You’d think that for all that we pay, the governmental oversight to avoid “fraud, waste, and abuse” would be professional, upstanding, and streamlined. Think again.
I saw this 66 y/o patient after a fall from a ladder on 8/13/13. He broke both upper arms and underwent Open Reduction and Internal Fixation (ORIF) on both arms. He basically had plates and screws put in so that his bones fragments would grow back together. He was the friend of the father of another therapist that I know, and came to me highly recommended.
His treatment was quite extensive, as he was barely able to move after all the trauma from the fall and surgery, and had been left without any treatment at home for almost 6 weeks. He was ready and eager to start his therapy, and had to wait until his home health agency had released him from nursing care. That’s a Medicare rule, and the nursing home reported to me that they had completed the 17-page document called an OASIS form, the day before.
I initially received payment for each of his visits, but just after the end of his treatment, nearly 4 months later, Medicare notified me that they were taking money out of my current patients’ reimbursement to cover the expenses of this patient’s first 12 visits. They were taking that money back because they say that he was under the care of the home health agency for another month longer than he actually was.
Normally in this situation, I have to contact the home health agency and obtain payment from them for the therapy, assuming that the patient was legitimately under the agency’s care. In this case, however, he was obviously able to get back and forth to therapy, and they had already provided me the OASIS as proof that they had released him.
I had to go through two levels of appeals. Each and every visit requires the same form to be filled out – even if the reason for the appeal is identical – and each and every visit required the same evidence. I put together a packet of 381 pages, and scanned it, just in case they denied my appeals, despite having all of the evidence, in black and white, in front of them.
It’s a good thing that I did! They denied my appeals through two additional levels, and I applied to have an Administrative Law Judge review the case. I again sent the same 381 pages to them…and honestly, I forgot about it.
TODAY – MORE THAN 4 YEARS AFTER HIS THERAPY – I was notified that a hearing time has been scheduled for December 27, 2017, at 9:30am with a judge in Kansas City. Fortunately, I can do everything by phone. I had to do this one other time, about 10 years ago, and prevailed after a 30 minute conversation with the judge.