Funding Focus

Arduous Audits and Keeping your Money!

• By Kelly Riley
• Nov 01, 2009

Inthis industry it has always been tough to understand all of the policies, protocols, rules and regulations to follow just to get paid. Now there is an entire litany of other policies, protocols, rules and regulations to meet in order to deliver the products and services to the end user.

The responsibilities for the reimbursement department are getting more complex, and now more than ever involve not only getting paid but keeping the money. While the auditing efforts of the Comprehensive Error Rate (CERT) contractors as well as the Program Safeguard Contractors (PSCs) are not new for 2009, the implementation of the Recovery Audit Contractors (RACs) as well as Zone Program Integrity Contractors (ZPICs) is.

An announcement delivered directly from CMS states:

“It is easy to say that all Medicare Survivalists have the potential to receive an audit request.”

I have to say I find the use of the word “survivalist” to be interesting and, of course, accurate.

The announcement last month of increased pre pay audits for both oxygen and PAP coming as a result of data gleaned from the CERT is of concern and something to plan for now, as well as the audits from the RACs that are starting to appear. Now there is aggressive auditing on both the pre payment and post payment side of reimbursement.

The RACs are being touted by CMS as part of an aggressive new program to prevent fraud and abuse in the Medicare program. The program is not exclusive to HME companies, and the contractor reviews claims for both Part A and Part B.

Currently there are four recovery audit contractors who cover the nation and carry the responsibility to conduct post payment audits with the objective of identifying both overpayments and underpayments. The RACs earn their fees on a contingency basis for both.With this in mind, it is easy to see how RACs could be a tenacious source with which to contend. Yes, the supplier still has appeal rights, and the RAC does not get paid until the case has been “won” in appeal. However, this is little solace to the provider as this process can be burdensome and costly.

Probably causing the most angst to suppliers now is the news coming from the DME/MACs in response to data gleaned from the CERT program. The program reports a significant increase in the number of claims errors. A letter from at least one medical director states that of all claims errors, nearly 31% come from oxygen claims.

Considering that there have been sweeping changes to the payment policies for oxygen, the medical director’s statement should come as no surprise. What is surprising is what is now being asked for in development:

“According to the CERT contractor, there must be documentation in the beneficiaries’ medical record within 6 months prior to the date of service for the claim in question supporting the continued use of oxygen by the beneficiary.”

The above statement implies that it will be necessary for the HME supplier to not only ensure that the beneficiary go to the doctor every 6 months, but ensure that the said beneficiary discuss with and have their doctor document the need for, continued oxygen use. The provider must then obtain copies of this documentation. If you are “selected” for one of these claims for development, it is important to note that these terms are not specified as a requirement in the oxygen LCD. There is an effort underway led by American Association of Homecare to address this issue and seek clarification. Currently the timeline for response is not consistent across the four DME/MACs, which adds to the confusion.

Plan now for audits by ensuring that every oxygen chart:

• Is a complete order that includes liter flow;
• Is reviewed, signed and dated on the CMN in a timely manner;
• Documents an in-person evaluation (by treating practitioner) within 30 days prior to the date of the initial CMN;
• Documents an in-person re-evaluation (by treating practitioner) within 90 days prior to the date of any recertification;
• Includes ongoing documentation of the medical management of the patient’s oxygen use in the patient’s records.

CPAP and supply claims constituted only 5.2% of the errors, and still made the cut for increased claim scrutiny. Claims subjected for further development will need documentation showing:

• Physician’s order
• Documentation from face-to-face evaluations
• Copy of sleep test
• Documentation of adherence to therapy
• Proof of delivery and product information

Note the physician evaluation post PAP application must document the patient is improving and will continue to use PAP as therapy.

Conducting your own internal audit now could relieve some added stress later

This article originally appeared in the Respiratory & Sleep Management November 2009 issue of HME Business.