- Human Interest
- O&P Practitioner
- Physical Therapist
- Other Healthcare Professional
Re: RAC Audits (Medicaid) - responses 1st batch
Posted By: Skewes, Ed on October 9, 2012
I've had two rejections thus far and surprisingly, they were for K-2 TF preparatory prostheses with standard components (locking knee, single axis foot etc)! The reasoning was our "documentation provided was insufficient to determine medical necessity". This included a detailed CMN including physician indication of K level and each specific component along with signed prescription. The worst part of this is that we had already provided the devices before being rejected and have no recourse excepting audit. We did not have an ABN signed as we had no idea these wouldn't be covered.
If you post please exclude my info.
State Medicaid rules vary and may not be representative of Medicare Policy. Best to review your provider manual to make sure you are in compliance and stay current with periodic updates.
Not sure how goes it in your state, but here in WA this is what we have to satisfy:
The prescription must be:
* Signed and dated by the prescriber;
* Be no older than one year from the date the prescriber signs the prescription; and
* State the specific item or service requested, diagnosis, estimated length of need
(weeks, months, or years), and quantity.
All form must be complete (no blanks) and must be signed by the clinician to include their credentials.
* If a letter of medical necessity is obtained for the services provides please remember:
* The letter must be signed and dated by the clinician (to include credentials).
* If using chart notes, they must be signed and dated by the clinician (to include credentials).
* The letter should include client specific justification for the service and all related accessories/items.
* The RX must be dated prior to the LMN and/or chart notes used as a LMN.
* Should be documentation of tried and failed less costly alternatives.
So, should they go 2 years retro, that's going to be fun.
ALSO NOTE FOR PRESCRIPTIONS:
Prescriber's signature must have credentials and currently we do not accept stamped or electronic signatures.
* Should be legible.
* The signature date is the valid date of the prescription.
* For a new request prescription can be no older than 90 days.
* For extension - prescription must be less than 1 year old.
LMN and Rx are not enough. The Dr. notes have to be really good, which as you say makes us responsible to make sure the doc writes a decent note. It is virtually impossible to make sure they do it. I don't know how many times you can ask a doc to rewrite their note before they find someone else or quit ordering things. There are going to be a lot of shops having financial problems over this. P
Prosthetics & Orthotics
Altru Health System
[E-mail Address Removed]
Improving Health, Enriching Life
Here is a web site with a list of current state RAC audits: http://www.medicaid-rac.com/medicaid-rac-activity-by-state/ and here is an article that might be helpful: http://www.ama-assn.org/amednews/2011/09/26/gvl10926.htm .
I suggest that you reviewe your state's documentation guidelines and make sure that you are meeting them. Also look at the bulletins for any updates. Pay careful attention to the effective dates. Then use that information to demonstrate that you did indeed meet the requirement as stated. Then make yourself a documentation checklist to use going forward to make sure your charts are in compliance.
CONFIDENTIALITY NOTICE: This e-mail communication and any attachments may contain confidential and privileged information for the use of the designated recipients. If you are not the intended recipient, (or authorized to receive for the recipient) you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please destroy all copies of this communication and any attachments and contact the sender by reply e-mail or telephone (813) 281-0300.
|The message above was posted to OANDP-L, the e-mail discussion list for orthotics and prosthetics.|