Editor's Note

Beating CMS to the Punch

DMEPOS represents an outsized share of audit appeals at ALJ. Providers must take action first.

They say that the devil is in the details. Or do they say that God is in the detail? Or is it both? Well, let’s just say that either expression is equally valid when it comes to HME claims documentation: You can suffer setbacks or ensure your success depending on how you approach your documentation.

That should be abundantly clear in today’s Medicare claims auditing environment. Ever since CMS ramped up its program integrity efforts, the HME industry realized that it was going to face a tsunami of documentation requests, recoupments and appeals that would drown them far quicker than competitive bidding ever would.

However, providers learned how to respond to these challenges. The situation is far from ideal, but providers have improved their efforts to document claims correctly the first time; get the right documentation in place in cases where they need to respond to an audit contractor’s request; they are staying on top of new audit programs and enhancements or expansions of existing audit programs; and in cases of recoupment they understand the appeals process and how to work to ensure they are fairly represented.

As I said, this situation is far from perfect, but providers have scaled up a pretty steep learning curve with considerable speed for the most part. It’s akin to learning how to do the backstroke in shark-infested waters.

While that speedy adaptation to a considerable regulatory challenge is laudable and deserves some praise, providers might have been a little too adept. The number of audit appeals that were elevated to the administrative law judge level at CMS’s Office of Medicare Hearings and Appeals quickly shot up to the six figures and by 2017 it had shot past the half-million-claim mark. Fortunately, this year it has dipped down to 484,000 appeals, but let’s be clear: the only other Federal court dealing with that volume of appeals is in the Social Security Administration.

Worse yet, Kim Brummett, vice president of regulatory affairs for the American Association for Homecare told attendees of its Oct. 16 Washington Update, which was held at Medtrade in Atlanta, that while DMEPOS represents 1 percent of Medicare’s spend, it currently represents 57 percent of the audit appeals sitting at the ALJ level at OMHA.

Brummett quipped during her presentation that “Being the biggest guy there is not necessarily a good thing,” and she’s absolutely right. Think about that ratio of Medicare’s DMEPOS spend vs. audit appeal volume. CMS is not going to be happy with it and it will take action. Because we represent such an outsized portion of all Medicare audit appeals, Brummett says CMS is considering fees for appeals as well as raising the dollar value of appeals.

Now, there is much truth to the argument that it’s the nature of the audit programs and how audit contractors pursue claims audits that has caused the surge in appeals, especially given that appeals for some programs have exceedingly high levels overturn rates. And I’m sure the good work that regulatory affairs experts such as Brummett do for the industry will continue to get more uniform and fair enforcement from the audit contractors.

However, it’s my opinion that the industry and individual business owners and managers need to take a more proactive position. They can’t wait on high-level fixes to protect their bottom lines. They need to invest in immediate front-line responses. Whether it’s employing technologies such as e-prescription or internalizing more painstaking policies and procedures in order to further batten down documentation prior to filing claims, HMEs must become much more hard-nosed about documentation, and get out in front of this issue. You don’t want CMS to make the first move.

On a related note, I want to welcome Cara Bachenheimer to the HME Business Editorial Advisory Board. It’s fitting this happens around Thanksgiving, as I’m extremely grateful to the board for its help in shaping our coverage. I’m sure Cara’s government relations expertise, which she now provides via her role at Brown & Fortunato, P.C., will benefit our coverage. Thanks, Cara!

This article originally appeared in the November/December 2018 issue of HME Business.

About the Author

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

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