this time (hmm….non dues revenue?). Unfortunately, these cases are causing many within our profession to encourage further “protective” regulations including creating a national PT CSI of sorts in what appears to be a consistent theme of replacing licensing boards and state practice acts in favor of national rules and regulations-a very dangerous trend in my opinion. Can we please just acknowledge that these are real criminals and leave the 99% who don’t violate alone and removed from further regulation?
While I don’t think PT is a widespread fraud problem, it is apparent that within medicare there are a ton of schemes going on and the efforts of quadrupling the number of anti-fraud Strike Teams as well as the recently released PSA’s along with CMS data mining gross variabilities should shut the majority of these down. There is even some legislation pending that would overturn prohibition regarding release of what medicare pays on a individual provider basis in an effort to expose those that have high medicare payments.
On a non-related fraud front initiative (but unfortunately linked by those that believe in widespread PT fraud), on Feb 2 CMS categorized PTs as the only practitioner group posing as “moderate risk” rather than “limited risk” of fraud which means we will be subject to the moderate risk of screening for our re-validations studies every 5 years. Under the moderate level of risk, we will also be subject to unannounced site visits. The rational for this? The 2010 OIG study about the 20 highest medicare payments per beneficiary (also included Miami Dade County). Unfortunately, you can’t extract from medicare data whether the payments went to POPTS or PT’s in truly independent practices which is a major flaw considering OIG has already released their report that shows overutilization in POPTS! Instead of fixing the rules whose unintended consequences caused this mess to begin with they will be going after 99% of PT’s who are completely in compliance. That’s your government’s logic at work.
@physicaltherapy
larry@physicaltherapist.com
