Review of Florida Physical Therapist's Medicare Claims for Therapy Services Provided During 2003

EXECUTIVE SUMMARY:

The objective of this review was to determine whether therapy services provided by a Florida physical therapist during calendar year 2003 met Medicare reimbursement requirements.  Of the 100 sampled claims, 96 did not meet Medicare's reimbursement requirements.  In total, 494 of the 702 physical therapy services contained in the 100 sampled claims did not meet one or more of the Medicare reimbursement requirements because (1) the physical therapist inappropriately used his provider identification number to bill for services performed or supervised by someone else, (2) the documentation for some therapy services did not meet Medicare requirements, (3) some therapy services were miscoded, and (4) a plan of care did not meet Medicare requirements.  The physical therapist did not have a thorough understanding of Medicare requirements and did not have effective policies and procedures in place to ensure that he billed Medicare only for services that met Medicare reimbursement requirements.  As a result, the physical therapist improperly billed Medicare and received $10,781 for the 494 services. We recommend that the physical therapist (1) refund to the Medicare program $411,781 in unallowable payments for therapy services provided in 2003 and (2) develop quality control procedures to ensure that therapy services are provided and documented in accordance with Medicare reimbursement requirements.  The physical therapist stated that he will address any issues concerning the audit through the Medicare appeals process.