After you have spent $3,000 for physical therapy and speech therapy combined or $3,000 for occupational therapy, Medicare may audit your case to make sure continued sessions are medically necessary. Your therapist needs to explain why additional sessions are indicated and clearly document this in your medical record.
Full Answer
What is occupational therapy (OT) on Medicare?
Occupational therapy (OT) is a form of rehabilitative care that can help people regain strength, dexterity, and skill after surgery, illness, or injury. For people on Medicare, OT can be used to enhance or restore the fine and basic motor skills that make daily living tasks easier.
What is the CPT code for occupational therapy evaluation?
CPT Code. Description. 97165. An occupational therapy evaluation of low complexity requires these components: An occupational profile and medical and therapy history, which includes a brief history comprising a review of medical and/or therapy records relating to the presenting problem.
How much does Medicare pay for outpatient therapy?
Under Part B, Medicare will likely pay for 80 percent of the Medicare-approved amount for outpatient therapy. You are responsible for 20 percent of that cost as well as your Part B deductible which is $185.00 as of 2019.
Does helps pay for outpatient occupational therapy?
helps pay for medically necessary outpatient occupational therapy if your doctor or other health care provider certifies you need it. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid.
What do Medicare auditors look for?
According to the CMS website, CERT audits are conducted annually using “a statistically valid random sample of claims.” Auditors review the selected claims to determine whether they “were paid properly under Medicare coverage, coding, and billing rules.”
What triggers a Medicare audit?
What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.
What will the Medicare auditor check during the audit?
Medicaid and Medicare auditors are briefed to scrutinize healthcare professionals on procedures for prescribing pain medications and narcotics to beneficiaries. So, brush up on California's opioid regulations and insurance coverage rules for pain management on Medicare, as well as others.
What happens when Medicare audits?
After the provider submits the requested universes, auditors will assess the data provided and determine whether any other information is necessary. This phase will last six weeks. Field work by auditors - Auditors will conduct webinar audits and evaluate sample data from the submitted universes.
What happens if you fail a Medicare audit?
If you fail to comply with the request, you will not receive reimbursement for the submitted claims. Even if you comply but the documentation doesn't support what you billed for, you won't get reimbursement.
Are Medicare audits random?
For example, the Medicare program is required to make random audits of 10% of all Medicare providers on an ongoing basis. An audit or investigation can result from complaints by patients about the quality or appropriateness of the care they received, or how they were billed for their care.
How long does a Medicare audit take?
After the provider is “targeted” using data analytics, the MAC performs up to three rounds of "probe and Educate." Each round takes about 90 days—30 days for MAC to review the claims, a few days to schedule an educational call, 45 days for providers to show improvement—and is centered around a one-on-one educational ...
How far back does a Medicare audit go?
Medicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed.
How far back can Medicare go to recoup payments?
3 calendar yearsFor Medicare overpayments, the federal government and its carriers and intermediaries have 3 calendar years from the date of issuance of payment to recoup overpayment. This statute of limitations begins to run from the date the reimbursement payment was made, not the date the service was actually performed.
What does an audit look for?
An audit examines your business's financial records to verify they are accurate. This is done through a systematic review of your transactions. Audits look at things like your financial statements and accounting books for small business.
What triggers a RAC audit?
RAC audits are not one-time or intermittent reviews and can be triggered by anything from an innocent documentation error to outright fraud. They are part of a systematic and concurrent operating process that ensures compliance with Medicare's clinical payment criteria, documentation and billing requirements.
What are CMS audits?
These program audits measure a Sponsoring organization's compliance with the terms of its contract with CMS, in particular, the requirements associated with access to medical services, drugs, and other enrollee protections required by Medicare.