As a therapist, you know how important it is to provide high-quality care to your patients and document your services accurately and timely. However, you also know how challenging it can be to keep up with the ever-changing rules and regulations of different payers, especially Medicare.
You may have experienced the stress and anxiety of facing an audit or a claim denial, or you may have heard horror stories from your colleagues. So how can you avoid these pitfalls and stay compliant and confident in your practice?
In this blog post, we will share some tips and best practices on how to stay compliant and pass audits as a therapist. We will cover the following topics:
- What are the common reasons for audits and denials?
- How can you ensure the medical necessity and appropriateness of your therapy services?
- How can you document your therapy services effectively and efficiently?
- How can you prepare for and respond to an audit or a denial?
What are the common reasons for audits and denials?
Audits and denials are becoming more frequent and aggressive in the therapy industry, as payers are looking for ways to reduce costs and prevent fraud and abuse. Therefore, we have grouped some of the common reasons for audits and denials as follows:
- Missing or incomplete documentation such as:
- Physician order or referral for therapy services,
- Documentation of the initial evaluation, progress reports, daily notes, or discharge summary.
- Records of the interventions, patient response, functional outcomes, or discharge recommendations,
- Documents of the frequency, duration, or intensity of therapy services.
- Absence of documentation of the medical necessity, clinical reasoning, or justification for therapy services.
- Insufficiency of documentation of compliance with payer-specific policies, rules, or guidelines.
To avoid these common reasons for audits and denials, you need to follow the standards of practice and ethical principles of your profession, as well as the specific requirements and expectations of each payer. Also, it is highly recommended to stay updated on the latest changes and updates in the therapy industry, such as the Physician Fee Schedule, the Home Health Final Rule, or the HHS’ Office for Civil Rights Settles Ransomware Cyber-Attack Investigation.
How can you ensure the medical necessity and appropriateness of your therapy services?
One of the key factors that determine the compliance and reimbursement of your therapy services is the medical necessity and appropriateness of your therapy services. Specifically, medical necessity and appropriateness mean that your therapy services are reasonable and necessary for the diagnosis or treatment of the patient’s condition as well as expected to result in improvement in the patient’s function, health, or quality of life.
Consequently, to ensure the medical necessity and appropriateness of your therapy services, you need to:
- Evaluate the patient’s condition, functional status, and goals; develop a plan of care with diagnosis, prognosis, goals, interventions, frequency, and duration and obtain the physician’s approval.
- Provide evidence-based and clinically sound interventions; monitor and document the patient’s progress and response and update or modify the plan of care as needed.
- Discharge the patient from therapy when the goals are met, the patient no longer needs or benefits from therapy, or the patient declines or discontinues therapy. At the same time, document the discharge summary with the patient’s status, outcomes, recommendations, and referrals.
How can you document your therapy services effectively and efficiently?
Documentation is a vital part of your therapy practice, as it serves as a legal record of your services, a communication tool with other providers and payers, and a quality assurance measure of your care. Nevertheless, documentation can also be time-consuming and tedious, especially if you have to deal with different formats, templates, and systems. How can you document your therapy services effectively and efficiently?
Here are some tips and best practices on how to document your therapy services effectively and efficiently:
- Use a standardized and consistent format and template for your documentation, such as the SOAP (Subjective, Objective, Assessment, Plan) or the DAP (Data, Assessment, Plan) format.
- Use electronic health records (EHR) or software that are compliant with the Health Insurance Portability and Accountability Act (HIPAA) such as ProbityCare.
- Use EHR or software features that can help you save time and improve your documentation quality. This includes drop-down menus, checklists, patient records management, clinical notes, and integrated documents and form builders.
How can you prepare for and respond to an audit or a denial?
Despite your best efforts to stay compliant and document your therapy services properly, you may still encounter an audit or a denial from a payer. Certainly, an audit or a denial can be stressful and frustrating, but it does not have to be a disaster. Instead, you can prepare for and respond to an audit or a denial by following these steps:
- Understand your rights and responsibilities as a provider, the types and reasons for audits and denials, the process and timeline, and the resources and support available.
- Be aware of your role and obligations, the audit and denial categories and criteria, the steps and deadlines, and the help and guidance you can get such as your compliance officer, legal counsel, professional association, or consultant.
- Keep a record and track of all your audits and denials, including the date, payer, patient, service, reason, outcome, and action taken.
- Provide the requested information or documentation, or the rationale or evidence for your appeal, in a clear, concise, and organized manner.
- Follow up and communicate with the payer until the audit or denial is resolved or closed.
- Learn from the audit or denial and implement any corrective actions or preventive measures to avoid or reduce future audits or denials.
Staying compliant and passing audits as a therapist can be challenging yet not impossible. Undoubtedly, if you follow this guide and our advice, you will be able to improve your compliance and documentation skills, reduce your audit and denial risks, and enhance your practice performance and patient outcomes. Above all, remember that compliance is not only a requirement but also a responsibility and a reflection of your professionalism and quality of care.
