- Human Interest
- O&P Practitioner
- Physical Therapist
- Other Healthcare Professional
Medicare Pre Payment Audits, Suggestions for Changes
Posted By: Jim DeWees on August 17, 2012
We have all seen several posts regarding these Pre Payment audits now, and we all recongnize now what this impact is going to be on our lives.
I feel that we can all come up with some suggestions or ideas that can help STOP this madness and hopefully get some things changed regarding the fraud and abuse that has sparked this situation. I will try and keep this short (try is the key word).
The problem: The OIG report states that the cost of lower limb prosthetics has risen something like 23% in speding, but the number of prosthetic limbs being provided went down 7% (not sure of the exact figures...this is from memory, which doesn't always work perfectly....maybe too many resin fumes now in my life).
Also, they claim that a significant number of the claims examined were not complete, missing modifier codes, or missing documentation, signatures, etc.
Now, the CAUSE of these "problems" or "findings" in the OIG: First of all, I don't think that ANY of us are 100% clear on the rules "TODAY". There is massive confusion on what is being required, what we are responsible for, and what we are expected to do. Some of this is an area of concern that I have, we have all seen some questions here in emails from prosthetists and orthotists that seem to be quite basic questions, and also that nobody in this field should be asking such basic questions, and if they don't know this basic information, how are they really working in this field (no offense to anyone on here). But this shows that even through our education, and also required continuing education requirements, something is missing.
Also, I have pointed out to some people on here, I keep ALL of my emails from the CMS (or NGS) listserve. I get a LOT of emails from them. My file on this computer dates back to Aug 4, 2011. It is just barely over one year old now. This file has 843 emails in it. ALL of them are from CMS. They all contain information about policy changes, or regulatory changes. Most of them just point to a website where we are supposed to go and read about these changes, and figure out what they are really saying. Many times, when I try to click on the website they include, it is "NOT FOUND" or missing page. So I have no idea what the changes were for that day!
Doing the math, in one year, there are 260 "business days", but taking off the federal holidays, it is roughly 248 days in a year. Then adding an extra week to my file, we are at roughly 253 business/work days. There were 843 emails sent out, making it nearly 4 emails per DAY!! This is nonsense.
Something kind of humorous that I want to share: Two weeks ago there was an Update regarding CPAP devices, and what it NOW required to bill for them. Then 2 days later, there was an ammened policy that came out which you had to open up the previous one, and then do some changing of words and figuring out what they REALLY mean. Then it got better, and 2 days later, MORE changes were made. Then the FINAL email came out (well, no more emails about this YET) , but when you look at what was added, then taken back, and re-worded, then revised....it comes back to just exactly how it was before these changes started. But now the paragraph on billing requirments is twice as long, but just twice as hard to read and understand what they want or require.
SOLUTIONS: This is the challenging part for us to come up with, but we MUST find some kind of simple suggestions for legislative changes that can be written and changed in DC.
1. I feel it is reasonable for us to demand that CMS can only make policy changes and requirement changes 2 times per year. They can work on changes all year long, BUT they can only announce these changes the end of June and December (or whenever, that is NOT important what months, but just every 6 months seems to be reasonable). WHEN they make these changes, they must give us 60 days (is that enough??) for us to get these in place, and implemented in our offices.
Also, they MUST have seminars or meetings in locations that are convenient, accessible, and reasonable that are not a financial hardship on us to attend. While none of us can be FORCED to attend these, at least they are available, and that gives us NO excuses for not knowing what the policies are.
Also, they must provide us with a packet of information that has CLEAR examples of what is now required, and what a "perfect" claim would look like.
2. They must prohibit CMS (NGS or whoever else is doing these audits) from doing the Pre-payment audits. We all work under a contract with CMS (thus..."Contracted Providers") We have obligations to abide by their rules, provide quality services in a timely fashion to the Medicare patients. AND at the same time, CMS is obligated to pay us in a timely manner for our work. These pre-payment audits are NOT something that would fall in this contract we have, and is something that they did one-sided to us.
We need to demand that CMS can only do audits AFTER the fact, and investigate for fraud when they have reasonable information or legitimate reasons to peform an audit. Just like any police office must have reasonable information that would cause a judge to issue a search warrant for someone's home or business, I feel that CMS must also have credible information that would trigger an audit. Doing these "blanket audits" is just plain wrong!
3. We should have the L-code system modified and make it where that only prosthetist that is certified or licensed can bill for the L-codes associated with lower limb prosthetics. We all have our Medicare Provider ID number, and we have all been visited by someone contracted by CMS in order to obtain this provider number. CMS needs to fix their system so that only Prosthetists can bill for these codes. That, to me, seems totally reasonable.
I realize there is the bill going around now, S.773, that our organzations are trying to push into law. But the problem I see with that bill is the there is the "exemption" for others who are doing O&P work, and billing for this work. This is a big area where the "fraud" is coming from (at least from my point of view), and this gives a "back door" entrance to others that are doing O&P and have no formal education or training to do this. So as long as this bill exempts other kinds of providers and gives them the right or authority to do O&P work, and are not being held to the same requirements that we are held to, I really have a hard time supporting this bill.
I think these are some reasonable suggestions to help fix this problem, and to stop this pre-payment audit deal going on. AND also this will help cut down on the "Fraud" which is more due to technical paperwork issues than anyone lying or doing illegal things just to make more money.
Let me know what you think of this, and if you have better suggestions, or more suggestions, please let me know. I am trying to compile ideas like this, and come up with something that we can all send to our lawmaker, representatives, politicians, and hopefully get ahead of this issue, and not just keep on working at it, putting out fires, or whatever.
Jim DeWees, CP
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