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The No Longer Grim Brothers

Date Published: January 23 2015

Once upon a time, back in 2002, DME’s fair-minded Godmother had the pleasure of meeting the Respiratory Therapist Brothers. The brothers were new to DME land and had entered the enchanted forest when they saw a need for quality respiratory services in their rural community.

The Respiratory Brothers became successful and opened two additional locations. They sought out the fair-minded Godmother’s services because of ever growing accounts receivable (AR). With the fair-minded Godmother’s assistance, they reorganized their central intake and billing to a cohesive efficient center. Over a period of six months they were able to resolve the existing receivables and bring the days outstanding down to a manageable 45 days. This might have been the end of the story if this was a fairy tale.

Imagine the fair-minded Godmother’s surprise when the brothers reached out to her for help more than a decade later. Apparently, the brothers had become the target for prepayment audit probes for E0601 (CPAP) and were receiving “unfavorable” outcomes for claims on and after the 4th month. It wasn’t a patient compliance issue; the brothers had a team of well-trained therapists to help their clients be successful with their CPAP Therapy. It was a paperwork issue. The brothers needed help and pronto! They could not continue to operate the business with an 85 percent denial rate on their core business.  

At first, the brothers had not been that worried because they were only receiving one or two audits a month.  Now they were receiving fifteen to twenty-five at a time. Their receivables were becoming monstrous and there was no relief in sight. 

The fair-minded Godmother examined the files and the issue was apparent. The patients were in compliance with the use of their CPAP’s, however, the physicians were not fully documenting patient compliance and outcomes to meet the ruler of the kingdom’s coverage criteria. Some of files were missing the F2F notes from the visit prior to the sleep study being performed. The majority of the issues were with the 31st and the 90th day revisit documentation. These progress notes did not contain enough documented evidence showing improvement of OSA symptoms, and often lacked clear documentation of patient’s adherence to therapy.

The fair-minded Godmother introduced the brothers to DMEevalumate.com. Standardized online documentation tools resolve compliance issues by providing easy to use DME F2F exam modules for referring practitioners. With the guess work out of the way, referring physicians are prone to produce compliant paperwork. The brothers got right to work introducing their referring physicians to the “magic” of using DMEevaluamate.com and the documentation began to turn around. 

“But be warned,” the fair-minded Godmother explained to the brothers. “The unwritten law of the land is that the probes will not ease up until you have approximately 20 ‘favorable’ outcomes in a row, then poof! they will begin to vanish.”

The monstrous AR still darkened the land. What the brothers were not aware of was the hidden spell contained within the MM8304 MLN Matter for Detailed Written Orders and Face-to-Face Encounters. This spell had been cast by the powerful CMS wizard, the ruler of the kingdom. Even the fair-minded Godmother was unable to vanquish the spell, which renders the supplier helpless as there is no recourse if the claim has already been submitted. Alas, this spell can only be warded off if the supplier has not submitted the claim.

Together, the fair-minded Godmother and the brothers fought the AR monster. They were able to save all the claims where the equipment had been delivered, but had not been billed. They were not able to save those that had been previously billed. This spell is a binding, unbreakable one and there is no getting around the consequences, they must write off the existing AR. The brothers were required to pick-up all their equipment and another supplier must deliver and begin servicing the clients. 

As the sun shines onto DME land, peace is restored in the enchanted forest served by the Respiratory Brothers. Word of the “magic” of DMEevalumate.com continues to be spread and the brothers can once again live prosperously ever after. 

~ Jamie Loper, co-founder of DMEevalumate.com and chief compliance officer.

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