Medicare audits and documentation
Darya Shahrokhi
Description
Collection
Title:
Medicare audits and documentation
Creator:
Darya Shahrokhi
Date:
3/3/2022
Text:
Dear all practitioners, billers, and O&P educated professionals who provide O&P services:
Recently Juan Chow LO sent an email regarding back braces audits. Many of you responded him and he shares them to all; many thanks to Juan.
I am writing this because this is one of the biggest problem we have with Medicare, and may be for other health plans soon!
Here is my understandings:
1- Medicare announced codes for OTS vs. custom fit on 2011-2012
2- They wanted to know how many of pre-fab items are being fit with-out any professional involvement; thanks to those DME companies that put the back or knee or … braces in the box and ship to the patient’s home!
3- Based on their analysis, they find that most of the time, pre-fab items are just shipped or fit with no expertise.
4- They started competitive bid program with a limited codes, but I’m pretty sure that they will add more codes soon. Now manufacturers are the winners of this program! They ship items to patients' homes, and get paid by Medicare 2 to 5 times more than what they would sell to us. And of course Medicare pays less.
I also want to share the fact that not all orthotists use heat gun or bending iron to adjust the back brace! We know that most of the times it just need to be sized.
Now O&P professionals and business owners are facing difficulties with Medicare audits, and the fact that they ask for the money back after even 5 years.
This is the issue with the pre-fab items; now what about custom made? For the custom made items, auditors are educated to find a lot of verbiage: Why we need to go with the custom vs. OTS? Has the patient tried OTS before? Did doctor add to his/her notes why OTS won’t work? Did we take a photo of the item? and ….
I know many companies which rather not to take Medicare patients because they don’t want to return money after 3-5 years.
We all went to the school and passed hard exams to be certify to provide O&P to the people who need them. We all want to work and survive. We all want to make money to pay our staff, our rent, our bills, and of course enjoy the life.
Every year more than 200 candidates are being certified and look for job. What if we won’t be able to provide pre-fab items because they don’t think any professional involvement is needed, or because of the competitive bid; and won’t be able to provide custom made items because doctor didn’t write everything on the notes? Are small companies going to shut down? What happens to their employees then? Can Hanger hire everybody?
Please don’t get me wrong; I’m not saying that Medicare should pay us without any question. We should do our best and we should do our job; but why a nurse or physical therapist can dispense a back brace at his/her office and get paid at full even in the bid area, and we won’t? why some DME companies that do not have any orthotist on-board would be able to ship items to the patients’ homes and get paid full? Why should we refund Medicare for a custom AFO when doctor didn’t write the reason of ordering custom AFO vs. OTS? and many other WHYs
The question is:
What should we do as a professionals to reduce this ridicules audits and rules?
I think we should be all together in this. Please, let me know what we should do? I always said that I’m ready for my share, anything that we can fight with these. Anything that we can get what we suppose to, not more and not less. How can we fight with these rules and where should we start?
Regards,
Darya Shahrokhi, CPO, FAAOP
Recently Juan Chow LO sent an email regarding back braces audits. Many of you responded him and he shares them to all; many thanks to Juan.
I am writing this because this is one of the biggest problem we have with Medicare, and may be for other health plans soon!
Here is my understandings:
1- Medicare announced codes for OTS vs. custom fit on 2011-2012
2- They wanted to know how many of pre-fab items are being fit with-out any professional involvement; thanks to those DME companies that put the back or knee or … braces in the box and ship to the patient’s home!
3- Based on their analysis, they find that most of the time, pre-fab items are just shipped or fit with no expertise.
4- They started competitive bid program with a limited codes, but I’m pretty sure that they will add more codes soon. Now manufacturers are the winners of this program! They ship items to patients' homes, and get paid by Medicare 2 to 5 times more than what they would sell to us. And of course Medicare pays less.
I also want to share the fact that not all orthotists use heat gun or bending iron to adjust the back brace! We know that most of the times it just need to be sized.
Now O&P professionals and business owners are facing difficulties with Medicare audits, and the fact that they ask for the money back after even 5 years.
This is the issue with the pre-fab items; now what about custom made? For the custom made items, auditors are educated to find a lot of verbiage: Why we need to go with the custom vs. OTS? Has the patient tried OTS before? Did doctor add to his/her notes why OTS won’t work? Did we take a photo of the item? and ….
I know many companies which rather not to take Medicare patients because they don’t want to return money after 3-5 years.
We all went to the school and passed hard exams to be certify to provide O&P to the people who need them. We all want to work and survive. We all want to make money to pay our staff, our rent, our bills, and of course enjoy the life.
Every year more than 200 candidates are being certified and look for job. What if we won’t be able to provide pre-fab items because they don’t think any professional involvement is needed, or because of the competitive bid; and won’t be able to provide custom made items because doctor didn’t write everything on the notes? Are small companies going to shut down? What happens to their employees then? Can Hanger hire everybody?
Please don’t get me wrong; I’m not saying that Medicare should pay us without any question. We should do our best and we should do our job; but why a nurse or physical therapist can dispense a back brace at his/her office and get paid at full even in the bid area, and we won’t? why some DME companies that do not have any orthotist on-board would be able to ship items to the patients’ homes and get paid full? Why should we refund Medicare for a custom AFO when doctor didn’t write the reason of ordering custom AFO vs. OTS? and many other WHYs
The question is:
What should we do as a professionals to reduce this ridicules audits and rules?
I think we should be all together in this. Please, let me know what we should do? I always said that I’m ready for my share, anything that we can fight with these. Anything that we can get what we suppose to, not more and not less. How can we fight with these rules and where should we start?
Regards,
Darya Shahrokhi, CPO, FAAOP
Citation
Darya Shahrokhi, “Medicare audits and documentation,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/255829.
