April 2018

OIG report on outpatient physical therapy claims may be flawed: CMA, APTA

The US Centers for Medicare and Medicaid Services (CMS) and American Physical Therapy Association (APTA) are challenging a recent Officer of the Inspector General (OIG) report, pointing out how flawed processes and misinterpretations are coloring the findings. The OIG report identified 184 noncompliant claims, from a sample of 300 Medicaid outpatient claims made in 2013 for physical therapy, totaling $12,741, The report extrapolates that these patterns may show that Medicare paid out as much as $367 million in physical therapy claims that didn’t meet CMS standards. CMS argues that a more thorough analysis would be required to back up the OIG estimate. Further, CMS stated that the OIG misinterpreted CMS coverage policies related to the concept of “significant improvement.”

“Most of the findings identified by OIG are likely attributable to documentation errors as opposed to fraudulent activity,” according to the CMS.

The APTA supports the CMS position that the OIG’s analysis included a flawed interpretation of the “improvement standard,” adding that the OIG study panel did not include any physical therapist on the team that reviewed claims and documentation. “Given the potential for misinterpretation of Medicare policy on outpatient therapy services and the role of physical therapists, APTA supports the inclusion of a physical therapist as part of the team conducting such reviews.”

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- Emily Delzell

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