Responses to : Cert Audits in regards to lacking physician documentation - Medicare Region A part 1
Marty Mandelbaum
Description
Collection
Title:
Responses to : Cert Audits in regards to lacking physician documentation - Medicare Region A part 1
Creator:
Marty Mandelbaum
Date:
8/10/2012
Text:
Original questions
*Dear List serve:*
*How many facilities are having problems with obtaining the clinical
information required by these Cert audits?*
*How many of your physicians are refusing to comply with these requirements?
*
*What are typical responses besides I don't get paid enough to spend all
this time for you to get paid?*
*Does it seem reasonable that in example 2 below that a replacement socket
would need this missing information if it was provided for the original
prosthesis?*
*Are there vascular surgeons in private practice that are willing to
provide a comprehensive evaluation for a prosthetic prescription?*
*Would it seem proper to have only physicians knowledgeable and willing to
complete a full evaluation to be the only ones able to prescribe a
prosthesis?*
*How many patients do you feel are being delayed or denied care because of
these requirements?*
*Thank you for your thoughts.*
*
*
****Note the CERT error examples cited in my question were posted in NHIC
DME MAC A Listserve they were not directed to my facility.*
*
*
*Responses (below did not seem to answer my questions)*
*
*
By the way AOPA is doing something about it see email from Tina Moran RE:
The Impact of RAC Audits in O&P Profession Aug 8th will be part two of this
as it exceeds line permitted.
*
*
*1- *Its happening to all of us and AOPA just ignores it.
*2- *Can I ask what region you are in? I am hearing several stories like
yours and was wondering what part of the country you are in... Thanks! And
Good Luck!
*3*- This Ridiculous requirement has been met w/apathy by our docs. Vasc
docs won't even dictate the eval when given to them. Not in their realm of
practice, I was told...so I asked the Physiatrist who oversees an amputee
clinic in our area if I can refer pts to him for an eval. Not unless pt
goes through his rehab! So fittings are delayed as pts wait to get into
see their PCP (sometimes up to a 5wk wait!)...then their documentation is
very poor relating to pt's prosthesis or prosthetic needs. Some won't
even look at a residual limb as THAT's not in their realm of knowledge!
We have 2 cases right now where physician signed but did not date Rx.
Their computer/fax machine dates the document so this is what we are
appealing with as our Pharmacist told us their Rx's are almost never hand
signed by docs, but computer or fax dated and this is Never questioned
except for controlled drugs.
All pts prosthetic intervention has been delayed & it will be years before
they figure out it is costing MORE.
Good Luck
*4- *I opened a small practice 2 years ago and I live in fear of a CERT.
That is pretty annoying. I have purchased OPIE and meet every week to make
sure we have all paperwork and continually talk to my pracs about proper
notes since even LMN's are not considered part of the medical records. I
would be interested to hear about your experience with this. Is there
someway to communicate that this seems unfair? How can we be responsible
for notes kept by a doctor who we have no relationship with other than they
signed the Rx. The prosthesis is probably the last thing on their mind
other than the fact that the patient needs one. This part of the medicare
system seems terribly unfair to me. I think our profession should find a
way to communicate and change this if possible. We have no control over
the effectiveness of notes kept by referring doctors. They signed it what
more can we do? Essentially what medicare is doing is saying you haven't
really earned any money until you have been audited and we determine you
don't have to give it back. And they can take it back even if you have a
detailed Rx, good notes, and have been perfectly honest if the doctor
who referred it has not documented properly that the person needs what you
have provided.
*5*- I just attended our local Medicare workshop last week and they
informed the group that all prosthetics are going to undergo a prepayment
audit to make sure what they pay for is what the patient needs and will
benefit from. Detailed prescriptions with doctor signatures was high on the
list of things they are looking for. Make sure to type in the doctors name
and NPI number under his signature so it can be identified as who the
doctor is even if it has his name at the top of the Rx. Crazy. I see you
billed for 12 stump socks. That is to many for one billing. Max number
allowed is only 6. Bill 6 more later in the year. They allow 12 per year
but only 6 at a time.
Those are just some of the things that came out of the discussion.
Make sure you attend your Medicare meeting in UpState NY when they schedule
it.
*5A* - 2nd response from same person
Hi again,
My question to the Medicare reps was why punish us, why not the docs who
order the stuff. There answer is because the doctors get paid by a
different division and are not in the same system as the DMEPOS suppliers
are. There will be cross communication in the future to the doctors
insurance group later once they decide how to approach them about this
subject. Our Medicare reps from region B are attending the MD's Medicare
seminars already trying to get information to them the best they can but
they don't have official dialog with them.
That is the response I got when I asked the question.
*6*- I have been putting off patient care until I get physician chart notes
that I think will meet the Dear Physician letter requirements. Its
CRAZY. I have a younger bilateral on disability that has not had a primay
care physician in his life, and has an unusual cognitive disability and no
social worker. He has now been to 4 or 5 different physicians to try and
get chart notes that meet the new Dear Physician standard without
success. Even when I send a copy of the Dear Physician letter for them to
read The Docs either don't understand or don't care. the first couple of
his attempts were to urgent care settings and there is info on blood
pressure and the patients pleasant personality and a sentence or two
about patient is here to get documentation to get his legs fixed from limb
maker but nothing that comes close to an
intelligent prosthetic assessment .... This guy is stumbling around with a
pair of damaged prostheses that cause breakdown and fall off when he tries
to resume The K4 LEVELS HE HAS BEEN AT FOR MOST OF HIS LIFE AS AN AMPUTEE.
This scenario has been repeated with a number of other patients. I also
have a situation where someone had an MVA resulting in a very short
transhumeral amp .Pt had good insurance and support I was able to fit with
myo hand/ linear transducer control/ boston elbow prosthesis. Pt got good
O.T. and was & is a daily prosthesic user. Pt lives hours away and did not
come back for a couuple of years. Went to local limb shop and got some
adj/repairs that were not to their satisfaction and came back to me.....Now
pt has gained weight socket no longer fits, linear transducer is broken and
pt is on social security disability. I get an RX cast and myo test for
socket replacement send the elbow back to Liberating Technology for
assessment and sensor speed hand back to Bock. the repair costs are10 to
15% of the replacement cost so I think no problem medicare would much
prefer a $12,000. socket replacement/hand/elbow refurbishment that
a $90,000.00 arm replacement.... wrong ! They won't pay for any of the
claim! I now have another big buck appeal and I have paid Bock and
Liberating Technologies for the repairs already not to mention new iceross
liners and refabricating the entire humeral section socket/frame wiring and
harnessing (I'm a dinosaur and still know how to make all this stuff on my
own so I do.) The denial said medicare won't pay to repair devices that
they did not pay for originally . So let that be a lesson if you get a
baby boomer that has a c-leg or vsp flexfoot that was paid for by another
insurance medicare won't pay for you to fix it but the may pay to replace
it but only if you have documentation that meets the Dear Pysician level
of documentaton. Even then there is no gurantee that you will get to keep
the money. They can go back three years to recoup payments that don't have
dear Physician levels of documentation...... I now have about $65,000.00
in appeal with medicare on 3 claims (most recent being a MPK definitive del
on a new amp That I think I have good physician chart notes on. This is
our new reality. I think the noise has to come from the patients and the
amputee coalition. It is our job to get our patient on board with the
coalition.... I have seen nothing out of the amputee coalition and their
board members have not returned my calls.
*Dear List serve:*
*How many facilities are having problems with obtaining the clinical
information required by these Cert audits?*
*How many of your physicians are refusing to comply with these requirements?
*
*What are typical responses besides I don't get paid enough to spend all
this time for you to get paid?*
*Does it seem reasonable that in example 2 below that a replacement socket
would need this missing information if it was provided for the original
prosthesis?*
*Are there vascular surgeons in private practice that are willing to
provide a comprehensive evaluation for a prosthetic prescription?*
*Would it seem proper to have only physicians knowledgeable and willing to
complete a full evaluation to be the only ones able to prescribe a
prosthesis?*
*How many patients do you feel are being delayed or denied care because of
these requirements?*
*Thank you for your thoughts.*
*
*
****Note the CERT error examples cited in my question were posted in NHIC
DME MAC A Listserve they were not directed to my facility.*
*
*
*Responses (below did not seem to answer my questions)*
*
*
By the way AOPA is doing something about it see email from Tina Moran RE:
The Impact of RAC Audits in O&P Profession Aug 8th will be part two of this
as it exceeds line permitted.
*
*
*1- *Its happening to all of us and AOPA just ignores it.
*2- *Can I ask what region you are in? I am hearing several stories like
yours and was wondering what part of the country you are in... Thanks! And
Good Luck!
*3*- This Ridiculous requirement has been met w/apathy by our docs. Vasc
docs won't even dictate the eval when given to them. Not in their realm of
practice, I was told...so I asked the Physiatrist who oversees an amputee
clinic in our area if I can refer pts to him for an eval. Not unless pt
goes through his rehab! So fittings are delayed as pts wait to get into
see their PCP (sometimes up to a 5wk wait!)...then their documentation is
very poor relating to pt's prosthesis or prosthetic needs. Some won't
even look at a residual limb as THAT's not in their realm of knowledge!
We have 2 cases right now where physician signed but did not date Rx.
Their computer/fax machine dates the document so this is what we are
appealing with as our Pharmacist told us their Rx's are almost never hand
signed by docs, but computer or fax dated and this is Never questioned
except for controlled drugs.
All pts prosthetic intervention has been delayed & it will be years before
they figure out it is costing MORE.
Good Luck
*4- *I opened a small practice 2 years ago and I live in fear of a CERT.
That is pretty annoying. I have purchased OPIE and meet every week to make
sure we have all paperwork and continually talk to my pracs about proper
notes since even LMN's are not considered part of the medical records. I
would be interested to hear about your experience with this. Is there
someway to communicate that this seems unfair? How can we be responsible
for notes kept by a doctor who we have no relationship with other than they
signed the Rx. The prosthesis is probably the last thing on their mind
other than the fact that the patient needs one. This part of the medicare
system seems terribly unfair to me. I think our profession should find a
way to communicate and change this if possible. We have no control over
the effectiveness of notes kept by referring doctors. They signed it what
more can we do? Essentially what medicare is doing is saying you haven't
really earned any money until you have been audited and we determine you
don't have to give it back. And they can take it back even if you have a
detailed Rx, good notes, and have been perfectly honest if the doctor
who referred it has not documented properly that the person needs what you
have provided.
*5*- I just attended our local Medicare workshop last week and they
informed the group that all prosthetics are going to undergo a prepayment
audit to make sure what they pay for is what the patient needs and will
benefit from. Detailed prescriptions with doctor signatures was high on the
list of things they are looking for. Make sure to type in the doctors name
and NPI number under his signature so it can be identified as who the
doctor is even if it has his name at the top of the Rx. Crazy. I see you
billed for 12 stump socks. That is to many for one billing. Max number
allowed is only 6. Bill 6 more later in the year. They allow 12 per year
but only 6 at a time.
Those are just some of the things that came out of the discussion.
Make sure you attend your Medicare meeting in UpState NY when they schedule
it.
*5A* - 2nd response from same person
Hi again,
My question to the Medicare reps was why punish us, why not the docs who
order the stuff. There answer is because the doctors get paid by a
different division and are not in the same system as the DMEPOS suppliers
are. There will be cross communication in the future to the doctors
insurance group later once they decide how to approach them about this
subject. Our Medicare reps from region B are attending the MD's Medicare
seminars already trying to get information to them the best they can but
they don't have official dialog with them.
That is the response I got when I asked the question.
*6*- I have been putting off patient care until I get physician chart notes
that I think will meet the Dear Physician letter requirements. Its
CRAZY. I have a younger bilateral on disability that has not had a primay
care physician in his life, and has an unusual cognitive disability and no
social worker. He has now been to 4 or 5 different physicians to try and
get chart notes that meet the new Dear Physician standard without
success. Even when I send a copy of the Dear Physician letter for them to
read The Docs either don't understand or don't care. the first couple of
his attempts were to urgent care settings and there is info on blood
pressure and the patients pleasant personality and a sentence or two
about patient is here to get documentation to get his legs fixed from limb
maker but nothing that comes close to an
intelligent prosthetic assessment .... This guy is stumbling around with a
pair of damaged prostheses that cause breakdown and fall off when he tries
to resume The K4 LEVELS HE HAS BEEN AT FOR MOST OF HIS LIFE AS AN AMPUTEE.
This scenario has been repeated with a number of other patients. I also
have a situation where someone had an MVA resulting in a very short
transhumeral amp .Pt had good insurance and support I was able to fit with
myo hand/ linear transducer control/ boston elbow prosthesis. Pt got good
O.T. and was & is a daily prosthesic user. Pt lives hours away and did not
come back for a couuple of years. Went to local limb shop and got some
adj/repairs that were not to their satisfaction and came back to me.....Now
pt has gained weight socket no longer fits, linear transducer is broken and
pt is on social security disability. I get an RX cast and myo test for
socket replacement send the elbow back to Liberating Technology for
assessment and sensor speed hand back to Bock. the repair costs are10 to
15% of the replacement cost so I think no problem medicare would much
prefer a $12,000. socket replacement/hand/elbow refurbishment that
a $90,000.00 arm replacement.... wrong ! They won't pay for any of the
claim! I now have another big buck appeal and I have paid Bock and
Liberating Technologies for the repairs already not to mention new iceross
liners and refabricating the entire humeral section socket/frame wiring and
harnessing (I'm a dinosaur and still know how to make all this stuff on my
own so I do.) The denial said medicare won't pay to repair devices that
they did not pay for originally . So let that be a lesson if you get a
baby boomer that has a c-leg or vsp flexfoot that was paid for by another
insurance medicare won't pay for you to fix it but the may pay to replace
it but only if you have documentation that meets the Dear Pysician level
of documentaton. Even then there is no gurantee that you will get to keep
the money. They can go back three years to recoup payments that don't have
dear Physician levels of documentation...... I now have about $65,000.00
in appeal with medicare on 3 claims (most recent being a MPK definitive del
on a new amp That I think I have good physician chart notes on. This is
our new reality. I think the noise has to come from the patients and the
amputee coalition. It is our job to get our patient on board with the
coalition.... I have seen nothing out of the amputee coalition and their
board members have not returned my calls.
Citation
Marty Mandelbaum, “Responses to : Cert Audits in regards to lacking physician documentation - Medicare Region A part 1,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/234307.
