Audit Allies: How Extending Your Resource Base Is Critical for Surviving Documentation and Audit Challenges

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Like many orthotics and prosthetics (O&P) practitioners these days, Christian “Zach” Smith, CPO, has run up against Recovery Audit Contractor (RAC) audits. They’re painful. They’re time consuming. And they’re a danger to his bottom line.

“As a practitioner, they certainly have had an impact on me in that they make me almost second guess every clinical decision I make,” says Smith, owner and CEO of Victory Orthotics & Prosthetics in Johnson City, Tennessee.

Smith’s latest run-in, he says, was a post-payment audit on a claim for items delivered to an inpatient under the two-day rule. As he remembers the rule, a practitioner could fit an orthosis while the patient is in the hospital under certain stipulations.

“We, of course, were fighting it,” Smith says. “We were following those guidelines. At some point, the requirements apparently changed, unbeknownst to us, and we still haven’t found what exactly…[the Centers for Medicare & Medicaid Services (CMS)] changed. They are saying the two-day provision was never meant to be about orthotics.”

Employees at his office spent about a week looking for the documentation to back up why it was allowable to submit the claim under the two-day rule, Smith says. He even had help from major manufacturers, all to no avail.

“Some of the best advice we had gotten was use their own regulations against them,” Smith says. “That was our goal, but we couldn’t find them. We couldn’t find the policy written anywhere.”

That can be the most difficult part of fighting RAC audits, says Molly McCoy, CPO. McCoy is the clinical partner for SPS’ Clinical Outcomes and Documentation Education (CODE) program. CODE is a new program that provides practices with individualized documentation support and education as well as RAC audit support.

“Independently operated O&P facilities are often very small companies with only a few people in the office,” McCoy says. “It takes a full-time person to do all the research and the documentation to keep up with the regulation changes.” CODE, she says, can help. “We can assist with all types of documentation for clinics,” she says. “We can do the research for them and…help them get paid and stay paid.”

Victory Orthotics & Prosthetics has three offices with 28 employees in all, including eight clinicians. In need of help, Smith says he contacted McCoy by e-mail. She went to work and had the documentation he needed in just five hours.

“They were denied in the hospital because of a reinterpretation by…[CMS] of the Medicare two-day rule,” McCoy says. “They needed ammunition to go back and argue their point.”

Smith says McCoy helped him fight back.

“We wanted to use Medicare policy to fight the issue,” he says. “We needed a document and she found it…. I certainly wouldn’t hesitate to contact her again.”

For practitioners like Smith, CODE could be just the right help at just the right time. RAC audits are increasing throughout the U.S. healthcare spectrum—not just in O&P, according to a June 2013 statement by the American Hospital Association (AHA). But smaller practices don’t have the necessary personnel to keep up with all of the changes, which seem to be happening with increased frequency.

“As an industry, we can’t take these things lying down,” Smith says. “This issue is just one thing on our plate among 50 other things.”

In the few weeks since its launch, the CODE support team has found that there is no real trend to denials or RAC audits, and that is what makes them so difficult to fight, McCoy says. “We’re talking about practitioners who understand these regulations, who look at them all the time and are trying to abide by the rules, but then all of a sudden the rule changes or is interpreted differently.. You can’t keep up.”

CODE was an idea five years in the making. It is the brainchild of McCoy and Regina Weger, SPS’ marketing manager, but back then the timing wasn’t right, they determined.

“Since then, we’ve been looking to see where this was going to go,” McCoy says. A year and half ago, she and Weger were talking about the best way to help practitioners and saw that other companies that were providing RAC audit support were using templates and restating regulation in understandable terms. “But we were looking for something that would be different.”

What they came up with is a way to combat RAC audits that is tailored to the individual problem faced by the clinic. There is no one-size-fits-all approach, McCoy says.

“It’s personalized, one-on-one,” Weger adds.

CODE is currently seeking to expand its educational resources for practitioners. McCoy is in the process of producing several 15-minute videos that address RAC issues and documentation, which SPS plans to post on its website and make available to practitioners at no charge. Written material isn’t always interpreted correctly, Weger says, and the videos will be an effective alternative to the written resources currently available on RAC audits. “The videos are unique to us,” she adds.

For O&P clinics, RAC audits are a bottom-line issue, McCoy says.

“Let us take the time to look up those regulations,” she says, “to help you fight the fight so that you’re not spending your hours doing that. We will help you free up time and get paid for the…[work] that you are doing.”

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