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The objective of our review was to determine whether payments to ABC Total Rehabilitation Care, Inc. (ABC) for physical therapy, speech-language pathology, and occupational therapy services were provided in accordance with Medicare reimbursement requirements. With the assistance of a program safeguard contractor, we reviewed selected claims submitted by ABC and paid by Medicare. ABC received $27,602 in unallowable payments for therapy services associated with 88 sampled claims, which contained 1,570 services that did not meet Medicare reimbursement requirements. Based on the results of our random sample, we estimate that ABC received $226,673 in payments for unallowable services. These services did not meet Medicare reimbursement requirements because: (1) services billed were rendered outside the approved plan of care, (2) services billed did not meet Medicare duration of therapy requirements, (3) documentation did not meet Medicare standards to support that services were actually provided, and (4) services billed were not medically necessary.
We recommended that ABC: (1) refund to the Medicare program the $226,673 in payments for services billed from January 1, 2002, through December 31, 2002, that did not meet Medicare reimbursement requirements; (2) follow its written policies and procedures to ensure plans of care contain all required elements and that services are adequately documented; (3) update its written policies and procedures to address Medicare requirements for duration of therapy services, identification of services rendered outside of the approved plan of care, and documentation of the patient’s need for neuromuscular re-education; and (4) identify and submit adjusted claims for services provided subsequent to our audit period that did not meet Medicare reimbursement requirements. ABC management chose not to provide comments on our draft report findings and recommendations.