The 2014 HME Handbook: Documentation
How to Protect Your Business with Iron-Clad Documentation Policies
Audits are an inescapable fact of life for HME provider businesses. CMS has committed itself to intensifying its pre- and post-payment audits, and RAC, CERT and ZPIC contractors can be depended upon to keep up the intensity in terms of auditing claims and requesting documentation from providers. As a result, providers need to make every effort to ensure they have business-wide documentation policies and procedures that are followed to a tee. Moreover, they also must work with their referral partners to ensure physicians and other healthcare professionals understand exactly what the provider needs in order to file a claim.
Moreover, the benefit of good documentation has been proven at the appeal level. Once a recoupment has been made and providers must appeal, they’ve demonstrated that, when they have all the necessary documentation, they can easily overturn that appeal and regain the recouped reimbursement. In fact, providers have been so successful in this regard, that they have forced CMS’ Office of Medicare Hearings and Appeals (OMHA) to delay assigning an Administrative Law Judge to any new audit appeals for two years. (That has created a whole set of additional problems; see “Learn More.”)
But the key to responding to auditor documentation requests, overturning recoupments lies in better documentation. In fact, better documentation is the key to avoiding audits altogether. What should providers be doing?
Policies and Procedures
Documentation starts with a plan. HME business ownership and management must outline specific policies and procedures that require complete and correct medical documentation for all claims. Every step of each workflow involving claims must conform to documentation requirements, and no claims should be able go past any step in the workflow without having the necessary documentation. Fortunately, providers Medicare accreditation should help in this regard (to learn more about this see “How to Renew Your Accreditation” on page 14).
Furthermore, these policies and procedures aren’t isolated to the business, either. Providers must work to ensure not only staff, but all referral partners conform to the outline documentation requirements. This means providers must educate physicians, staff and other healthcare professionals to let them know what is needed. Use in-services and other meetings as opportunities to convey those needs so that those partners understand any changes in documentation policies. Don’t forget, these professionals are undergoing the same audit frustrations with Medicare as your business, so they should be fairly understanding in terms of the requirements to which you must conform.
Take a Team Approach
Again, prevention is the name of the game, and that requires a team approach. Once the plan is outlined, it is essential that all employees involved in the claims process comprehend all documentation requirements needed to ensure that claims will not raise flags with audit contractors. Staff should also know what is required to respond to auditor documentation requests. Work with internal and third-party experts as needed to train everyone on the team who needs help, and require all claims staff to regularly refer to key reference documents such as jurisdiction supplier manuals to monitor any possible policies changes or new requirements. Consider appointing various leaders in the business that can act as management’s agents to ensure each department conforms to the policies and procedures.
Check Your Work
Another key element in audit prevention is ensuring that the documentation policies and procedures are being followed and actually working as intended. Ownership and management must routinely check claims to determine if they are exposing the business to audits through a faulty or missing workflow step. Claims should be reviewed for missing or incorrectly formatted documentation elements, and if any are found, the provider should be looking for repeat problems to isolate a trend. This way the provider can fix the problem before it becomes an actual problem in terms of an audit.
So how do providers isolate those problems? A key way is through their billing, claims and management software systems. All of the audit contractors are owned by software and technology firms and are taking a highly automated approach in trying to identify red flags. So, the majority of audits result from data analysis. This means that HME providers can use their software reporting tools in similar ways to warn them about possible audit risks, and to help them analyze their claims for any possible danger of being audited. Moreover, HME software systems can help providers implement the workflow procedures that will ensure they are collecting all the necessary documentation up front, and that it is formatted the correct way. Also, because billing software houses all documentation electronically, it inherently makes responding to auditor documentation requests much easier. Auditors will stipulate which documentation is needed, and the provider can quickly retrieve it to prove the claim’s validity.
Points to Remember:
- Audits pose a clear and present danger to HME providers businesses.
- The high rate of appeal overturn shows that good documentation pays off.
- Providers should outline documentation policies and procedures that impact every aspect of their workflow.
- They must not only communicate these requirements to staff, but also referral partners.
- Providers should also perform self audits to ensure their documentation policies are working as intended.
- Using HME software systems can help implement their documentation policies and pinpoint areas where they need to improve.
- The decision by CMS’ Office of Medicare Hearings and Appeals (OMHA) to delay assigning an Administrative Law Judge to any new audit appeals for two years has meant that providers’ reimbursement is not only sitting in limbo, but perhaps risking severe penalties. To learn more on that topic, read “Flirting With Disaster,” in the March print edition of HME Business.
This article originally appeared in the June 2014 issue of HME Business.