No Documentation = No Delivery!

Date Published: August 14 2015

A DME referral is as only good at the documentation that supports it.

The Recovery Audit Contractors (RAC) are back and stronger than ever with the development of a fifth team dedicated to identifying overpayments for durable medical equipment nationwide.

My challenge has been creating an understanding with DME suppliers that a referral is only as good as the documentation that supports it. If the paperwork isn’t compliant, the DME provider is at a higher risk of failing an audit. If a provider does not pass an audit, they can be assured that their company will be targeted for future audits.

There is a common misbelief among competitive bid winners that they are exempt from audits but this is not the case. The RAC is a for-profit entity who generates revenue by identifying improperly paid claims. The best way to be prepared for a RAC audit is to treat every order as if it is undergoing an audit. Section 6407 of the Affordable Care Act requires the treating practitioner to conduct an in-person or “face to face” office visit with the patient prior to prescribing 166 DME items including CPAPs, hospital beds, manual wheelchairs, etc. The practitioner must document the FTF encounter, detailing the need for each prescribed item. Providers are required to obtain compliant documentation prior to delivery.

I was encouraged to hear from Woody O’Neal who recently passed a Medicare audit of PMD claims and attributes success to subscribing to a web-based program for collecting FTF documentation. In my experience, practitioners document the FTF evaluation in one of two ways: either by referring to a lengthy check list or by using an online electronic template that prompts the user to ask questions regarding social, environmental and past history of the patient. Online electronic templates require the practitioner to include pertinent tests related to the physical exam, such as manual muscle testing of the upper and lower extremities and compare all the information with Medicare’s coverage criteria using algorithms to determine medical necessity. An online program that lets practitioners know during the FTF exam which equipment, if any, the patient qualifies for is a win-win for everyone.

O’Neal’s philosophy is something all providers should follow: No documentation, no delivery. Congratulations O’Neal! I 100 percent concur.

~ Jamie Loper, Chief Compliance Officer for

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