Today's post comes from Tom Ambury, PT and compliance officer at PT Compliance Group. Thanks, Tom!

Greetings, WebPT Members! It is a pleasure to write for your blog, which aligns directly with our philosophy of helping our fellow therapists practice confidently, efficiently, and profitably. I also enjoyed meeting a number of you at Evolve 2012: Long Beach last month.

On July 30, "Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder announced the launch of a ground-breaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud." But this is really not news. The Federal Government has been sharing information, technology, and software for several years now. One example of this shared technology is the analytical software insurance companies use to identify statistical anomalies in claim submissions that might require further investigation.

Have you ever received a probe audit? You might have and didn’t even know it. A probe audit is like a recon mission; insurance companies collect intelligence to assess your documentation for weaknesses after they identified your clinic through a statistically aberrant pattern. Typically, the insurer only wants additional information to justify the medical necessity of a service you provided on one date. However, if you get several requests following one another by the same insurer, this is a probe audit.

So, what do I do?  

Don’t take these probes lightly. In fact, you should never take any request for documentation to justify your services lightly. If you are the subject of a probe audit, here’s how to handle it:

  1. Gather the requested information and review before sending
    • You will need:
      • The physician’s referral unless direct access
      • A signed Authorization for Treatment
      • A signed plan of care covering the date of service requested, if required
      • The initial evaluation or reevaluation covering the date of service
      • The visit note for the date of service
      • The flowsheet, if you use them, covering the date of service
      • If your signature is illegible, a signature attestation sheet
      • A list of abbreviations covering the visit
      • An addendum to the note explaining the medical necessity of the services provide
  2. Verify that your billing is accurate for any documentation you submit
  3. Ask for help. Call in another therapist, staff member, or a compliance expert if you are unsure that your documentation adequately justifies your services.

Do I have to complete an addendum to the documentation?

You only need to complete an addendum to the documentation if your insurer requests one. The insurer will most likely request a Letter of Justification of Medical Necessity, which, if requested, you are required to complete. If your documentation is flawless, you may not need an addendum. But for most of us multitasking in a busy clinic, an addendum might be a good idea.

How do I write an addendum?

  • Appropriately date the addendum for date completed and include verbiage like, “This is an addendum to the documentation for (Date of Service).”
  • Include in detail why your treatment was medically necessary:
    • Be specific
    • Be objective
    • Be measurable
    • Sign and date

Do I have to submit all this additional information?

You are only required to submit the information the insurer requests, but remember, you are being probed for documentation weakness. It’s important to respond with your best foot forward because, should they find a pattern of weakness in your documentation, a larger audit will follow. 

This is a lot to take in, and it’s by no means meant to scare you. Many therapists successful get through probe audits. If you ever need help, have questions, or just want to learn more, though, PT Compliance Group is here. Feel free to contact me at questions@ptcompliancegroup.com, or call 888-680-7688. You can also post questions and feedback in the comments section below. 

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