The Best Defense is a Good Offense!

Posted on in Billing/Reimbursement

the-best-defense By: Pam Felkins Colbert, JD, Vice President, The van Halem Group

How’s Your Defense?

With fall in the air, we automatically think of football, whether it is NFL, SEC, or high school! The “the best defense is a good offense” adage applies to football and many other endeavors, including billing for health care services. All providers and suppliers are keenly aware of the numerous Medicare contractors’ pre-payment reviews. The results of these audits are published for all to see and learn that your best defense is a good offense. Your “good offense” is complete and accurate documentation to support your claims. Reduce your errors and increase your revenues! The DME MAC for Jurisdiction A, NHIC, has published specific examples of errors identified during the CERT reviews of “Common Errors on the Power Mobility Device (PMD) 7 Element Order” over the past years, which include:
  • No 7-Element order submitted
  • Order missing one of the 7 elements
  • No confirmation the supplier received a copy of the 7-Element order within 45 days after completion of the Face-to-Face
  • 7-Element order and detailed product description are on the same document
  • 7-Element order is dated prior to the Face-to-Face
2013 CERT DME Taskforce webinar NHIC, Jurisdiction A DME MAC, published another CERT report on May 21, 2015, of specific examples of errors identified during the CERT reviews of Power Mobility Devices (LCD L21271) from October to December 2014 claims submitted, which include:
  • Missing: Signed & dated attestation by supplier or the LCMP that the LCMP has no financial relationship with the supplier AND Documentation that the wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional, who had a direct, in-person involvement in the wheelchair selection for the beneficiary (K0861-NU-KH PWC Group 3 / E1008/E2311/E2377/E2313/E1028/E0955/E1028/E2326/E2617-NU-KX) date of svc: 12/23/13
  • Missing: Face-to-Face exam from referring MD which clearly supports the beneficiary presents for a mobility exam (K0856-NU-KH – PWC, Group 3 / E1002/ E2620/ E2310/ E0955/ E1028/ K0040/ E2361/ E2209/ E2622-NU_KX) – date of svc: 11/15/13
CERT Connection Error Article – View page 5 The 2014 HHS CERT Report found that of the Top 20 DMEPOS Service Types with Highest Improper Payments, Wheelchairs ranked No. 8 (Motorized), No. 11 (Manual) and No. 14 (Options/Accessories). The primary error for each was insufficient documentation, which was No. 8 / 94.7%, No. 11 was 94.9% / and No. 14 was 87.7%. Once you are on CMS’ radar for ongoing errors and potential fraud and abuse, it is very difficult to get off. As seen from the above reports, the same errors continue from year to year in the submission of claims for PMDs. As a result of this pattern, CMS announced on July 15, 2015, that the Prior Authorization of Power Mobility Devices (PMDs) Demonstration, which was scheduled to end on Aug. 31, 2015, would be extended to Aug. 31, 2018 for all 19 states (the original 7 states and the 12 additional states added in July 2014). The Prior Authorization Demonstration project found that expenditures for PMD claims processed from September 2012 - November 2014 for PMDs had a decrease from $20 million to $3 million in the 7 demonstration states. The number of beneficiaries receiving PMD in the 7 states decreased by 69% and in the non-demonstration states, they decreased by 65%. With the substantial savings identified in the Preauthorization Demonstration, and with the ongoing error rates in the 2014 CERT Report, it’s time to realize these errors can cost you the game! DME MAC Jurisdiction D, Noridian, is conducting a specific Medical Review of HCPCS code K0823 and all related accessories. June 16, 2015, the report for the final edit effectiveness results from October 2014 – February 2015 found that the review of 273 claims for K0823 had 145 claims denied, which was a potential improper payment of 54%. They found that the documentation didn’t support the claim, didn’t have detailed product description, didn’t support the beneficiary’s mobility limitation and some had NO documentation submitted. Noridian noted that Suppliers are in violation of Supplier Standard No. 28, when upon request, they fail to provide requested documentation to the Medicare contractor, adding the consequences of failure to provide records may not only be a claim denial but also a referral to the NSC. Not sending in any records equals just not showing up on the field. Producing all but one document or incomplete document is a fumble you can’t afford.

A Strong Defense is Needed in All Arenas

CMS is now monitoring your error rates under a new Final Rule and it can cost you more than the game. It can cost you your billing privileges. CMS issued a new “Final Rule” on Dec. 3, 2014, under authority of the Affordable Care Act, for “new safeguards to reduce Medicare fraud.” This new rule “improves CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare.” CMS now has the authority and ability to:
Revoke billing privileges of providers and suppliers that have a pattern or practice of billing for services that do not meet Medicare requirements. This is intended to address providers and suppliers that regularly submit improper claims in such a way that it poses a risk to the Medicare program.
Do you submit complete and accurate supporting documentation? Do you file duplicate claims? Did you use the correct code or modifier? Know the answers to these and other questions to build your strong offense during these audits and you will have a strong defense in protecting your billing privileges and your revenues. Another arena where a strong offense is required is with the Recovery Audit Contractors (RACs). CMS has made numerous changes to the new RAC contracts, which were rebid and are currently under bid protests. Once the new RAC contracts are final, there will be one national RAC for DMEPOS. One of the “improvements” by CMS in response to “industry feedback” is that ADRs limits will be based on the provider’s / supplier’s compliance with Medicare rules. So the lower your error/denial rates are, the lower your ADRs requests will be … and vice versa!

How Do You Strengthen Your Defense? Internal Auditing!

Internal Audits are like going to the weight room and working out to build your muscles and strength. It is critically important that you perform internal audits and monitor your claims to ensure complete and accurate documentation - before THEY audit you. It is critically important that you identify and correct errors in your claims. It is critically important to not “regularly submit improper claims” or “have a pattern and practice of billing for services that do not meet Medicare requirements” and pose a risk to the Medicare program. Otherwise, you are at risk of increasing more pre-pay and post-pay audits by CMS contractors and even having CMS revoke your billing privileges. Stay strong! Build a great offense for the best defense of your services!
About The van Halem Group, LLC Our business is understanding the nation’s preeminent health care entitlement program. Since the program’s inception in 1965, its amended and growing charge has often confounded beneficiaries and providers, troubled oversight agencies, and in the worst cases, allowed for fraud and abuse within the system – costing Americans millions. Our proven experience and sound counsel, captured in lectures and publications, has uniquely positioned us as a resource to health care providers, government agencies, Medicare contractors, legal counsel, law enforcement and journalists.   The van Halem Group, LLC is a small business that has become the nation’s most respected Medicare consulting and auditing firms. Collectively, our leadership team has over 130 years of related experience. Since 2006, we have helped our clients navigate complex issues related to Medicare and Medicaid. We specialize in compliance, audits, investigations, medical review, appeals, enrollment, coding, education and training.   Learn more at