Key Information for Refill Requests: Audits Are Happening and Will Be Intensifying!

Posted on in Government and Advocacy

By Ronda Buhrmester, Director of Reimbursement, VGM & Associates

As a DME supplier, don’t take for granted the documentation requirements for refill requests. Audits do happen and will happen when least expected from a pre-payment or post-payment contractor. Refill requests must be completed for consumable and non-consumable supplies when a patient is requesting a delivery to their home.

Consumable supplies are those that get used up such as ostomy, urological, diabetic test strips, and surgical dressings. Non-consumable supplies are those that are more durable that require periodic replacement. Some of those supplies include CPAP supplies, BiPAP supplies, mastectomy products, etc.

If the patient comes into your store to pick up the supplies, a refill request is NOT required. 

Refills cannot be dispensed automatically; there needs to be communication with the patient to assess the need for the refills. This communication can occur no sooner than 14 calendar days prior to the shipping date. When contacting the patient, the refill request information must be documented, whether it’s on a supplier-created form, template in billing software, or an automated service. No matter the method of patient contact, the information needs to be documented. In the event of an audit, this information will be requested.

Refill Requirements

Here are the requirements for a refill request: 

  • Name of patient or authorized representative
  • Date of request
  • Description of EACH item being requested
  • For consumable supplies: The quantity of each item remaining until nearly exhausted
  • For non-consumable supplies: Assess why each item is no longer functional, such as:
  • CPAP mask is broken
  • Mask interface is not sealing, causing leaks
  • Filter is discolored
  • Mastectomy bra is stretched out

The Detailed Written Order

Next step: Check your detailed written order. Is it valid? Has it expired? State laws determine the length (time frame) for which an order is valid. Most state laws require an annual order for supply-type items such as the ones discussed in this article: ostomy, CPAP supplies, etc. It’s highly recommended to get an order annually to meet not only the state law requirements but also the continued medical need requirements. Continued need says timely documentation is within the preceding 12 months, which can be in the form of the chart notes (office visit) or an order.

Another key element for DWOs is making sure to include the frequency of refills for each item. For example, CPAP nasal masks can be replaced once every three months, tubing once every six months,  ostomy pouches depend on the type of product but changing can be once every three days. Depending on the type of product, it is very important to have all the elements on a detailed written order for it to be valid.

Proof of Delivery

The final step is the proof of delivery. When a patient walks into your store to pick up the product, make sure the proof of delivery lists your store’s address as the delivery address, or the patient’s address is crossed out, or have some indicator that the product was picked up in the store. If this is not done, the delivery ticket appears as though it was a delivery or shipment to the patient’s home. This can cause an unfavorable decision in an audit if it is not clear on the proof of delivery that it was an in-store pick-up.

When a delivery service is being used to ship the product, a tracking number is created. The records must link the shipping invoice (with the tracking number) to the confirmation of delivery from the shipping service (USPS, FedEx, UPS). The confirmation of delivery (USPS, FedEx, UPS) must be pulled from the shipping service’s website and stored in the patient’s file. The confirmation of delivery is part of the documentation that will be requested in an audit along with the shipping invoice that, again, links to the tracking number. The shipping services DO NOT store these confirmations, so DO NOT expect it as it will be gone within months.

Following the requirements for requests for refills is so important because audits are happening with CPAP supplies now and will escalate as seen in this OIG report. While this report is related to CPAP supplies, audits can occur for any refill request items, both consumable and non-consumable.

For those suppliers who dispense CPAP supplies, this is the time to do a self-audit. Run a report of your CPAP supply patients, and check their files for the following:

  • Valid DWO
  • Request for refill documented
  • Proof of delivery completed
  • If a shipping service is used, a copy of the shipping invoice AND confirmation of delivery with tracking number that links all together

Please contact me with any questions.

Ronda Buhrmester, CRT, CFm
Director of Reimbursement, VGM & Associates
C: 217-493-5440
[email protected]