wayne h. van halem, ahfi, cfe president the van halem group, llc 934 glenwood ave se; suite 200...

Wayne H. van Halem, AHFI, CFE President The van Halem Group, LLC

934 Glenwood Ave SE; Suite 200 Atlanta, GA 30316

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– Meet criteria for items/services– Liability

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 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

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 (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

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


• 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?


• 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


• 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


• On March 15, 2013, Section 3.3.2.1(C) 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”


• Amended Section 3.3.2.1.1(B), 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.


• 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


• 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

• 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

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 (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)

• 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


• 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


COMPLIANCEPROGRAM


• 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)

• 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 (Tracking)

• Consider esMD connectivity (www.cms.gov/esMD)– Speeds up processing times– Reduces operating costs– Costs less– Better audit trail

DWO and Face-to-Face requirements

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

• 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


• 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

WOPD

• 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

• 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 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


• 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


• 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

What does the future hold?

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

But don’t be scared. Just get prepared.

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%

QUESTIONS?

Wayne van Halem, PresidentThe van Halem Group, LLC

934 Glenwood Ave SE, Suite 200Atlanta, GA 30316

404-343-1815 (office) 404-748-1115 (fax)Wayne@vanHalem Group.com

www.vanHalemGroup.comwww.HCComply.com

wayne h. van halem, ahfi, cfe president the van halem group, llc 934 glenwood ave se; suite 200...

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