Upcoming OIG Scrutiny for Hospital-based Outpatient Rehabilitation Services

(PYA Alert dated March 9, 2007)

Is your facility affected by the January letter issued by the Office of Inspector General Program Integrity Unit (PI) of the Georgia Department of Community Health (DCH)? If so, the window of opportunity to assess and prepare is shrinking.

Federal regulations require the Division of Medical Assistance (DMA) within the DCH to perform comprehensive utilization review of services billed to and paid for by the Medicaid program. In accordance with Part I, Section 304 of the DMA Policies and Procedures manual, PI recently performed a review of hospital outpatient rehabilitation claims with dates of service between 07/01/2004 and 06/30/2006, identifying “what appears to be potential billing errors submitted for reimbursement by hospitals for outpatient rehabilitation services.”

As defined by Federal regulation, “rehabilitation” is not covered in the Hospital Program as stated in Part II, Section 903.5 of the DMA’s Policies and Procedures manual. Short-term services such as physical therapy, occupational therapy, and speech language pathology therapy are covered "immediately following and in treatment of acute illness, injury, or impairment when certain criteria are met."

Beginning in April 2007, PI will begin reviewing claims in question. The January OIG letter encourages providers to review their claims related to outpatient rehabilitation services. Part I, Policies and Procedures for Medicaid/PeachCare for Kids Manual Chapter 300, Section 304.10, Self Disclosure will apply to reviews performed that reveal overpayment consideration.

Has your organization evaluated its potential exposure related to outpatient rehabilitation claims? The PYA Clinical Compliance and Reimbursement team of professionals is prepared to help you evaluate the appropriateness of services provided in accordance with the above guidelines, analyzing potential overpayment impact, and providing guidance for disclosure of this information accordingly. Please contact Carol Eyer at (800) 270-9629 for additional details.

The information provided via PYA Alert, Tax Planning Alert, or Audit and Accounting Alert should not be construed as accounting, auditing, consulting, or legal advice on any specific facts or circumstances. The contents are intended for general information purposes only.  Please contact us at (800) 270-9629 to discuss your specific situation or to discuss any specific questions you may have.

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