Get that Documentation, MACs Say

BALTIMORE — HME providers often express frustration with
physicians in the ongoing battle to obtain proper documentation for
Medicare claims. Cajoling, begging and even educating doctors has
its limitations, callers complained during a Jan. 13 CERT
teleconference hosted by the four DME MACS.

But representatives of the CERT (Comprehensive Error Rate
Testing) Education Task Force formed by the MACs confirmed on the
call that responsibility ultimately rests with providers.

As part of CMS’ efforts to reduce Medicare fraud, providers have
seen increased claims reviews and requests for additional
documentation to support payments. The call covered topics
including medical records requests, responding to those requests
and CERT appeals. According to officials on the call, the top six
claims garnering the most frequent errors are for oxygen, diabetic
supplies, power mobility devices/wheelchairs, nebulizers and drugs,
enteral nutrition and PAP devices.

In prepared comments designed to address these documentation
concerns, one CERT official said:

It is the supplier’s responsibility to obtain the
documentation needed to support the medical necessity of the
equipment being supplied. If the physician does not supply you with
the documentation that you request, you can explain to them that it
is stated in the Program Integrity Manual that for any DMEPOS item
to be covered by Medicare the patient’s medical record must contain
sufficient documentation of the patient’s medical condition to
substantiate the necessity for the type and quantity of items
ordered and for the frequency of use or replacement if applicable.
The information should include the patient’s diagnosis and other
pertinent information, including but not limited to duration of the
patient’s condition, clinical course as to whether it is improving
or worsening, the prognosis, nature and extent of functional
limitation, other therapeutic interventions, past experience with
related items.

It also states that there must be information in the
patient’s medical record that supports the medical necessity and
substantiates the answers on the CMN if applicable, or information
on a supplier prepared statement or physician form if applicable.
If the physician continues to refuse to cooperate with your request
for documentation, you can always inform them that your company
will not be able to supply the equipment as ordered until the
information has been provided.

In a question-and-answer session during the call, one provider
lamented, “We do not have control over what physicians document or
do not document in their medical records. CERT is holding us
accountable for the lack of physician documentation … If the CERT
is asking for medical record documentation that would go back
longer than seven years, how can we as a supplier control the fact
that a physician no longer has that documentation?”

Amy Capece, outreach/education manager for the Jurisdiction A
DME MAC (NHIC), responded, “This is probably not what you are going
to want to hear, and you are not going to like what I am going to
say, but it truly is the responsibility of the supplier to have the
information in your file and readily accessible and available to
support the medical need and the criteria for the equipment you are
providing …We highly recommend that when you take on a
patient, you make sure that you have the documentation and the
information for the medical support of the equipment you are
providing to that beneficiary.”

Noting that physicians are receiving audits as well, added
Capece’s counterpart James Herren from Jurisdiction C (Cigna),
“Doctors do need to document, document, document.”

Yet another questioner took up the issue, saying, “The CERT
program is placing all the responsibility on the provider to talk
with physicians and to train physicians, but who are we to question
what the physician is putting in the chart?”

The lengthy response boiled down to the importance of a proper
intake, and continuing to educate physicians. “Have a conversation
with your physicians,” said one official, “and act like a partner
with that physician.”

Providers can contact the CERT customer service line at
888/779-7477 and via the Internet at www.certprovider.org.

For the PowerPoint presentation from the teleconference, which
includes recommendations for reducing claims errors, see the

NHIC Web site under “What’s New.”