Recent activities dealing with Pre-Payment Audits
Jim DeWees
Description
Collection
Title:
Recent activities dealing with Pre-Payment Audits
Creator:
Jim DeWees
Date:
3/22/2013
Text:
Hello all,
Today has been a busy day, but I feel a productive day with some issues.
First, I contacted the OIG and found that they will NOT investigate a claim
at first. She told me that I will file the complaint with them, and it will
go to CMS for them to review and possibly take action.
The complaint was basically that I have proof and documentation in my
records that include ALL of the necessary papers and signatures to provide
services to the Medicare beneficiaries. But I feel that National Government
Services (NGS) is intentionally denying claims in a fraudulent manner and
intentionally causing financial hardship on my business, and also causing
damage or lack of services to other Medicare patients.
Next, I contacted CMS and went to their website to file the Freedom of
Information Act form, requesting that they find the name of the physician
who reviewed the medical claims, and I gave them the CMS claim number, and
the CCN numbers so they can easily find the patient file and hopefully get
the name of this physician. I told them I needed this name for proof that
NGS is actually following the rules in having a medical professional review
the claims to either approve or deny them. Also, I told them that I am
going to submit this physician to the state medical licensing board for them
to determine if this physician is putting the financial interest of NGS
ahead of the patient care.
Next, I went to the Small Business Administration website and called them,
and was directed to the online form to file with a complaint against a
person or a business who is possibly harming my business in an illegal or in
a wrongful way. It was easy to fill out, and I wrote exactly how I felt
that NGS, being contracted by Medicare, has created a financial burden on my
company, and is resulting in delayed services to other Medicare
beneficiaries because of the risk associated in providing services and
expensive devices to these patients.
I have already gotten emails back from all 3 agencies confirming that they
did receive these complaints.
Also, I did get another escalation at NGS to a higher supervisor
yesterday, once I told them I was going to file with the OIG, they decided
that I should speak to someone higher, and maybe they can get this claim
paid and NOT denied. I was just on the phone with him (yes, 5:15 pm on a
Friday evening....he sounded shocked to actually get me on the phone...he
was hoping to leave a message....BUT he got to listen to me rant at him for
about 20 minutes about this). He wants to get this resolved before I file
these complaints.....and I told him TOO LATE. He said he will be back
with me on Tuesday and let me know what he was able to do with this claim.
I told him that IF he gets it fixed, then my complaints are without merit
and therefore will be dropped I guess. But if I have to send this on to a
higher level, then these complaints are going to get worse. They do not
like getting OIG complaints.
I have now passed 7 audits with no problems. But the first audit is still
denied, even after the first appeal. But I will NOT give up on this claim!!
The patient is upset about this in a major way as well. The reason for THIS
denial is that the physician wrote the patient is eager to get a prosthetic
leg to return to his normal life, and also he had no limitation prior to
the amputation, and will have no limitations after he receives a leg. BUT
now NGS states the reason for denial is that the physician did not document
a Desire to walk.
This is ridiculous and needs to be stopped! But, I will fight them any way
I can.
I encourage ALL of you to file complaints with the OIG against the
contractor who is doing damage to YOUR businesses. When I did this against
Humana a couple years ago (Humana Medicare replacement plan), it got very
quick response from Humana to get this claim paid and get this OIG complaint
resolved.
DO NOT GIVE UP!!! KEEP FIGHTING FOR EVERY CLAIM. If you give up, that is
what they are hoping for, and then they realize that the MORE they do this,
the more they are going to keep from all of us.
Have a great weekend,
Jim DeWees
Today has been a busy day, but I feel a productive day with some issues.
First, I contacted the OIG and found that they will NOT investigate a claim
at first. She told me that I will file the complaint with them, and it will
go to CMS for them to review and possibly take action.
The complaint was basically that I have proof and documentation in my
records that include ALL of the necessary papers and signatures to provide
services to the Medicare beneficiaries. But I feel that National Government
Services (NGS) is intentionally denying claims in a fraudulent manner and
intentionally causing financial hardship on my business, and also causing
damage or lack of services to other Medicare patients.
Next, I contacted CMS and went to their website to file the Freedom of
Information Act form, requesting that they find the name of the physician
who reviewed the medical claims, and I gave them the CMS claim number, and
the CCN numbers so they can easily find the patient file and hopefully get
the name of this physician. I told them I needed this name for proof that
NGS is actually following the rules in having a medical professional review
the claims to either approve or deny them. Also, I told them that I am
going to submit this physician to the state medical licensing board for them
to determine if this physician is putting the financial interest of NGS
ahead of the patient care.
Next, I went to the Small Business Administration website and called them,
and was directed to the online form to file with a complaint against a
person or a business who is possibly harming my business in an illegal or in
a wrongful way. It was easy to fill out, and I wrote exactly how I felt
that NGS, being contracted by Medicare, has created a financial burden on my
company, and is resulting in delayed services to other Medicare
beneficiaries because of the risk associated in providing services and
expensive devices to these patients.
I have already gotten emails back from all 3 agencies confirming that they
did receive these complaints.
Also, I did get another escalation at NGS to a higher supervisor
yesterday, once I told them I was going to file with the OIG, they decided
that I should speak to someone higher, and maybe they can get this claim
paid and NOT denied. I was just on the phone with him (yes, 5:15 pm on a
Friday evening....he sounded shocked to actually get me on the phone...he
was hoping to leave a message....BUT he got to listen to me rant at him for
about 20 minutes about this). He wants to get this resolved before I file
these complaints.....and I told him TOO LATE. He said he will be back
with me on Tuesday and let me know what he was able to do with this claim.
I told him that IF he gets it fixed, then my complaints are without merit
and therefore will be dropped I guess. But if I have to send this on to a
higher level, then these complaints are going to get worse. They do not
like getting OIG complaints.
I have now passed 7 audits with no problems. But the first audit is still
denied, even after the first appeal. But I will NOT give up on this claim!!
The patient is upset about this in a major way as well. The reason for THIS
denial is that the physician wrote the patient is eager to get a prosthetic
leg to return to his normal life, and also he had no limitation prior to
the amputation, and will have no limitations after he receives a leg. BUT
now NGS states the reason for denial is that the physician did not document
a Desire to walk.
This is ridiculous and needs to be stopped! But, I will fight them any way
I can.
I encourage ALL of you to file complaints with the OIG against the
contractor who is doing damage to YOUR businesses. When I did this against
Humana a couple years ago (Humana Medicare replacement plan), it got very
quick response from Humana to get this claim paid and get this OIG complaint
resolved.
DO NOT GIVE UP!!! KEEP FIGHTING FOR EVERY CLAIM. If you give up, that is
what they are hoping for, and then they realize that the MORE they do this,
the more they are going to keep from all of us.
Have a great weekend,
Jim DeWees
Citation
Jim DeWees, “Recent activities dealing with Pre-Payment Audits,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 27, 2024, https://library.drfop.org/items/show/234882.
