Audit Climate – Taking The Temperature

Published in Government Relations on May 22, 2024

Audit Climate This post was originally featured in Medtrade Monday.

As we near the midpoint of 2024, what are the main billing/reimbursement headaches being faced by providers?

As senior director of Payer Relations at VGM since 2012, Ronda Buhrmester has helped HME providers with countless billing and reimbursement questions. With roughly 30 in-person visits per year to HME companies and trade shows, Buhrmester is all too familiar with onerous audits and other challenges.

Medtrade Monday sat down with Buhrmester and colleague Kim Cucé, director of Business Optimization at VGM, to get a better idea about the headaches being faced by providers as they near the midpoint of 2024.

Medtrade Monday: How would you characterize the current audit climate?
Buhrmester: It’s onerous. It’s not only traditional Medicare or Medicare fee for service that are preferring the audit. Suppliers are getting hammered by all the payers, whether it’s a pre-pay audit or a post-pay audit.

Medtrade Monday: What types of examples are you seeing?
Buhrmester: Suppliers would pass an audit for certain HCPCS [Healthcare Common Procedure Coding System] codes and think they’re done, and the next thing you know they’re getting another audit in the same product category—just different HCPCS codes. They could be pulling the same documentation for the same patient, so it’s onerous. We’ve even learned that suppliers now have audit departments and audit teams. That’s a non-revenue generating area.

Cucé: We talked with suppliers at the Great Lakes conference and they had 22 active TPE [Targeted Probe and Educate] audits, with all different HCPCS codes. They actually wrote to CMS and CMS paused some of those audits because they absolutely could not keep up with them.

Medtrade Monday: What are the common mistakes you’re seeing?
Buhrmester: Well, unfortunately it becomes a policy interpretation issue. It essentially becomes subjective. It’s unfortunate that the interpretation of medical records, as written by physicians or practitioners, will fall on DME suppliers to ensure that it follows policy. The interpretation leads to challenges. We know audits need to continue. However, the scrutiny that gets performed with these audits has gone a little too far.

Medtrade Monday: Do you have an example of that?
Buhrmester: CMS had made oxygen policy more lenient and not so burdensome during the pandemic. That policy has changed and oxygen audits are at a top five error rate. The number one error is the testing requirement where they’re expecting the physician to co-sign or mention in a medical record that they’ve reviewed the test results. We know that there’s language in the national coverage determination by CMS that says there needs to be evidence that this has been reviewed. However, it’s gotten to the DME MAC level and they’re interpreting that as meaning that physicians need to co-sign or mention those test results in their visit with the patient. That’s where we think it’s gone too far, and we’ve actually had open communication with the medical directors on this topic to actually look at that again.
Cucé: CMS would have suppliers go back and ask the doctor to co-sign, and it’s almost like we’re questioning the doctor. Physicians are saying, ‘Of course I reviewed it. I wouldn’t have ordered the oxygen if I didn’t review it.’ So it’s almost like we’re questioning the physicians and they’re becoming very frustrated.

The doctors say, ‘It’s part of my medical record. I ordered it, I saw it, and it’s a need. Why do I have to sign something now?’ It’s gone too far. We’re hoping that the DME MACs will review this because it has become a burden. We’ll see. This conversation with them just literally happened a few weeks ago. So we’re hoping they will circle back and not be so strict.

Medtrade Monday: Is there a timeline to revisit?
Cucé: It’s up in the air. When they say that we’ll take this back and talk about it, that’s where it’s left. They won’t give us a timeline. We have another meeting this summer. We hope before then, but we’ll see.

Medtrade Monday: What is the situation with competitive bidding right now?
Buhrmester: Right now we’re in that gap period. Competitive bid contracts ended at the end of last year. CMS is revisiting the language and the next round, so that’s why there’s a pause. The next round probably won’t be implemented until 2026 at least—maybe farther out than that, because we know it takes at least 18 months to go through that entire process of the announcement of the competitive bid round, evaluations, and then announcing the contractors. They’re nowhere near that. Will it happen? Another round will happen at some point because it’s in legislation. The competitive bid is law, so it has to happen—unless language is changed to remove it.

Medtrade Monday: What are the most frequent concerns that you hear?
Cucé: Providers are feeling defeated. They’re not seeing a bright future on the financial side. They’re frustrated, because at one point during the pandemic we were recognized for our services because we were playing a critical role in the post-acute health care model. Instead of continuing that recognition, they’re almost getting slammed now back to reduced rates, plus audit burden. It’s like our costs went up and reimbursement went down. Some providers and suppliers almost feel like they’re being attacked.

Buhrmester: Along with that, there are staffing issues. That’s been a big struggle for suppliers. Even though we say it doesn’t seem so bright for suppliers, we’re trying to find solutions. You don’t have the allowables right now, and we don’t know what’s going to happen with those in the future—but there are options. You can do non-assigned. You can offer cash. You can automate more of your work to remove some of those FTE components. Using bots for prior authorization submissions is one example. We have to be open to those changes and those opportunities.

Medtrade Monday: How can HME providers avoid audits?
Cucé: I don’t think you can avoid audits at this point. The better question is how do you survive them or pass them? There are softwares that do help with all of that, but even with the best of softwares, when there are misinterpretations of the policy from the reviewer, even the best of software is not going to help. One of the things in the SOAR act is the clinical template for oxygen. We’re hoping to get this passed, because that clinical template allows physician and nurse practitioners to fill out the key components that are needed for oxygen.

It has all the coverage criteria listed, so it’s easy for physicians to go in and answer these questions in their EMR and then sign off on it. That would then get sent to the supplier and be considered the medical record, along with getting an order and that is supposed to help in the audit situation. If we can get these clinical data elements [CDEs], that would be a huge factor for DME suppliers and physicians. It would also help patients to get the products they need to treat their health conditions.

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