Review of World Gym Physical Therapy Center Outpatient Rehabilitation Facility Program

EXECUTIVE SUMMARY:

This final report provides you with the results of our review of World Gym Physical Therapy Center's (the Provider) Outpatient Rehabilitation Facility Program.

The objective of our review was to determine whether the Outpatient Rehabilitation services claimed by the provider during the Fiscal Year (FY) ended December 31, 1997 met the Medicare eligibility and reimbursement criteria.

We reviewed a statistical sample of 100 claims containing 2,075 units of service that were provided to 82 Medicare beneficiaries during FY 1997. Ninety-two claims representing 1,966 units of service did not meet the Medicare eligibility and reimbursement requirements:

• 55 claims containing 1,270 units of service were considered unallowable by medical review personnel because the services were provided without proper certification or order.
• 28 claims containing 597 units of service were disallowed by medical review personnel because the supporting documentation did not support the need or medical necessity of the services.
• 9 claims containing 99 units of service were considered unallowable by medical review personnel because they were either not documented or the supporting documentation was considered inadequate.

The Provider claimed gross charges totaling $873,763. Based on the results of our review, we estimate that $518,479 did not meet the Medicare eligibility and reimbursement requirements and, therefore, constituted an overpayment.

This overpayment occurred because the provider did not conduct monitoring activities to ensure that the beneficiaries admitted to the program met the eligibility criteria. In addition, the provider did not implement controls to ensure that the services were properly authorized by a physician and documented in the beneficiaries' folders.

We are recommending the Health Care Financing Administration (HCFA) direct the FI to:

• recover the $518,479 in overpayments for 1997; and
• ensure that the provider establishes controls to ensure that beneficiaries are eligible for Outpatient Rehabilitation services, and that the services are properly authorized and documented.