Medicare- further discussion-Three issues-denial of payment/ RAC audits/physician documentation
Randy McFarland
Description
Collection
Title:
Medicare- further discussion-Three issues-denial of payment/ RAC audits/physician documentation
Creator:
Randy McFarland
Date:
5/29/2013
Text:
Hi Listserve members,
Medicare Denials
For several years we have been paid by Medicare for two replacement gel
liners. Recently we provided and invoiced Medicare for a very active Symes
patient 7 months after his original prosthesis delivery we were just denied
for two and we were paid for just one. We didn't know that Medicare was
going to say that two liners are no longer medically necessary. We didn't
have patient sign an ABN probable denial because not medically necessary
form so we can't charge the patient. Does Medicare figure this is just the
cost of doing business? With this prescient, we should be able to have the
patient sign an ABN form in case Medicare determines it wasn't medically
necessary. However, the ABN is to be used when WE feel something is not
medically necessary, NOT if MEDICARE decides it isn't medically necessary.
RAC audits
Regarding the RAC audits where they take back monies paid to us, we are
expected to appeal up to an Administrative Law Judge (ALJ) (Most RAC audits
are reversed, by the way) to collect the claw back from the payment for
our services. All that happens to the RAC auditors when their denial is
reversed is that their commission is reversed. I suppose that the auditors
have nothing to lose, figuring that many of us won't bother to appeal for
the smaller decisions to be corrected, so they'll just get to keep their
commission for their decisions, right or wrong. Shouldn't there be a
punitive financial penalty that goes back to the wronged provider when their
improper decisions are corrected? Fair is fair!
Physician documentation requirements
We practitioners are being put in the position of having to badger
physicians (who don't have the time) to write the required letters and
specified patient medical records documentation to prove medical necessity.
If their efforts are inadequate, who pays the price? We do, via non-payment
for our efforts. A major contributing factor is that the physician is has
little incentive to make such documentation a priority in their busy day
other than their own professionalism to help their patients. Meanwhile, we
are put in the middle, irritating the physician, while the patient is
pushing us to provide our care. It's ironic that fraudulent providers have
more time to make up documentation than legitimate physicians have to meet
the requirements. By the way, Medical documentation should also include the
physical abilities of the patient, like the Amputee Mobility Predictor tests
for. The motivation of the candidate is reflected by his/her determination
to stand and walk in parallel bars prior to prosthetic fitting. Such
physical abilities prior to amputation may be impacted by problems with the
involved leg like a failed knee implant, infection, joint damage, etc.
Discussion
The above policies seem to push us towards not accepting assignment.
problematic for most patients. but it would save Medicare money, which I
understand is their goal. Medicare is OK paying for legitimate services. The
ethical providers in our profession need to come up with ways we can help
Medicare weed out those doing fraudulent invoicing some of which might not
even be in our profession. We need Medicare to reach out for our assistance
in this regard rather than running us all through the ringer at the expense
of our businesses and reimbursable care for our patients.
Conclusion
The direction this is all taking us makes me realize that all this scrutiny
of medical necessity should take place BEFORE we provide our services, so
everyone agrees on the reimbursement BEFORE we commit time and materials we
can't recoup after a denial. The pre-authorization could then be considered
without the need for subsequent reviews or claw backs unless the patient
expresses concern or fraud is suspected. What are reasons that pre-approval
of payment would not be preferable to the current situation?
Randy McFarland, CPO
Medicare Denials
For several years we have been paid by Medicare for two replacement gel
liners. Recently we provided and invoiced Medicare for a very active Symes
patient 7 months after his original prosthesis delivery we were just denied
for two and we were paid for just one. We didn't know that Medicare was
going to say that two liners are no longer medically necessary. We didn't
have patient sign an ABN probable denial because not medically necessary
form so we can't charge the patient. Does Medicare figure this is just the
cost of doing business? With this prescient, we should be able to have the
patient sign an ABN form in case Medicare determines it wasn't medically
necessary. However, the ABN is to be used when WE feel something is not
medically necessary, NOT if MEDICARE decides it isn't medically necessary.
RAC audits
Regarding the RAC audits where they take back monies paid to us, we are
expected to appeal up to an Administrative Law Judge (ALJ) (Most RAC audits
are reversed, by the way) to collect the claw back from the payment for
our services. All that happens to the RAC auditors when their denial is
reversed is that their commission is reversed. I suppose that the auditors
have nothing to lose, figuring that many of us won't bother to appeal for
the smaller decisions to be corrected, so they'll just get to keep their
commission for their decisions, right or wrong. Shouldn't there be a
punitive financial penalty that goes back to the wronged provider when their
improper decisions are corrected? Fair is fair!
Physician documentation requirements
We practitioners are being put in the position of having to badger
physicians (who don't have the time) to write the required letters and
specified patient medical records documentation to prove medical necessity.
If their efforts are inadequate, who pays the price? We do, via non-payment
for our efforts. A major contributing factor is that the physician is has
little incentive to make such documentation a priority in their busy day
other than their own professionalism to help their patients. Meanwhile, we
are put in the middle, irritating the physician, while the patient is
pushing us to provide our care. It's ironic that fraudulent providers have
more time to make up documentation than legitimate physicians have to meet
the requirements. By the way, Medical documentation should also include the
physical abilities of the patient, like the Amputee Mobility Predictor tests
for. The motivation of the candidate is reflected by his/her determination
to stand and walk in parallel bars prior to prosthetic fitting. Such
physical abilities prior to amputation may be impacted by problems with the
involved leg like a failed knee implant, infection, joint damage, etc.
Discussion
The above policies seem to push us towards not accepting assignment.
problematic for most patients. but it would save Medicare money, which I
understand is their goal. Medicare is OK paying for legitimate services. The
ethical providers in our profession need to come up with ways we can help
Medicare weed out those doing fraudulent invoicing some of which might not
even be in our profession. We need Medicare to reach out for our assistance
in this regard rather than running us all through the ringer at the expense
of our businesses and reimbursable care for our patients.
Conclusion
The direction this is all taking us makes me realize that all this scrutiny
of medical necessity should take place BEFORE we provide our services, so
everyone agrees on the reimbursement BEFORE we commit time and materials we
can't recoup after a denial. The pre-authorization could then be considered
without the need for subsequent reviews or claw backs unless the patient
expresses concern or fraud is suspected. What are reasons that pre-approval
of payment would not be preferable to the current situation?
Randy McFarland, CPO
Citation
Randy McFarland, “Medicare- further discussion-Three issues-denial of payment/ RAC audits/physician documentation,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/235137.
