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PRACTICAL SOLUTIONS TO SAFEGUARD YOUR BUSINESS. Internal and External Problem Areas. Identify problem areas - External. Audit Contractors ZPIC/RAC/CERT/DME MAC/SMRC Physicians/Medical Providers Documentation Compliance with Medicare requirements Beneficiaries

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identify problem areas external
Identify problem areas - External
  • Audit Contractors
  • Physicians/Medical Providers
    • Documentation
    • Compliance with Medicare requirements
  • Beneficiaries
    • Meet criteria for items/services
    • Liability
combating the problems audit contractors
Combating the problems (Audit Contractors)
  • Visit contractor websites (RAC, DME MAC, SMRC) to review upcoming areas of investigation
  • Sign up for listservs and attend free educational events
  • Develop a rapport with education staff
  • Take a look at all 4 regions’ educational materials
  • Utilize checklists internally
  • Review appropriate use of KX modifier
combating the problems audit contractors1
Combating the problems (Audit Contractors)
  • Track audits, appeals, and outcomes
  • If you notice a pattern developing, schedule a meeting with DMAC staff
  • Request reopenings
  • Practice internal audits
    • Compare to services provided
    • Review widespread review results
    • Review policies to ensure documentation and coverage criteria guidelines are met
combating the problems beneficiaries
Combating the problems (Beneficiaries)
  • Patients are equally responsible in the process
  • Medicare does not pay for everything
  • Educate patients on what Medicare may or may not cover
  • Get the patient involved and explain that they may be liable without physician records or if they don’t qualify
  • Use properly executed ABNs
combating the problems beneficiaries1
Combating the problems (Beneficiaries)
  • Know the medical policy and screen your patients to ensure they truly have the covered conditions and the documentation supports the criteria are met
  • Utilize the upgrade policy
combating the problems physicians medical providers
Combating the problems (Physicians/Medical Providers)
  • Try to get as much documentation up front or as quickly after providing the service as possible
  • Educate your physicians on the criteria for coverage
  • Begin communicating with your largest referral sources
  • Conduct risk analysis of your claims and your referral sources to determine most appropriate course of action
combating the problems physicians medical providers1
Combating the problems (Physicians/Medical Providers)
  • If they are cooperative and educated, you may not need to request documentation every time
  • If physician is not cooperating, are you willing to accept referrals from them?
    • Have you ever denied to accept a referral from an uncooperative physician?
combating the problems physicians medical providers2
Combating the problems (Physicians/Medical Providers)
  • Proactive education
    • Remind them it’s their legal obligation to comply and that you are partners in the care for the patient
  • Cover letters
    • Contractors are precluded from taking adverse action against a supplier who uses cover letters.
  • Approach the physician from a “compliance” perspective
    • Other suppliers not collecting documentation may not be in compliance
    • It’s a environment of strict regulatory oversight
    • It’s not you requiring this, it’s Medicare
combating the problems physicians medical providers3
Combating the problems (Physicians/Medical Providers)
  • Work with Office Managers and explain the need for the documentation to remain compliant
    • Could result in additional scrutiny on the physician practice as well
  • Advise physician and their staff that without documentation, Medicare may deny the claim and the patient may be responsible for payment
combating the problems physicians medical providers4
Combating the problems (Physicians/Medical Providers)
  • On March 15, 2013, Section of the amended PIM states that “physicians/LCMPs [licensed/certified medical professionals] who fail to submit documentation upon a supplier’s request may trigger increased MAC or RAC review of the physician/LCMP’s evaluation and management services”
combating the problems physicians medical providers5
Combating the problems (Physicians/Medical Providers)
  • Amended Section, states “CMS does not prohibit the use of templates to facilitate record-keeping.”
  • Templates are defined as “tool/instrument that assists in documenting a progress note.”
  • “Templates cannot merely contain check boxes, predefined answers, limited space to enter information, etc. These types of templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.”
  • Physicians who use this templates must make them the default method of documentation for DME.
combating the problems physicians medical providers6
Combating the problems (Physicians/Medical Providers)
  • Documentation of on-going need
    • Get annual orders on all on-going services
  • Illegible medical records
    • Get them transcribed or ask physician to
  • Illegible Signatures
    • Get signature logs/attestations
combating the problems physicians medical providers7
Combating the problems (Physicians/Medical Providers)
  • If your clinical records do not document the criteria from the LCD, communicate with the physician to get amendments to the documentation.
    • Amendments are perfectly acceptable if they are dated currently and clearly identify it as such.
    • Can either be additional information on previous progress notes or a new progress note that references the patients condition on the date the item/service was provided.
    • If prior to the date of service in question, it will be considered
    • Remember, it’s your responsibility to establish medical necessity prior to providing the equipment
identify problem areas internal
Identify problem areas - Internal
  • Documentation
    • Supplier documentation
    • Clinical documentation
  • Compliance
    • Billing accurately to Medicare
    • Adhering to supplier standards and policy guidelines
  • Timely tracking/response to ADRs, denied claims, and appeals
combating the internal problem documentation
Combating the internal problem (Documentation)
  • Do not highlight medical records
  • Submit only documentation that supports the need for the item in question
  • A prescription is not considered as part of the medical record.
    • Remove medical necessity information
combating the internal problem documentation1
Combating the internal problem (Documentation)
  • Do your internal documents contain all the required elements?
  • Conduct a comparative analysis of your internal documentation
    • Or as a GAMES member, vHG will do it for you, for free!
  • Are they completed fully?
    • Implement a product specific documentation checklist that must be completed prior to billing for item
  • Audit-ready files
combating the internal problem compliance
Combating the internal problem (Compliance)
  • Implement processes to get claims paid up front
    • Review policies with staff
    • Obtain documentation and review prior to claim submission
  • Internal Controls
    • Quality Assurance Program – do you have one?
  • Prior approval process
    • Review frequently audited items to be sure coverage/documentation criteria is met and have someone “approve” each delivery
combating the internal problem compliance1
Combating the internal problem (Compliance)
  • Draft written policies and procedures related to risk areas
  • Appoint a Compliance Officer and/or Compliance Committee
  • Implement a comprehensive education and training plan
  • Implement a regular audit plan
  • Respond promptly to detected offenses and develop corrective actions
  • Have open lines of communication
  • Enforce disciplinary standards through well-publicized guidelines
combating the internal problem compliance3
Combating the internal problem (Compliance)
  • Been suggested since 1999
  • Public/Private partnership in protecting the Trust Fund
  • CMS will only do business with the most compliant of organizations
  • Not having one in this environment is risky and negligent
  • Affordable Care Act makes it mandatory
  • It protects your business
  • Top-down commitment
  • Use our compliance assessment tool
combating the internal problem tracking
Combating the internal problem (Tracking)
  • Develop an internal mechanism to track audits to avoid missed deadlines
    • Redetermination: 120 days (30 days – avoid offset)
    • Reconsideration: 180 days (45 days – avoid offset)
    • ALJ: 60 days
  • Audit Tracking Tools
    • Spreadsheets with built-in formulas to identify approaching deadlines and provide warnings
    • Software
    • The van Halem Group
combating the internal problem tracking1
Combating the internal problem (Tracking)
  • Consider esMD connectivity (
    • Speeds up processing times
    • Reduces operating costs
    • Costs less
    • Better audit trail
general information
General information
  • Effective 7/1/2013
  • Enforced (WOPD/NPI) 1/1/2014
  • Face-to-face evaluation
    • Not currently being enforced
  • WOPD
    • Currently enforced
  • Physician NPI
    • Currently enforced
face to face requirement
Face to Face Requirement
  • Items that currently require a detailed written order prior to delivery per instructions in the Medicare Program Integrity Manual
  • Items that cost more than $1,000
  • Items that CMS believes are particularly susceptible to fraud, waste and abuse
  • Items CMS believes are vulnerable to fraud, waste and abuse based on reports of the OIG
face to face requirement1
Face to Face Requirement
  • Must be conducted by MD, DO, PA, NP or CNS
  • Must take place within 6 months prior to written order
  • Evaluation must:
    • Show the beneficiary was evaluated and/or treated for a condition that supports the item(s) of DME ordered
    • Include documentation to support coverage criteria and medical necessity for DME ordered
  • Must be received by the supplier prior to delivery of DME
    • Date stamp or equivalent required
  • Basic elements
    • Beneficiary’s name
    • Physician’s name
    • Date of the order and the start date, if start date is different from the date of the order
    • Detailed description of the item(s)
    • Physician signature and signature date
    • Physician NPI (NEW)
  • Must be received by supplier prior to delivery of DME
affected medical policies
Affected Medical Policies
  • Pressure Reducing Support Surfaces (PRSS)
  • Hospital Beds
  • Oxygen
  • Ventilators
  • Mechanical In-exsufflation Device
  • High frequency chest wall oscillation (HFCWO) devices
  • Positive Airway Pressure devices/Respiratory Assist Devices (PAP/RAD)
  • Nebulizers
  • Blood Glucose Monitors
  • Seat Lift Mechanisms
  • Patient Lifts
affected medical policies1
Affected Medical Policies
  • Pneumatic Compressors
  • UV Lights
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • Osteogenesis Stimulator
  • External Infusion Pump (EIP)
  • Automated External Defibrillator
  • Cervical Traction Device
  • Manual Wheelchairs & accessories
  • Speech Generating Device (SGD)
  • Other Misc DME
face to face requirement2
Face to Face Requirement
  • Regulation requires that the MD, PA, NP, or CNS conducted a needs assessment, evaluated, and/or treated the beneficiary for the medical condition that supports the need of the Specified Covered Item ordered.
  • The name of the item does not need to be explicitly documented in the face to face encounter
  • A treating MD who orders a Specified Covered Item following an inpatient stay may rely on the record of a face to face encounter performed by a hospitalist or in-house hospital MD if the encounter occurred within 6 months
face to face requirement3
Face to Face Requirement
  • The supplier must know whether all the requirements under the final rule have been met
  • The supplier must request, and the physician must provide, documentation from the of the face to face encounter with transmission of WOPD
  • Supplier will know, before delivery, if the requirements have been met
more audits
More Audits…
  • Supplemental Medical Review Contractors
  • Zone Program Integrity Contractors vs Unified Program Integrity Contractors
  • RAC Program expansion
  • Managed Care risk
  • Extrapolated overpayments
  • High dollar volume edits
the van halem group llc
The van Halem Group, LLC
  • Audit/Appeal Tracking and Reporting
  • Audit Response Solutions
  • Medical Record Collection
  • Appeal Prep
  • PreScreen Reviews
  • Proactive Audits
  • Education and Training
  • Compliance Packages
  • Compliance Program Design and Implementation
  • GAMES Discount of 10%

Wayne van Halem, President

The van Halem Group, LLC

934 Glenwood Ave SE, Suite 200

Atlanta, GA 30316

404-343-1815 (office) 404-748-1115 (fax)