Will the Centers for Medicare and Medicaid Services (CMS) ever
decide to change the national policy regarding medical necessity
documentation? I doubt it, at least not in the near future.
CMS has had the ability to recoup much of providers' hard-earned
reimbursement by holding them responsible for what is written in
physician's progress notes. Have you ever read those notes? I have
boxes of examples in my office from working on provider audits, and
I can tell you that most are useless.
Why not revise the Certificate of Medical Necessity (CMN) so it
contains the information required by the Durable Medical Equipment
Regional Carriers (DMERCs) and CMS? Per Judge Lawrence Karlton's
preliminary ruling in the Maximum Comfort case in the Eastern
District of California, “[The existing statute] plainly
specifies that Congress intended that whatever information may be
required by carriers from suppliers to show the medical necessity
and reasonableness of DME must be contained in a CMN.”
The final ruling will only be binding in the Eastern District of
California. CMS will most likely file an appeal since the agency
feels it needs to see physician notes to determine medical
necessity. I am sure they feel they cannot police fraud and abuse
otherwise.
But since the physician has always been considered the
“captain of the ship” who determines medical necessity,
how can CMS expect a provider to do the same? CMS' response has
always been, “The providers are the ones receiving
reimbursement for the item from Medicare, so they are
responsible.” Can you imagine walking into a doctor's office
and telling him you do not feel he is correct in prescribing
particular equipment for his patient? It would not take long for
you to be thrown out of the same door you came in!
To be sure, the CMN needs improvement. For example, it asks no
questions regarding clinical evaluations by a physical or
occupational therapist, or on physician progress notes. Although
one coverage criterion states that the patient must be capable of
safely operating power wheelchair controls, the CMN doesn't address
the issue.
Why isn't there a question that asks, “Without the use of
a power wheelchair, would this patient be bed- or
chair-confined?” or, “Is this patient
non-ambulatory?” The CMN should ask physicians to note any
special conditions or problems relating to a patient's medical
needs. Oddly enough, Medicare does not see a physician's Letter of
Medical Necessity (LMN) as meaningful in the decision-making
process, even with a physician's signature.
A well-written CMN should make it possible for CMS to be assured
that the physician answers questions detailing all criteria per
Medicare policy, and that the patient qualifies.
The Maximum Comfort ruling states that Congress, not CMS, sets
the criteria and documentation necessary to demonstrate Medicare
eligibility for DME items. Since Congress states the CMN is
sufficient for reimbursement purposes, why have things gotten so
out of control? Providers must stand up for their business and our
industry. Work all of your denials. If you have to go through all
five steps of the appeals process to receive reimbursement for
items you delivered, then go for it!
I strongly believe providers in all four regions should and will
use this court ruling as precedent when faced with overpayment.
This case is the eye-opener that providers have needed for some
time. Thanks, Maximum Comfort, for a job well done.
For more information on the California court case involving
Maximum Comfort, see the August 2004 issue of HomeCare.
Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. A
reimbursement specialist, Bunch delivers educational seminars
worldwide, helps develop corporate compliance plans and serves as a
consultant for fraud and abuse cases. She can be reached at
678/445-1221 or via e-mail at
target="_blank">BILLHME@aol.com.
