Posts: 228
Joined: May 21, 2002
From: Illinois
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I wanted to post this about an issue that our clinics are dealing with CMS. In the last 2 weeks we have received over 1500 envelopes stating an ADR on various patients to be returned within 30 days. My wife and I own 2 different clinics, one part A CORF and one part B Outpatient. Conveniently, CMS has gone the prepayment route of the ADR on both clinics at the same time. We have no prior billing issues, no previous audits, no verbal or written complaints and we actually had a group come in prior to these ADR's on-site to interview, take pictures, and copy charts, to which when asked, stated we were clean and everything was completely legit. We have received no letters from CMS stating they were going to audit us or put us on review. We have called and emailed CMS over the past 2 weeks multiple times with no return calls or emails to inform us of what is going on. I wanted to see if anyone had any information of what we were encountering and if there were any contacts anyone had that we could obtain. We have 60% of our patients on Medicare and between the two clinics, we can not make payroll for an extended period of time if we are not getting paid for the services we are performing. We have no problems sending CMS records to review as we feel that we do everything correctly, but we do feel that we should be informed of what is going on and why. The CORF part A has been in existance since the mid 90's and the part B outpatient clinic since 2005 with zero issues, I feel this is ridiculous that a payor can withhold reimbursement and jeopardize our business and the employees that work for us at this time. Anyone's input and advice is appreciated in this matter. Our next step is to obtain an attorney if we do not get any return calls from Medicare.
Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
Well... maybe the KX modifiers triggered the ADR. I hardly ever use KX modifiers and over 40% of my population are Medicare beneficiaries. In the instances I do use a KX modifier... the patient has multiple issues and my documentation immediately, readily describes the predicted issues and the anticipated necessity for extended services. I also always have one or two or three extra ICD-9 codes immediately included with the first and all claims submitted.
Posts: 392
Joined: September 15, 2004
From: Minnesota
Status: offline
Unfortunately, I see this as a way for CMS to justify their existance. They will audit practices and slowly force many to go out of business to they can prove they are being tough on fraud even if there isn't any. Another way to limit access to serices and build an outcry for single payor insurance.
Posts: 228
Joined: May 21, 2002
From: Illinois
Status: offline
The audit part is fine, but the fact that they have requested over 2000 patient visits to be sent along with not being paid on the claims in over a month now, with no initial letter, no return phone call, no return email to state the reason. There is no way to keep up payroll when everything is frozen like this. Unbelievable!
Posts: 228
Joined: May 21, 2002
From: Illinois
Status: offline
Plus, the KX modifier is in place and we use it when its needed. We have our documentation in place and thinks its complete bull#*#* that they would use that as a trigger to mass audit us.
I guess you have never heard the term ADR'd to death. This looks like a classic example. I am sorry you are on that end of it.CMS has made it very clear in many posts that they are looking to shut down a majority of CORFs. I am not surprised to hear this as well. for the fun of it, they put EVERY CORF in Palm Beach through Broward county on a minimum 50% review last quarter regardless of past events. The CORF business is becoming impossible to deal with. If you have a buyer in the area I'd suggest thinking hard about it.
but to answer some of your questions. When they came and audited, they knew what they were looking for. Practice utilization that was flagged was based on diagnoses codes, billing patterns, use of units per patient patterns, use of modifiers, and all around the data that you submit. Before you can doctor your charts, they come in and audit. They then DARE you to send in charts that have been changed, because if you do not think they are looking to see if you have manipulated any chart in any manner, then I hope you have a great lawyer.
People confuse good intentions with good practice. CMS does not care about good intentions. Benchmarking alerts CMS to your clinic, but again, ALL CORFS are feeling it big time with the increased scrutiny across the healthcare continuum from hospitals through home health and CORFs. ORFs are much safer business models right now, but even they have their issues. The glory days of PT were int he 80s with a bit of a resurgence last decade, but we are in for some VERY tough times. Good luck balancing patient desires, doctor's desires, your income desires, and CMS desires...CMS always wins.
Posts: 228
Joined: May 21, 2002
From: Illinois
Status: offline
bgalindpt: I reviewed your website and it seems that we may be able to utilize your services, but I am concerned about you stating that if I had a buyer, that I should consider that at this time.
Sorry again for what you are going through. I am very knowledgeable in this arena that you speak of but much more so in the realm of home health. My associate, Pauline Franko, ont he other hand, is a wizard on your end. Tell her I sent you! http://encompassmedicare.com/
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