Summary: GAO reviewed the need to improve the processes Medicare intermediaries use to review claims for outpatient rehabilitation services.
GAO visited three Medicare claims processing contractors and reviewed the documentation supporting the claims. GAO noted that the documentation necessary to establish initial eligibility for rehabilitation services included: (1) a medical history providing the basis for rehabilitation; (2) an evaluation of the beneficiary's condition; and (3) a treatment plan listing the therapy provided and its expected goals. However, GAO found that: (1) 29 percent of the 346 cases reviewed lacked a patient treatment plan, or a medical history; (2) documents were incomplete or unspecific; (3) claims processing contractors paid $50.2 million in rehabilitation service charges over a 2-year period without sufficient documentation; and (4) in many of the cases and services that were insufficiently documented, beneficiaries were probably not eligible for coverage. GAO also found that the Health Care Financing Administration (HCFA) required that all claims receive a medical review to determine coverage and developed physical therapy guidelines to improve internal controls over outpatient rehabilitation payments.
