More Audit News
Jim DeWees
Description
Collection
Title:
More Audit News
Creator:
Jim DeWees
Date:
4/2/2013
Text:
Hello All,
First off, I have to admit that I am wrong on an earlier post about what
codes trigger an audit. I am now batting 100 on the audits, EVERY leg I
have made since November has been subjected to an audit. Not ALL of the
pages of the claims are getting audited, and up until yesterday, every claim
with the L-5301 (BK base code) has been audited.
Yesterday I got 2 more audits. The page with the base code was paid without
the audit, and was the page with the L-5980 (Flex Foot or equal....a K-3
foot code) was also paid and NOT audited. That was interesting.....
But the page with the silicone liners, knee sleeves, and socks was the page
that got the audit this time. It was the least expensive page of the
claims, and makes no sense.
(But the 2nd audit request I got yesterday, these are PRE-PAYMENT audits,
was for the L-5301 page).
On another topic, I was part of a Medicare (NGS) Medicare University
webinar. I raised me hand and was allowed to ask a question. I was the
first question they took, and I mentioned this audit and how the term
Eager was used by the physician and not Desire regarding the patient
wanting to walk. I asked if there was someone at NGS who is reasonable and
decent to talk to who can explain this to me and hopefully get to some
understanding about grammar and what the definition of eager is. Also, I
went on to say that I have filed the formal complaints with OIG, SBA and
also submitted the request, Freedom of Information Act, for the actual name
of the physician or nurse who is reviewing this claim so that I can see
where he/she is licensed and question that license and their intentions for
how they are making decisions for this patient, and what their actions and
decisions are doing to the provider and the patient. (This question and
comments were being heard by everyone attending this live webinar.) They
quickly tried to stop my comments and questions, and said that someone will
call me and speak with me privately. They did call me about an hour after
the webinar ended.
During this conversation, her comments were What we see here at NGS is a 75
year old man who had his leg amputated, and you claim he is out doing yard
work again, working on his property and also helping his wife with her
needs....and that doesn't justify him needing a prosthetic leg in our eyes.
I was stunned..... So my first comment back to her was: Oh yeah, that's
right! Under Obamcare, anyone over 75 doesn't deserve medical treatment,
give him some pain pills and hope that he dies! She said she isn't going
to debate Obamacare, but that is NOT what her decision is based on. So I
then again stated that he is out taking care of his yard and his home, and
he NEEDS a leg to do this. I told her that I also have a prosthetic leg,
and without my leg, it is impossible to push a mower to even cut my own
grass. BUT with my prosthetic leg, I can do my own yard work, AND I even
help my neighbors (who are older) take care of their yards, cleaning up
leaves in the fall, etc.
She then asked me Well, how big is this man's yard? And then I lost it
with her. I asked her if that is NOW another one of MY duties? Now I have
to educate physicians on what to write regarding amputee patients.....I also
have to educate and make sure that the physicians are enrolled in the PECOS
deal.....NOW I also have to go to the patient's homes and survey their
properties, or get on GIS systems and get the dimensions of their property
and notate this in their medical notes.....REALLY???? Then I asked her
where in the CMS policies does it have a yard ownership criteria to
determine their K level of function.. Is it a 1/2 acre yard that gets you a
K-3, or a full acre yard? What about those who live in a condo or
apartment? They don't have any yard to maintain, so therefore they don't
have a need to use a prosthetic leg at all. WOW!!!!!! I have seen NOTHING
in CMS rules about the size of a patient's yard.
Anyway, she finally just hung up the phone.
Ironically, her name is Charity Bright....I thought this MUST be a joke.
Working at Anthem, she has NO charity and wasn't that bright. It must be a
joke, similar to the names we make up for our example letters with
physician or patient names. I have called to report her to her supervisor,
but of course he has not called me back still.
Another thing that she said, when I asked her about IF she feels that they
are so right in their denials, and are just following CMS rules then how
is that possible when the ALJ reviews and decisions are overturning their
denials more than 90% of the time.
Her answer: They have a different set of rules to follow than what we have.
I was again stunned!! Really? Does CMS have one set of rules for these
contractors to go by to deny these claims? And then CMS has a different set
of rules for the ALJ's to follow to see if the denials are legitimate? I
really do NOT think that there are different rules for them to follow. BUT
the difference is that the ALJ's have NO financial interest at all in
denying claims. NGS and all the others have a HUGE financial interest in
denials of claims.
Another issue with her was that she started in educating me on the
policies, and I told her that I know FULL WELL what the rules are and the
requirements. I have passed 9 of the 10 audits. AND the only reason the
first one is denied now is over the word Eager vs. Desire. And, I pointed
out that any ALJ is going to see that when the physician said he is eager to
get leg so he can walk and return to his normal life again, they will take
that as him having the desire to walk and return to his normal life. BUT I
pointed out that obviously I DO know what the requirements are, as I have
passed 9 of these audits.....ALL 9 of these audits. I KNOW what they want,
and what to send in.
I asked her how many more are they going to do to me, and how many times
will it take them to realize that I DO have the documentation that is
required, and that they are wasting their time and energy reviewing my
claims? WHEN are they going to leave me alone? She said they are in the
process of compiling a list of providers who have passed a certain number of
the audits, and see how many of the audits are passed in a row, and then
they are going to drop their provider number from the audit list.
SO, if that is true, hopefully here pretty soon, I might be removed from
this audit list, and then I can use my time doing other things besides
answering the questions on these audits, making a TON of copies of
paperwork, standing in line at our wonderful government postal office (at
least 45 minutes waiting and waiting in line....with workers moving at a
snail's pace....everyone grumbling and getting really annoyed at the
situation, etc......a GREAT way to end a wonderful day at the office these
days....)
Anyway, hopefully more and more of us can get the paperwork right, and get
it submitted in a way that they accept and pass. AND then they might
realize they are wasting time with these audits. BUT there are still too
many of us who are not getting the proper physician documentation, and are
not passing these audits. And, unfortunately, little has been done by our
organizations to help us out here in the trenches to know exactly how to
pass these audits. Sure, there are pages and pages of legal terms and
generalities....but there are no clear examples or exactly WHAT we need to
really do.
So, this is the latest in my Audit World experience. Be prepared to now be
a surveyor on top of everything else....how crazy is that.
Have a great afternoon.
Jim DeWees, CP
First off, I have to admit that I am wrong on an earlier post about what
codes trigger an audit. I am now batting 100 on the audits, EVERY leg I
have made since November has been subjected to an audit. Not ALL of the
pages of the claims are getting audited, and up until yesterday, every claim
with the L-5301 (BK base code) has been audited.
Yesterday I got 2 more audits. The page with the base code was paid without
the audit, and was the page with the L-5980 (Flex Foot or equal....a K-3
foot code) was also paid and NOT audited. That was interesting.....
But the page with the silicone liners, knee sleeves, and socks was the page
that got the audit this time. It was the least expensive page of the
claims, and makes no sense.
(But the 2nd audit request I got yesterday, these are PRE-PAYMENT audits,
was for the L-5301 page).
On another topic, I was part of a Medicare (NGS) Medicare University
webinar. I raised me hand and was allowed to ask a question. I was the
first question they took, and I mentioned this audit and how the term
Eager was used by the physician and not Desire regarding the patient
wanting to walk. I asked if there was someone at NGS who is reasonable and
decent to talk to who can explain this to me and hopefully get to some
understanding about grammar and what the definition of eager is. Also, I
went on to say that I have filed the formal complaints with OIG, SBA and
also submitted the request, Freedom of Information Act, for the actual name
of the physician or nurse who is reviewing this claim so that I can see
where he/she is licensed and question that license and their intentions for
how they are making decisions for this patient, and what their actions and
decisions are doing to the provider and the patient. (This question and
comments were being heard by everyone attending this live webinar.) They
quickly tried to stop my comments and questions, and said that someone will
call me and speak with me privately. They did call me about an hour after
the webinar ended.
During this conversation, her comments were What we see here at NGS is a 75
year old man who had his leg amputated, and you claim he is out doing yard
work again, working on his property and also helping his wife with her
needs....and that doesn't justify him needing a prosthetic leg in our eyes.
I was stunned..... So my first comment back to her was: Oh yeah, that's
right! Under Obamcare, anyone over 75 doesn't deserve medical treatment,
give him some pain pills and hope that he dies! She said she isn't going
to debate Obamacare, but that is NOT what her decision is based on. So I
then again stated that he is out taking care of his yard and his home, and
he NEEDS a leg to do this. I told her that I also have a prosthetic leg,
and without my leg, it is impossible to push a mower to even cut my own
grass. BUT with my prosthetic leg, I can do my own yard work, AND I even
help my neighbors (who are older) take care of their yards, cleaning up
leaves in the fall, etc.
She then asked me Well, how big is this man's yard? And then I lost it
with her. I asked her if that is NOW another one of MY duties? Now I have
to educate physicians on what to write regarding amputee patients.....I also
have to educate and make sure that the physicians are enrolled in the PECOS
deal.....NOW I also have to go to the patient's homes and survey their
properties, or get on GIS systems and get the dimensions of their property
and notate this in their medical notes.....REALLY???? Then I asked her
where in the CMS policies does it have a yard ownership criteria to
determine their K level of function.. Is it a 1/2 acre yard that gets you a
K-3, or a full acre yard? What about those who live in a condo or
apartment? They don't have any yard to maintain, so therefore they don't
have a need to use a prosthetic leg at all. WOW!!!!!! I have seen NOTHING
in CMS rules about the size of a patient's yard.
Anyway, she finally just hung up the phone.
Ironically, her name is Charity Bright....I thought this MUST be a joke.
Working at Anthem, she has NO charity and wasn't that bright. It must be a
joke, similar to the names we make up for our example letters with
physician or patient names. I have called to report her to her supervisor,
but of course he has not called me back still.
Another thing that she said, when I asked her about IF she feels that they
are so right in their denials, and are just following CMS rules then how
is that possible when the ALJ reviews and decisions are overturning their
denials more than 90% of the time.
Her answer: They have a different set of rules to follow than what we have.
I was again stunned!! Really? Does CMS have one set of rules for these
contractors to go by to deny these claims? And then CMS has a different set
of rules for the ALJ's to follow to see if the denials are legitimate? I
really do NOT think that there are different rules for them to follow. BUT
the difference is that the ALJ's have NO financial interest at all in
denying claims. NGS and all the others have a HUGE financial interest in
denials of claims.
Another issue with her was that she started in educating me on the
policies, and I told her that I know FULL WELL what the rules are and the
requirements. I have passed 9 of the 10 audits. AND the only reason the
first one is denied now is over the word Eager vs. Desire. And, I pointed
out that any ALJ is going to see that when the physician said he is eager to
get leg so he can walk and return to his normal life again, they will take
that as him having the desire to walk and return to his normal life. BUT I
pointed out that obviously I DO know what the requirements are, as I have
passed 9 of these audits.....ALL 9 of these audits. I KNOW what they want,
and what to send in.
I asked her how many more are they going to do to me, and how many times
will it take them to realize that I DO have the documentation that is
required, and that they are wasting their time and energy reviewing my
claims? WHEN are they going to leave me alone? She said they are in the
process of compiling a list of providers who have passed a certain number of
the audits, and see how many of the audits are passed in a row, and then
they are going to drop their provider number from the audit list.
SO, if that is true, hopefully here pretty soon, I might be removed from
this audit list, and then I can use my time doing other things besides
answering the questions on these audits, making a TON of copies of
paperwork, standing in line at our wonderful government postal office (at
least 45 minutes waiting and waiting in line....with workers moving at a
snail's pace....everyone grumbling and getting really annoyed at the
situation, etc......a GREAT way to end a wonderful day at the office these
days....)
Anyway, hopefully more and more of us can get the paperwork right, and get
it submitted in a way that they accept and pass. AND then they might
realize they are wasting time with these audits. BUT there are still too
many of us who are not getting the proper physician documentation, and are
not passing these audits. And, unfortunately, little has been done by our
organizations to help us out here in the trenches to know exactly how to
pass these audits. Sure, there are pages and pages of legal terms and
generalities....but there are no clear examples or exactly WHAT we need to
really do.
So, this is the latest in my Audit World experience. Be prepared to now be
a surveyor on top of everything else....how crazy is that.
Have a great afternoon.
Jim DeWees, CP
Citation
Jim DeWees, “More Audit News,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/235001.
