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Department of Health and Human Services

Office of Inspector General -- AUDIT

"Results of the Medical Reviews Performed on Selected Medicare Claims for Physical and Occupational Therapy Services Provided During Calendar Year 2002 in the State of Texas," (A-06-03-00085)

March 29, 2005

Complete Text of Report is available in PDF format (338 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


This report provides the results of our review of a non-statistical sample of 100 physical and occupational therapy claims submitted for payment by 10 therapists in Texas during calendar year 2002.  Our audit objective was to determine if the therapy services billed on these claims met Medicare reimbursement requirements.  Medical reviewers from TriCenturion, a Program Safeguard Contractor for the Centers for Medicare and Medicaid Services, determined that 2,709, over 99 percent, of the 2,734 services contained in the 100 sampled claims did not meet one or more of Medicare’s reimbursement requirements because the therapists did not maintain adequate documentation, the therapists did not meet the plan of care requirements or someone other than the billing therapists performed the services.  Based on the results of the medical review, the therapists received $57,253 for services that should not have been billed to Medicare.  We recommended that TrailBlazer Health Enterprises, LLC (TrailBlazer), a Medicare Part B carrier, recover these improper payments.  TrailBlazer agreed with our findings and recommendations.