NGS issues, Medicare/CMS audits

NGS issues, Medicare/CMS audits

Jim DeWees

6/11/2015

Hello Everyone,

I have a question for everyone in Region B. Are others finding that the
audits are being denied for NGS claiming that insufficient documentation
or services were not delivered to the beneficiaries?

Just to better clarify the situation, I want to start by stating that I am
having about 100% audits on ALL lower limb prosthetic claims (K-1, K2, K3,
it does not matter the level). I have passed 100% of these audits since
these started. They have not found a reason to NOT pay me for the services
that I provide.

BUT

This is the 2nd time in a row where after the pre-payment audits, they
determined that they would not pay for the claim because they claim that
some item, or document, was not submitted, and therefore was determined Not
Medically Necessary.


The first denial was due to a missing signature attestation, but the person
on the phone explaining this to me could clearly see that there is indeed a
signature attestation in the packet that they received, which is scanned
into their system. The only option at that point was to file the
redetermination, which takes additional weeks to review and process.

After the re-determination (and I stated the reason was due to the person
reviewing the claim either deliberately did not see this attestation, or for
whatever reason failed to see it, but they DID have it). It was approved
and paid, but several months later.

Today, I am fighting another claim. We had the pre-payment audit, did not
pass. We were paid for 2 pages of the claims (there were 16 codes, broken
into 3 separate claims at Medicare since they only allow 6 codes per claim).
Today, we received a letter of Overpayment and wanting the entire amount
returned in 30 days for the 2 pages that were paid. The reason stated is
services were not provided.

In the phone conversations today, they cannot tell me why it was decided
that it was not provided. The person at level 1 stated that the delivery
ticket was not specific enough with information about the codes that were
billed. I looked at the Delivery Ticket that was submitted with the audit,
and it DOES have the model, make and serial number of the knee that was
provided as well as the foot, make, model, and serial number.


So, it seems to me that it is a standard issue now for some reviewers to not
see documentation and deny the audits based on that oversight. OR they have
people who are not competent to recognize what some documentation is, and
deny based on that reason.


Is anyone else having issues with the audits being denied originally based
on missing or incomplete documentation? And then on the Re-Determination
level, they approve and pay the claim?

Please let me know if anyone else is having similar issues with these
audits.

Thanks

Jim DeWees, CP