Accreditation and Audits

Two accreditation experts discuss the relationship between accreditation and audits.

When it comes to implementing solid documentation policies and procedures, Medicare accreditation can help considerably in making sure that providers integrate the right documentation, so that they reduce their audit exposure, and increase their ability to quickly follow up on audit contractor documentation requests.

Two accreditation organization experts, Sandra Canally, RN, president of The Compliance Team, and Wendy Miller, BOCO, LO, CDME, chief credentialing officer for the Board of Certification/Accreditation, sat down with HME Business to discuss accreditation as it relates to audits.

HMEB: How can accreditation help providers reduce their exposure to audits? Are there specific documentation policies and procedures that you as an accreditation organization really focus on?

Canally: Certainly compliance with the DMEPOS accreditation quality standards with any of the approved AOs would help a provider reduce their exposure. Lets start at documentation for the products, or equipment ordered. There needs to be tight, accurate and comprehensive documentation at order intake. Most importantly, that the item ordered is the item delivered.

It is then up to the provider to show proof of that. There must be proof of delivery, along with the model, serial and manufacturer numbers of the item delivered.

They then must follow the local coverage determination for the items billed, which will drive any additional documentation requirements such as a face to face.

The next thing is looking at who the ordering doctor is, and has that doctor’s license been verified with the state board in a specialty that makes sense, as well as a location that is conducive to their patient population. For example, if the provider is located in Los Angeles, why are all of their orders coming from San Francisco?

When we look at volume being ordered by the same physician, we then would expect to have the license verification documented. If it is missing, we will check, and on occasion we have found a pathologist or OB/GYN doctor ordering items such as power chairs — not good.

Miller: BOC accredited facilities are required to maintain comprehensive documentation of submitted claims, and guidelines for doing so are provided in our Accreditation Standards Guide. Although some audits are inevitable, meticulous documentation and record-keeping can reduce the probability of being frequently or repeatedly audited.

HMEB: What about audit requests? When a provider does get a request from an auditor, how can accreditation help them accurately and rapidly follow-up on that request?

Miller: BOC’s Facility Accreditation Standards mandate that accredited facilities maintain documentation in a manner in which the retrieval and provision of any information requested by an auditor should be seamless.

Canally: Again it is about the documentation behind the orders. Does the provider have proof that the patient that received diabetic shoes paid by Medicare is indeed a diabetic?

HMEB: Does the same hold true for appealing to audits? How can accreditation
help a provider effectively appeal an audit?

Miller: A primary objective of the accreditation process is educating suppliers on the importance of maintaining documentation in a way that is well-organized and compliant. If an accredited supplier implements and maintains the policies and procedures that are required to become accredited, appeals should be minimal and easy because the information for auditors will be readily available and easily accessed. The maintenance of records and the other documentation accreditation requires will ensure the best possible outcome at the earliest level of an appeal.

Canally: If the provider has no idea what to do, it should call and talk with its accreditation organization to ask questions. The AO should be able to point to the quality standards that would apply, and direct the provider to the processes it has in place to meet those standards. At the end of the day, it is always about documentation — if it is not documented it is not done!

This article originally appeared in the April 2016 issue of HME Business.

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