Steps to Rock-Solid Documentation
As providers are beset by a flood of audits, they must ensure clean claims documentation. Here are some key considerations.
- By Cindy Horbrook
- Apr 01, 2013
When it comes to audits, solid documentation is a provider’s only defense. The HME industry continues to work in order to convince CMS to reign in its out of control audits, while providers continue to put into place documentation processes that make sure their claims are rock-solid.
“If they [providers] don’t have strong documentation, then they have no defense,” says Wayne van Halem, CFE, AHFI, president of The van Halem Group LLC, a firm that helps providers respond to and appeal audits. “With the very strict adherence to the policies, it’s not enough just to have documentation. It’s got to be documentation that shows that the criteria for coverage from the LCD have been met or else it will result in a claim denial, and the more denials you get the more scrutiny you’re under.”
So while the HME industry continues to convince CMS that it must reign in its out of control audits, providers must continue to put into place documentation processes and procedures that will ensure they have clean claims from the get-go.
“You almost have to put yourself in their shoes. It’s not that we always agree with what the LCD says, the hoops that you have to go through,” says Georgie Blackburn, vice president of government relations& legislative affairs for Blackburn’s Pharmacy. “The bottom line is we’re contracted to provide under their guidelines, and until the guidelines change, and that’s my job now trying to impact healthcare policy, but until we can get guidelines changed then we have to certainly abide by them if we want to keep the money that we earn.”
CMS’s Audit Surge
Van Halem cites the implementation of the Affordable Care Act as a key reason for the increased CMS audits.
“We saw the budgets for program integrity activities increased just prior to that, and part of it is that the administration wants the legislation to be budget neutral, so the way to do that is to increase the number of audits that are recouping on claims that they determine to be paid incorrectly,” he explains.
Another issue is the significant error rates in the audits, as much as 70 to 95 percent in some instances.
“The way in which they’re doing these reviews with very strict adherence to policies and no clinical judgment being used, it’s causing these high error rates and when they see high error rates then clearly we have to audit more to try to improve that because it’s a refl ection of them too,” van Halem adds.
And there is the issue of how the audit contractors are compensated by CMS.
“Obviously there’s an incentive for them to do audits, but then the ZPICs have been awarded contracts, in some cases, in excess of $100 million and they have to show CMS a return on that investment in order to keep that contract,” van Halem says.
As a result, many providers have gone into a combination preventative-defensive mode when it comes to documentation. Blackburn’s is one of them.
“We do as much as we can upfront to make sure it is absolutely accurate,” she says. “If we were signing the check on behalf of Medicare, we think this is a clean claim.”
Education Is Essential
To ensure those clean claims, providers are taking a variety of steps to ensure they have the right documentation processes and procedures in place. At the foundation of those processes and procedures lies a solid foundation in education.
“Education, every day,” stresses Peggy Walker, RN, billing/reimbursement adviser for U.S. Rehab/VGM.
“You must know the Medicare policies,” adds Blackburn. “You must know the local coverage determination policies inside and outside and that reflects your training.”
Training is important to every single person in an organization—from the person who answers the phone in the back office to the employee who sees a customer at the counter. “If that employee doesn’t know the policy, then they may give a wrong answer and that starts the process,” Blackburn explains.
One aspect of Blackburn’s training is emphasizing to staff to read what they receive.
“It’s not a matter of ‘Gee whiz, the doctor wrote a lot of stuff, so we’ve got a great medical record here. It’s three pages long.’ It’s what the content is,” she explains. “The training goes in to absolutely learning how to interpret as though you are a COTA (certified occupational therapist assistant) or you are an RN. You have to learn medical terminology.You have to understand the etiology of the disease process. It’s a puzzle and you have to make sure all the pieces add up before you dismiss a piece of equipment.”
Blackburn says staff should understand the policies from any payor source, but especially Medicare because providers are so prone to get audited by Medicare.
“It’s absolutely necessary for every firm that wants to bill to Medicare to ensure that they do the optimal amount of training. Otherwise their dollars are not protected,” she says.
Every provider should also have a supplier manual from their jurisdiction and encourage staff to reference it frequently, according to Nancie Cummins, RMC, CMCO, CMC, accreditation advisor for The Compliance Team Inc.
“When I go into an office or a DME company, I want to make sure they have a supplier manual there, whether they access it online or they have it printed out because that’s a valuable tool,” she says. “If we’re talking about documentation in a written order, you can go to the supplier manual and it’s going to tell you what the seven elements are.”
In addition, Walker and Cummins both recommend taking advantage of the many online resources such as listservs for every jurisdiction, webinars, Web-based training and podcasts. Attending events such as Medtrade or VGM’s Heartland Conference can provide a wealth of information.
“They need to be a part of their state association because Medicare is not all,” explains Walker. “Their state association keeps them up on Medicaid and other insurances as well.”
Recognizing the Signs of Fraud and Abuse
Cummins also stresses the importance of knowing about fraud and abuse, to alleviate potential red fl ags in documentation.
“Know that if you’re writing off patients’ balances and you’re not documenting that it’s a hardship and you have some criteria in your practice of what a hardship is and you have a hardship letter in place— that becomes abuse, so make sure you know what is fraud and abuse so you’re not accidentally caught up into doing it because you think you’re doing the right thing when it actually really isn’t,” Cummins says.
Getting it Right from the Referral Sources
From illegible documentation to missing signatures, sometimes it’s the physicians and other referral sources that can make getting the right documentation a challenge.
And since many denials are due to administrative errors, providers should know what type of signatures are needed, what forms need to be date stamped and which items need a written order prior to dispensing so they can make sure they get it right the first time.
“If the documentation is illegible, that’s a key piece because if you can’t read it, the auditor can’t read it,” Cummins says.
The experts agree that getting the referral sources on board with making sure documentation is correct goes back to training and education. That means educating the doctors before the information is needed and keeping an open line of communication with the physician’s office to be able to retrieve information when necessary.
“We have a program development manager that works with all the different managers that sets up wound care seminars, rehab seminars, that type of thing, where we’re educating and facilitating understanding, trying to answer questions,” Blackburn says. “And those questions we don’t have the answers for we try to get it from the right sources, but we definitely want to be the conduit to information for our referral sources and that has helped us to protect our documentation process.”
Walker recommends making sure that the referral sources are aware of the CMS check off sheet.
“This is one page check off sheet that they can hand to the physicians and it’s actually in the LCD policy,” she says. “Take those into your training courses when you’re working with referral sources. It’s an education issue all the way around.”
Utilizing the data generated by their software and technology systems can help providers identify anomalies is extremely important, such as the same provider all of the time, the same referral sources all the time, a big spike in claims submitted or a big spike in denials processed.
“If there is an anomaly in your business, you’re able to identify that anomaly quickly and remedy it within your own operation so that it doesn’t happen again,” says Steve Andrews, general manager of customer services at Brightree LLC, an HME software company. “Or just be on notice that ‘this is a real something that happened, and I should know that I’m probably on an audit radar at this point in time.’ Just be prepared for it and have all your documents and processes tight so that when you do get audited, you’re able to respond quickly and efficiently.”
Another way that technology can help with the audit process is by installing what Andrews calls “payor product rules” for specific payors.
“This example would be obviously Medicare, whereby you’re able to say for this particular product I need for something, a certain circumstance, to be in existence, and if that certain circumstance is not in existence, then put a flag out to me so I don’t let a claim go out the door,” he explains.
Many software programs provide electronic document storage, which gives providers the ability to quickly and easily access documentation circumneeded in the event of an audit.
“You’re not scrounging through a bunch of boxes of paper or trying to go after things that are not current, that you don’t currently have in your facility,” says Andrews.
Having electronic data storage also allows providers to correspond quickly with Medicare through their esMD (Electronic Submission of Medical Documentation) system.
“There is a correlation between the speed at which you respond to audits and the success or failure you have in being targeted for another one, so being on top of that is extremely important,” says Andrews.
No End in Sight
With no indication of audits coming to an end or even slowing down, it’s more important than ever for providers to have all their ducks in a row before an audit letter darkens their doorstep.
“I’m hopeful that at least some reasonableness will enter the process. As of right now, there isn’t any in the pro cess,” says van Halem. “The claims get audited. They have to go to appeals and because of the volume of audits that are being conducted, the appeals workload has significantly increased, so it takes about a year or more to get to an ALJ (administrative law judge), and ALJs are still overturning a significant amount of claims because they can tell that it’s reasonable that these patients need the equipment.”
If an Audit Letter Arrives
There are simple steps and tasks that providers can take to make sure their documentation is clean, organized and easy to understand should an audit letter come their way. One of the first things to do is read the letter and understand exactly what the auditor is asking for.
“They want to make sure that they organize their paperwork, make sure their paperwork is very concise very detailed, very in order,” says Walker. “I always suggest number one they want use a cover letter explaining everything that they’re sending and put it in the order of the request from the reviewer.”
Providers should also make sure the pertinent parts of the medical documentation are clear and easy to identify.
“One of the things I see a lot of is the documentation wasn’t there, but then you look at it, it’s there, it’s just that maybe it’s on the third page of the physician’s progress notes rather than the first page,” she says. For example, with a power chair claim Medicare may be looking for manual muscle testing.
“They need to underline where the manual muscle testing is, asterisk it and say on page three of the PT notes is manual muscle testing,” she adds.
In addition, providers should number all the pages, page 1 of 30, page 2 of 30, etc… and put the patient’s name, Medicare number and date of service on the top of every page in bold letters. Then be sure attach the audit letter back with the response.
“Denial rates are ridiculous, and these denial rates, some of them are even going up in some of the jurisdictions, so you’re looking at these denials and there’s something going on, so what can I do as a supplier to decrease my denials, what do I have complete control of?” says Walker.
Providers have control tasks such as the home environmental evaluation, organizing the paperwork and date stamping the paperwork when received.
“So these are the things I can do--making sure the signatures are legible, if they’re not, get an attestation statement before you send the paperwork in,” she says. “There are a lot of things we can do to prevent denials on the second time around if we pay attention to what we’re doing,” she says.
This article originally appeared in the April 2012 issue of HME Business.