Mediare Requirements for passing an Audit.

Mediare Requirements for passing an Audit.

Jim DeWees

12/13/2012

Hello everyone, I have participated in 2 Medicare webinars this week, Medicare University which is put on by National Government Services (owned by Anthem Blue Cross). They are the administrators/ contracted company to handle Medicare claims in my region. I have asked then for a list of items they are looking for in an audit, or some kind of checklist that we (the prosthetists/providers) can follow and KNOW that we have EVERYTHING they will be looking for. Their answers to these questions are vague and flat out bad. They do NOT have a cookie cutter kind of criteria they use....(that is a quote from her on Tuesday). Every case is unique and is treated as an individual case, using varying information. This seems totally WRONG to me. It seems that ALL of the claims should have the same kind of documentation, physician notes, etc. It seems that if NGS is picking and choosing what criteria they are looking for, that could be a discriminatory action by NGS, holding different providers to different standards. So, I have made a list of what I have gathered is NECESSARY for us to have in our files: 1. Chart notes, which are clearly signed and dated by the prosthetist about what was provided to the patient, dates of what was done for the patient. 2. Physician's notes: They must be clearly signed, and also have his/her name typed or printed as well. If the signature is NOT legible, then an attestation must be signed by the physician WITH his signature, printed name, and credentials, and the date of when he/she wrote the chart notes. If the notes are signed electronically, then they require the protocol/procedure of what kind of verification they use for their electronic system. 3. A signed Prescription with ALL the Lcodes and definition of the code....ALSO the physician's name MUST also be written on the Rx. 4. A signed receiver or Delivery slip by the patient, which also has to have ALL the procedure codes (Lcodes) with the date on it also. (If someone other than the patient signs for the delivery, then that must be documented and probably add the legal power of attorney for the person who signs.) Also, the date the patient signs must be the Date of Service For an audit, you must also include: 1. I write a narative about the patient, making him/her sound like a real human being, with desires, abilities, family, etc. which makes this case better as for why the patient NEEDS a leg. This is usually less than one page, but kind of outlines the process and what has gone into making the leg. 2. I also include a typed up list of answers to the questions on the back of the CMS Audit papers. There were 5-6 questions, some were only answered with In the packet or Documents are enclosed. Others needed a longer answer, like Is the device new or used, or what is the make and model of the item.....and so I made sure to state that ALL the componentry is new, nothing is used on the limbs. Also I will spell out what foot the patient got, and why...the benefits and advantages for the foot. I think this helps them to realize that this is NOT just something off of some shelf, but it very customized. 3. Copies of the actual audit paperwork, with the case numbers, patient ID numbers etc. 4. Finally, copies of ALL of the above listed paperwork (1-4 above) I firmly believe that with ALL of this documentation, and having everything in order, dates all match up, doctor's notes are written PRIOR to the date of service, etc. that we will pass these audits. ONCE we are passing these audits at more than some specific percentage (maybe 40 percent failing rate....maybe 25%) then NGS(Anthem) will realize they are spending MORE money to pay people to review these claims than what they are making or getting in return. If we can ALL get our records straignt and in order, and when NGS realizes they are getting no results for this added staffing and time invested, then maybe these audits will cease. (But maybe I am just dreaming).
Nowhere have I seen a list, a checklist, of WHAT we must include. If someone has time, or wants to make a clear list, a condensed version of sorts, maybe we can all use that as our guidelines. IF anyone has anything else they want to add to this list, please do so....IF it is something that I am missing, PLEASE let me know. (I think I have put down everything that I have sent to them for the audit...) I do realize that many of us need to do a better job of doing this paperwork, and having clean records. We need to KNOW what we are required to send in....and don't trust or even think that NGS of Anthem is going to tell us what they are looking for....because it is in THEIR best interest for us to NOT have the proper documentation, and that way THEY keep the money. In the meantime, we need to be active in going political with this, and hopefully as a group we can show everyone about what kind of important work that we do to help other people in their lives. We can change policies hopefully, where this pre-audit burden doesn't destroy our businesses. Thanks Jim DeWees, CP