Audit Information

Audit Information

Jim DeWees

5/15/2015

Hello Everyone,

I thought that I should share this information with everyone. I am in
Indiana (Region B for Medicare). For the past few years my office has been
dealing with a very high rate of the Pre-payment Audit requests from
Medicare (National Government Service, Inc, which is owned by Anthem Blue
Cross). I have a 100% passing rate for these audits, and am very careful
with ALL documentation prior to providing services to any patient.

I have been able to create a system in my office that requires that ALL
amputees must follow the same guidelines regardless of who the payor is. I
have thought for a long time that sooner or later, all insurance companies
are going to follow the process that Medicare has, and they are going to ask
for documentation in order to prove that the patient really does have the
medical necessity for some prosthetic device.

Last month, I got my first audit from Humana. This patient has the Humana
Advantage (Medicare replacement) plan, and they sent a request for ALL
medical documentation to have it reviewed by their Payment Integrity
department. I have had 2 more of these audit requests in this past month.

This week, I got a request from Anthem requesting that ALL medical
documentation, physician notes, prescription, determination of Functional
Level, etc. be sent to be reviewed before they can process the claim. After
talking with the person at Anthem, they are now doing random audits for
medical necessity, trying to cut down on fraud.

Fortunately, I have ALL of this documentation. Every patient that comes to
my office is required to have a physical therapy evaluation where they
perform the Amputee Mobility Predictor, I also have the therapist sign the
Signature Attestation Form (which is printed on the back of the Medicare
Audit Request form). I also require that the patient has an evaluation with
their physician. Some physicians have been very uncooperative in doing
these exams, stating that there is no way for them to bill the insurance for
an evaluation or for writing the documentation explaining what their
functional level is, or any of the wording that Medicare requires in the
patient progress/chart notes. The local Physical Medicine, Rehabilitation
specialist is seeing several of the amputees now, although his office is
very busy, and it can take up to 6 weeks for the amputees to be able to have
this appointment. I just have to explain to the patients that this is how
Medicare and insurance operates today, and what THEY require today. I
apologize to them for the delay in being able to walk again and getting a
leg, BUT this is what the policies are causing today.

Once I have all of the documentation and I KNOW that it will be sufficient
(well, we never really KNOW what is sufficient, but at least it raises that
level of hope that this is sufficient documentation and chart notes), then I
can go ahead and deliver the prosthetic device to the patient.

Fortunately, I have been doing this for ALL patients, and not just those
with Medicare. ALL of the insurance companies are now doing this. I was
happy that I was able to quickly send (by fax) the notes to Humana, and I
was paid for the prosthetic leg that I delivered to this lady.

I am also glad that I have ALL of this paperwork for the patient with
Anthem. I was able to fax that to Anthem as soon as I was off the phone
with them (in the Philippines of course) and got the fax number to send this
to. IF I had not been requiring this for EVERY patient here, I would be in
a bad situation now, and worried that I would NOT get paid for these, and
any other prosthetic limb that I have made for others with private
insurance.

So, just beware, that these private companies are now doing the audits, and
so do what you must to get the paperwork in order to be ready.

Thanks

Jim DeWees, CP