Follow up on same similar post
Jim Del Bianco
Description
Collection
Title:
Follow up on same similar post
Creator:
Jim Del Bianco
Date:
7/13/2020
Text:
List,
I sent a message a few weeks ago about same/similar denials and the
challenges in region C related to denials for these claims. Many people
responded with concerns and stories about similar challenges.
By way of follow up I want to share my experience. I called CGS and worked
my way to a meeting with a CGS provider relations senior analyst. She
listened to my concerns and asked that several of the claims be forwarded
to her for review with CGS. Many of these claims were overturned during
this review and sent back for payment. We did have detailed records that
met all of the criteria. She was very helpful and wonderful to work with. I
requested a meeting with the medical director, Dr. Hoover during our
conversation. I wrote a letter to Dr. hoover and The CGS team member
discussed with him my concerns and shared my letter.
A meeting was set up last Friday. I was a bit nervous. When I got on the
call Dr. Hoover as well as Dr. Brennan, the medical director for Region B
and a few other CGS team members were on the call as well as a CPO. I
discussed my concerns. They stated that the concerns had been shared by
others, most notably O.T.s whose splints were denying. It seemed little had
been said by our profession directly. Dr. Hoover indicated they would be
working to resolve this issue and look more closely at the claim edits in
place and train the team members auditing these claims to look more closely
at records that justify a change in condition. He stated if I did not see
an improvement we could meet again.
There were a couple other critical lessons. First, I asked Dr. Hoover what
a provider like myself could do to be a better team player for Medicare. He
discussed the Operation Brace Me where millions and millions of dollars
of fraud were being conducted by DMEPOS providers (No legitimate ABC
certified O&P groups were involved in this).He said that we, as honest
providers, need to be aware and report these type of issues to the OIG. He
felt we knew who the bad players were and these situations need to be
reported. He felt if we had a better neighborhood watch less fraud would
occur. This fraud was from the groups calling Medicare beneficiaries and
mailing stuff to their homes. The bottom line was these audits are in place
because of that. I can't remember the number of dollars but it was
staggering. I promised Dr. Hoover I would share this message with my state
chapter and as many others as I could. Second, reasonable efforts by honest
providers can go a long way. Our trade associations need our help and can't
be left to do it on their own.
In preparation for this call I decided to join the NAAOP. It seemed the
most direct group to put my dollars in a place that was fighting these
issues. The other popular groups didn't return my calls for help and the
NAAOP did so that made joining them easier too.
It was fascinating discussing audits and medical records and competitive
bidding and pre-authorization. Much is coming our way and we need to work
together to be a part of the solution and help the DMEMACs understand who
we are and what we are doing and what hurts.
I will also likely be added to a DMEMAC O&P advisory board to CGS which I
didn't even know existed. This will give me a chance to share what everyday
life is like in an O&P clinic. Ideally policies could be in place that
would limit fraud without punishing honest providers. Fraud and overuse
exist and until those are brought under control the audits will remain. My
main concerns are that the records don't seem to be read by these audit
people.
Many responded to my original list post with stories of considerable pain.
I hope this message give you some hope and encourages you to reach out in a
positive way to your DMEMACs. I am nobody, really, and I feel I
accomplished a good bit over the last 4 weeks. You can do it!!
Next I/we need to find out who oversees the larger Performant audit group
and/or others and ensure that our notes are being considered in the records
review. We shouldn't have denials of every claim that hits them when there
is a reasonable amount of documentation in place to justify what was
provided.
--
Jim Del Bianco CPO
I sent a message a few weeks ago about same/similar denials and the
challenges in region C related to denials for these claims. Many people
responded with concerns and stories about similar challenges.
By way of follow up I want to share my experience. I called CGS and worked
my way to a meeting with a CGS provider relations senior analyst. She
listened to my concerns and asked that several of the claims be forwarded
to her for review with CGS. Many of these claims were overturned during
this review and sent back for payment. We did have detailed records that
met all of the criteria. She was very helpful and wonderful to work with. I
requested a meeting with the medical director, Dr. Hoover during our
conversation. I wrote a letter to Dr. hoover and The CGS team member
discussed with him my concerns and shared my letter.
A meeting was set up last Friday. I was a bit nervous. When I got on the
call Dr. Hoover as well as Dr. Brennan, the medical director for Region B
and a few other CGS team members were on the call as well as a CPO. I
discussed my concerns. They stated that the concerns had been shared by
others, most notably O.T.s whose splints were denying. It seemed little had
been said by our profession directly. Dr. Hoover indicated they would be
working to resolve this issue and look more closely at the claim edits in
place and train the team members auditing these claims to look more closely
at records that justify a change in condition. He stated if I did not see
an improvement we could meet again.
There were a couple other critical lessons. First, I asked Dr. Hoover what
a provider like myself could do to be a better team player for Medicare. He
discussed the Operation Brace Me where millions and millions of dollars
of fraud were being conducted by DMEPOS providers (No legitimate ABC
certified O&P groups were involved in this).He said that we, as honest
providers, need to be aware and report these type of issues to the OIG. He
felt we knew who the bad players were and these situations need to be
reported. He felt if we had a better neighborhood watch less fraud would
occur. This fraud was from the groups calling Medicare beneficiaries and
mailing stuff to their homes. The bottom line was these audits are in place
because of that. I can't remember the number of dollars but it was
staggering. I promised Dr. Hoover I would share this message with my state
chapter and as many others as I could. Second, reasonable efforts by honest
providers can go a long way. Our trade associations need our help and can't
be left to do it on their own.
In preparation for this call I decided to join the NAAOP. It seemed the
most direct group to put my dollars in a place that was fighting these
issues. The other popular groups didn't return my calls for help and the
NAAOP did so that made joining them easier too.
It was fascinating discussing audits and medical records and competitive
bidding and pre-authorization. Much is coming our way and we need to work
together to be a part of the solution and help the DMEMACs understand who
we are and what we are doing and what hurts.
I will also likely be added to a DMEMAC O&P advisory board to CGS which I
didn't even know existed. This will give me a chance to share what everyday
life is like in an O&P clinic. Ideally policies could be in place that
would limit fraud without punishing honest providers. Fraud and overuse
exist and until those are brought under control the audits will remain. My
main concerns are that the records don't seem to be read by these audit
people.
Many responded to my original list post with stories of considerable pain.
I hope this message give you some hope and encourages you to reach out in a
positive way to your DMEMACs. I am nobody, really, and I feel I
accomplished a good bit over the last 4 weeks. You can do it!!
Next I/we need to find out who oversees the larger Performant audit group
and/or others and ensure that our notes are being considered in the records
review. We shouldn't have denials of every claim that hits them when there
is a reasonable amount of documentation in place to justify what was
provided.
--
Jim Del Bianco CPO
Citation
Jim Del Bianco, “Follow up on same similar post,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 6, 2024, https://library.drfop.org/items/show/255037.
