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?
- By David Kopf
- Dec 01, 2019
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
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 DMEevalumate.com, which
provides a system that helps referrals and providers ensure accurate and correct
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
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,
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.
HMEB: How does DMEevalumate.com 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 November/December 2019 issue of HME Business.
David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.