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Audit Survival 101

Date Published: November 15 2013

A Successful Game Plan and Strategy Wins Audits

If you have ever spent time playing board games like Chess, Battleship and Scrabble, you know how important it is to think strategically. It is human nature to want one-upmanship, beat your rival and succeed. Understanding your opponent and the game board provides important strategic advantages. This psychological “survivor-like” warfare exists in the durable medical industry.

 

The Centers for Medicare and Medicaid Services (CMS) provides auditors with a playbook to use when they are reviewing patient records. In that playbook, if a CMS rule states that “something” must be documented, then it must. Auditors are not allowed to make assumptions and they cannot fill in the blanks. One scenario I came across recently was that an Occupational Therapist (OT) ruled out the use of a cane and a walker and although the referring physician endorsed the OT’s notes, according to the CMS playbook the physician should have ruled out the use of a cane and walker in his face-to-face evaluation. It doesn’t matter that the patient is a complete quadriplegic and only has use of his fingers. It’s obvious that the patient cannot use a cane, walker or manual wheelchair. In this case a simple statement from the referring physician would be sufficient to keep the DME provider in the game, such as "The patient is unable to use a cane, walker and manual wheelchair secondary to C4 SCI quadriplegia; patient only has use of his fingers."

 

In the respiratory arena, physicians must document which alternative treatments have been tried and proven ineffective prior to ordering home oxygen. However, in the case of a chronic obstructive pulmonary disease (COPD) patient, a statement such as "all other treatments for COPD have proven ineffective and home oxygen has been ordered" doesn't meet the CMS playbook rules. The referring physician needs to provide detailed information, such as "Bronchodilator-ipratropium and Arformoterol and Fluticasone were effective for a short while. A combination of Adair and Symbiotic were also tried prior to starting the patient on Phosphideesters-4, the results were moderate and exacerbation still present. Patient also experienced significant weight loss of 10 pounds.  Oxygen therapy has been ordered as part of my treatment for COPD. Oxygen therapy has been ordered to increase the patient’s ability to participate in activities of daily living (ADLs) and improve quality of life.”

 

In the case of a Recovery Audit Contractor (RAC) you have 45 days to provide the supporting documentation for each record requested. Your first chess move should be a Knight who will step quickly across the board to gather the paperwork as fast as it can and get it back to the RAC. If you choose to hide behind Pawns and wait until the 44th day to send the paperwork back to the RAC you will most likely ensure another audit and inevitably more record requests. You might as well surrender your King now because there are not enough Knights on the board to keep up with RAC requests in this scenario.

 

Have you ever played Twister? Put your right hand on green if you completed an accurate and compliant DME paperwork process and received an affirmative decision from Medicare, then received an audit, reviewed the paperwork and sent it back only to receive an "unfavorable" decision in reply. Left hand on blue if you appealed this decision with a "redetermination" request within 15 days to stop recoupment. The redetermination addressed the decision rational in a clear precise manner. If the rational states the paperwork didn't rule out a cane and the face-to-face evaluation does rule it out, redetermination directs the reviewer to where it can be found within the paperwork; page 3 paragraph 2 underlined. It's vital to keep a timeline of audits. Keep track of what stage they are in, when a reply should be received and what needs to be the next step. I received a Zone Program Integrity Contractors Audit (ZPIC) in 2010 for a CPAP claim with a date of service in March 2008. It finally passed favorably in September 2013 when I fell off the Twister mat.

 

I recently spoke with a power mobility company owner (who shall be known as Bob) who is receiving RAC audits requesting more than 30 patient records every other month. Bob is failing a quarter of them secondary to medical necessity. Bob’s business is made up of mostly high-end rehabilitation; clients have spinal cord injuries and amyotrophic lateral sclerosis. There is no doubt that these patients need wheelchairs, yet Bob is still receiving unfavorable results. His frustration is evident, "I'm one of the good guys. We do everything above board but if this keeps up I'm out of business." In 2012 Bob paid $30,000.00 for a consulting firm to develop and implement a compliance plan so that he would pass audits. In the face of continued unfavorable RAC audits Bob is now scratching his head and asking himself WHY? 

 

The answer is that the rules of the games governed by CMS are not always black and white but often grey and constantly changing. It takes playing the game to truly understand the rules. We also need to think like an auditor. In order to think like an auditor, DME providers need their own CMS playbook. Medicare checklists for documentation do exist. Familiarize yourself with the top documentation denials using the RAC reports that can be found online. Go to:http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/PMD_DocCvg_FactSheet_ICN905063.pdf and https://www.cgsmedicare.com/jc/mr/PDF/MR_checklist_oxygen_grp1.pdf

Put this information together in a down and dirty form. Then review your paperwork like an auditor. If something is missing, take Bob’s quadriplegic example, you must get the physician to write a clarification statement, not an addendum, and include it with the face-to-face documentation.

 

Much like winning strategies for thousands of board games, understanding the different rules and knowing the playbook of other participants is necessary to win. Use all resources available to keep yourself informed and up-to-date on the trends and changes in the industry like HME News, the CMS website and your DMEPOS MAC website. Subscribe to an online face-to-face evaluation program that will insure your referral sources play by the rules every time. Don’t let an auditor sink your battleship.

 

Jamie Loper, ATP, co-founder of DMEevalumate.com.

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