Physical therapy is the treatment of functional limitations to prevent the onset or delay the progression of physical impairments after illness or injury. Medicare pays for physical therapy in at least two settings:
I. Through the Part A hospital insurance benefit, Medicare pays for physical therapy as a component of skilled nursing care, either in the intensive care setting or in a post-hospital skilled nursing facility. To qualify for reimbursement, such therapy must meet the criteria for skilled nursing care under 42 USC – 1495i. To qualify, a patient eligible for Medicare must show a qualifying hospital stay of three or more days within the 30 days prior to entering the skilled nursing facility. A physician must order procedures for the patient that are appropriate to be performed only in a Skilled Nursing Facility (SNF), such as rehabilitation therapy, and must certify that the patient’s condition is such that they can practically only be cared for in a SNF . When certifying, the physician must determine that the patient’s condition should improve or achieve stability in response to curative care. SNF medical staff must write a plan of care for each skilled nursing patient based on the individual’s needs and circumstances. Once those requirements are met, Medicare will pay for 100 days of skilled nursing care per patient per period of illness, although a 20% patient copayment is required after the first 20 days. Once a patient qualifies, Medicare pays for all skilled nursing facility expenses, including the patient’s custodial care and room and board (custodial care is not covered by Medicare). Typically, a SNF receives approximately $ 650 per day from Medicare for a qualifying skilled nursing patient.
II. Additionally, through Part B supplemental insurance, Medicare reimburses for physical therapy in limited circumstances. To qualify for reimbursement, outpatient physical therapy services must: (1) be reasonable and medically necessary; (2) be released to a Medicare beneficiary under the care of a physician; (3) be provided under a plan of care periodically recertified by a physician; and (4) be supplied by or under the direct supervision of qualified personnel.
Medicare regulations require that physical therapy services be performed (1) by a state-licensed physical therapist or (2) by or “in connection with” the services of a physician or other medical professional licensed to perform such services under the state law pursuant to 42 CFR § 410.60. Under the “incident to” rule, a physician may bill for physical therapy services performed by non-physician personnel as long as such services (a) are commonly provided in a physician’s office and are an integral part of the services covered by a physician. doctor; (b) included in a treatment plan designed by the physician and in which the physician actively participates; and (c) provided under the direct supervision of the physician.
To bill directly, rather than through a physician, a physical therapist must have a state license. Physiotherapy services performed in connection with a physician’s services may be performed by personnel without a license; however, such personnel must meet all qualifications of a licensed physical therapist, including graduation from an approved physical therapy education program.
Regardless of who performs physical therapy services that will be billed to Medicare or Medicaid, such services must be provided in accordance with a sufficient plan of care established by a physician or licensed physical therapist performing the services. Under 42 CFR § 410.60, the plan must “prescribe[] the type, amount, frequency, and duration of physical therapy … to be provided to the individual, and indicate[] the diagnosis and the planned objectives “.
Therapy Abuse Medicare Benefit
Unfortunately, physical therapy fraud is rampant. In 1994, the Office of the Inspector General, Department of Health and Human Services released a report that found that 78% of physical therapy billed by physicians did not constitute true physical therapy. In 2006, the OIG released another report, stating that a staggering 91% of physicians’ physical therapy bills submitted in the first half of 2002 were deficient in at least one respect. Through intense research and investigation, we have identified and discovered the following types of physical therapy fraud:
(a) billing for therapy services performed by unqualified personnel;
(b) billing for therapy services that were never performed or only partially performed;
(c) bill for therapy services when, in fact, the service provided was not qualified or amounted to maintenance therapy, or both, and did not constitute physical therapy;
(d) billing for therapy services performed under a poor plan of care;
(e) billing under individual therapy codes for group therapy services.
Under federal and some state false claims laws, whistleblowers can file suit against fraudulent therapy and skilled nursing companies under seal and can share up to 25% (and in some circumstances 30%) of the award. However, reporting corporate fraud takes courage, and the law rewards that courage with certain protections. The False Claims Act provides that a complainant’s case be filed under seal and that the identity of the complainant be protected during the course of the government investigation. In addition, federal law protects against retaliation by requiring the reinstatement of wrongfully terminated employees with the same level of seniority, and the award of double back pay, interest, and attorneys’ fees. More than $ 22 billion of taxpayer funds have been recovered under the False Claims Act over the past two decades. Despite all the efforts and success of the government and private attorneys who control the Medicare program under the False Claims Act, the only way that fraud can be effectively fought is for knowledgeable people to ( industry experts, administrators, nurses and therapists) come forward and say enough is enough.