Problem Solvers

The Changing Face of Documentation

Referral sources' face-to-face documentation concerns have grown as 'acute' as HME providers. Why is this change happening and what does it mean for HME?

The industry is seeing a reversal in the claims documentation process, particularly when it comes to face-to-face documentation. Where once providers had to beg and plead for proper documentation, now physicians, hospitals and health systems want to get their documentation right and they want to ensure HME providers are getting that correct documentation.

The onus of responsibility has shifted since prior authorization went into effect, and the change in the “documentation relationship” between referral sources and provider has steadily been picking up momentum. I sat down to discuss this issue further with Greg Sims, CEO of, which provides a system that helps referrals and providers ensure accurate and correct face-to-face documentation.

HMEB: So, the documentation worm has turned. What’s caused this change?

Sims: Reimbursement cuts are affecting hospital systems just like they’re affecting the DME industry. So, you have COOs in hospitals, hospital systems, and large practitioners looking at how they can cut costs. One of the issues that they have is that, for a practitioner to do a face-to-face evaluation and create a narrative, they’ve narrowed it down to about being 55 minutes’ worth of their time. … They have a 15-minute face-to-face; they make some notes; and then they go back to their office; and they try to create a narrative. Hopefully, it’s correct. But if it’s not, then there’s some back and forth between the DME company. There are addendums that need to be reviewed and signed. It is a lengthy process.

They looked at how much time are spending doing the documentation to make sure that it meets Medicare’s coverage criteria. And the opportunity cost taken by that process is two or three patient encounters. If you multiply that times depending on how many evaluations they do, how many face-to-face counters they have, and multiply that by, say, 2,500 practitioners in a hospital system, then they’re looking at millions of dollars when it comes to opportunity cost. Now, all of a sudden, there’s more of a concern about documentation on behalf of the practitioners.

HMEB: So, face-to-face documentation has become a huge cost concern to hospitals and health systems, and they want to make the process efficient. Thus, the change.

Sims: It is being dictated by the hospital systems and the administrators of the systems because they’re looking at dollars and cents. And it doesn’t make sense for them for everybody to have a different means of creating that documentation. There are lots of different means that doctors use to create that documentation. However, if they had a universal means of doing it and making sure that it meets Medicare’s coverage criteria each time, why not do it?

HMEB: And then both providers’ and referrals’ documentation concerns are abated, because they’re all speaking the same language and using tools to document a claim and make sure that that documentation passes muster.

Sims: Correct.

HMEB: How does fit into this scenario? It seems like you’re functioning as the Rosetta Stone in this process.

Sims: It’s a fairly simple program, really. It goes from the most basic questions down to the minutia to really nail down every single piece of Medicare’s coverage criteria for each piece of equipment. If you went into the evaluation for a PMD or for respiratory or for general DME, the system goes through and says, “What’s the most basic question that we need to ask to start this face-to-face encounter? Is the patient here today for a face-to-face evaluation for a power mobility device?” Well, if the answer’s “no,” then the program says, “Well, why are you here? It doesn’t make any sense.” Then, the system goes from there.

HMEB: What would you say to HME providers in terms of what should they be thinking about in regards to this shift?

Sims: There has been a quantum shift in the way that DME providers have been addressing their positions when it comes to the documentation issues. Traditionally it’s always been the less squeaky you can be, the more referrals you should expect from that practitioner. The more pushback you give them about documentation, then the fewer referrals you might receive.

Years and years ago, DME providers actually had to bake that into their business load. Their position was, “ I know I’m going to fail this number of audits because my paperwork may not be great in these categories.” But now the audit world has changed; if you start failing audits, there’s blood in the water, and you’re going to go out.

There is no wiggle room anymore for documentation; it has to be correct. So, our most successful providers have actually completely changed the relationship with their practitioners. Instead of the provider coming to the practitioners and saying, “Please give us business, please give us referrals,” they have gone to, “We will not accept a referral from you unless you use this program.

“It doesn’t make any sense for us to receive faulty or inaccurate documentation to provide a piece of equipment; to have that beneficiary have that equipment for a year; while we fight through the system to try to get the right documentation. At the end of the day, if we get audited, the money gets recouped.

We’ve lost the equipment. We’ve lost our funding. It’s better to not do business, than to deliver the equipment and then not get paid for it.”

It makes more sense for providers to make sure they get the proper documentation up-front, rather than lose not only the equipment, but also reimbursement.

HMEB: Greg, it sounds like you might be telling me good news in relation to documentation and audits.

Sims: It is. There’s a large quantity of providers for whom we’re ensuring the documentation is correct and they’re not having to worry about it. It has taken a huge load off their shoulders. And there’s a lot of infrastructure costs, there’s a lot of overhead involved in making sure that all of that documentation is correct and then fighting it on the back end. They are eliminating all of that.

This article originally appeared in the Nov/Dec 2019 issue of HME Business.

About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.

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