Medicare Audit Issues: Another thought!!

Medicare Audit Issues: Another thought!!

Jim DeWees

1/24/2013

Hello Everyone, It has been a few days since I have sent out a public email to you all. I truly appreciate all the feedback that I have gotten, and the support. On good note, I did get a phone call from the Supervisor of the Provider Support team at the CMS contracted administrator. I spoke with her last week about WHAT information was not submitted to them that resulted in the denial of my audit. She was the ONLY person at the insurance company that seemed to have the ability to read what was on the computer file about my claim. As I said in a previous post, this was all over the Signature Attestation form that I didn't submit for MY name. This was not something that I had ever seen as being required for me. I knew that I must send these attestations for physicians, if their signatures are not legible. That has been resolved, and the appeal is in process at this moment. BUT yesterday she called me, out of the blue, to tell me that she has been watching my claims and audits closely, and she told me that my 2nd audit (another patient claim) has been reviewed and it DID pass the audit, and was sent to the pay floor, and I should get the money deposited into my account in a few days. That was great news, knowing that at least ONE of my audit packets passed the test without needing to go to appeal. I had expressed to her that ALL my packets for these audits have EVERYTHING that is required. I expressed to her about how passionate I am about this process, and how I am 100% compliant with the process, and the physician's notes are included, and are exactly what CMS requires. The prescriptions are also done 100% compliant with their policies. My chart notes are also carefully written and reviewed for accuracey and completeness. She said that she could see that, when she was looking over my packets. That is why I was so frustrated and angry with them over claiming that the level of service was not justified by the notes submitted. AND all of this was over something so simple as my signature, which is on file when I got my Provider ID Number. It is also on the very contract that I have with Medicare. Anyway, I was relieved and excited, and shocked, when she called ME to tell me that my next audit packet did pass. I must have said SOMETHING that has caused her to take such interest in MY cases, and my claims, and audits. I don't really think that I scared her or anything that did this, but obviously there is some reason that she appears to be doing MORE than usual for me and getting my claims processed and passed. But there are 3 more sitting there, and she said the next one also looks good....but can't tell me anything exactly about the status of it YET. HERE'S THE IMPORTANT PARTOn to another topic (this is part of the conversation I had with this supervisor, about what I feel could be a game changer for these audits.....and she said that she hopes it will not get to this point where I do this) : As I mentioned before about the importance of us getting the names of the physicians, nurses and others who are employed by Anthem, NGS, or whoever YOUR regional contracted administrator who makes the medical determination , I still feel strongly about WHY we must do this. I mentioned that maybe it is possible to have patients file lawsuits against them for malpractice, in that they are making medical decisions, plans of treatments, or DENIALS of plans of treatments, even though the local physicians and healthcare providers have recommended and prescribed certain services, such as prosthetics. I got one reply from someone on the list that these physicians employed by these administrators could be considered as employed by the Federal Government, and therefore they cannot be sued by anyone. This might be true. But another thought that came to me, which I feel is a much better option. This thought is that we can file a complaint with the state licensing board for these physicians.
IF we truly feel that these physicians or nurses that have reviewed our claims, and go contrary to what we have submitted, then we MUST act in some manner to stop these physicians (or nurses) from hurting the patients, or denying payments for the services after the fact. I discussed this with the supervisor the other day (my first phone call with her), about how I will find these names and turn them in to their state boards, and have their licenses examined and reviewed by this board. Each state has a medical board, and these state medical boards provide the physicians with the license to practice medicine. If the physician doesn't have a license, then they cannot practice medicine, or function in that capacity. As we all know, MOST physicians are totally frustrated by the insurance companies, just like we are! Most of them have even harder feelings against these insurance companies. IF we could provide this board with the name, and proof that some physician was working for the insurance company, I can't help but guess that this board would most likely revoke the license of the physician who was working against them. I know that the state medical boards, which are comprised of medical doctors, would take this very seroiusly. I am not saying this in a manner of getting even with these physicians that work for the insurance companies, BUT this is a system that has been set up to protect patients from being harmed by physicians, AND this is also a system set up to help insure that the physicians obey the rules and laws, and also help insure that the physicians do what is in the best interest of the patients. I honestly feel that there are some physicians, employed by these insurance companies, who are NOT looking out for the patient's best interest! They are working to only help the insurance companies make bigger profits! They are working to get a bigger bonus check when they save the insurance companies a lot of money. What are the thoughts from all of you about this? Does this sound like a possible, or reasonable action that we could take? Again, I am not saying any of this as a method of revenge or anything. But this is an action that I feel we can take that can help keep these physicians more honest, or more focused on the patients. If these physicians working for the insurance company realize that they could also be turned in with a complaint about some decision they made, denying services for prosthetics for NO reason.....which went against a fellow MD who KNOWS the patient and prescribed this service....these physicians might make different decisions. I am not 100% against these audits. Unfortunately, these audits are necessary in some cases. Unfortunately, there is obvious fraud going on in a few cases, and that has turned this audit process into something that now we ALL are being caught up in. Some of the denials are legitimate. Some are due to cases where there might be real over utilization, or where some prosthetists do not have the necessary paperwork. It is our duty to KNOW what is required, and to be compliant with the procedures. But what I AM totally against is the insurance nit picking over the notes, and denying the payments due to minor issues that are common sense issues. It has come to a point where these over-seers need some oversight on what THEY are doing. Maybe this oversight can be the state medical boards, and have them do the job of policing these physicians and insurance companies. Please share your thoughts about this. Thanks to all of you, Jim DeWees, CP