Q&A with Wayne van Halem: Getting Documentation, and Getting It Up Front

Wayne van Halem, president of The van Halem Group, Atlanta,
notes that for audits of any kind, the issue that has, by far,
caused the biggest problems for providers is insufficient physician
documentation.

“It’s frustrating for many because you don’t have much control
over what physicians do, but you’re still liable,” van Halem says.
“However, it is very important to remember that your only defense
in an audit is your documentation.”

He adds that “the burden of being placed on prepayment review or
appealing large overpayments is costly and overwhelming for most
businesses and can end up having a devastating impact.

“In this environment, it is not a question of “if” you are going
to be audited, it’s a question of “when,” continues van Halem, who
has worked as both a Medicare fraud investigator and national
appeals manager. “The industry must take appropriate steps to
prepare to break the cycle. You may think your documentation looks
good, but that is not often the case.

“It’s time for the industry to stand up and work together to
gain the needed cooperation from the physician community so they
can continue providing this much needed service to Medicare
beneficiaries.”

Question: Is it important to get documentation up front
before filing a claim to Medicare, even though the policy states
you’re not required to have it in your files?

Answer: Absolutely. Unfortunately, this
industry has not historically obtained documentation up front
before filing a claim because its not required. However, when you
attempt to obtain the documentation later upon request from
Medicare, it’s often not there or is not sufficient to meet the
tough Medicare policy requirements. That will result in a claim
denial and could lead to additional scrutiny.

Whether we like it or not, providers are liable for the
supporting documentation. So, not obtaining the documentation up
front is gambling that you will be able to keep your money down the
road if and when the claim is audited. If you are not getting
documentation up front, you are not only leaving yourself
vulnerable but you are making it more difficult for other providers
in the industry to obtain the documentation to meet Medicare
requirements.

Question: What if the physician does not respond or
complains about requests for documentation?

Answer: I hear consistent complaints from
clients who are requesting documentation proactively or in response
to audit requests that the physicians respond saying other
companies in the area aren’t requesting documentation so they will
refer to them instead. But you should hold that physician
responsible for doing something they are legally obligated to do.
Section 1842(p)(4) of the Social Security Act mandates they
comply.

However, the DME industry has not come together collaboratively
to address this issue, and it has become a huge problem. Unless the
industry starts working together, the issue will never be
solved.

I am also asked often why physicians aren’t held liable. While I
believe very strongly that they should be, that is not likely to
happen. However, if the industry works together to educate
physicians on how to document appropriately when they prescribe
medical equipment or supplies — and if the documentation is
requested up front — physicians will begin accepting that as
a normal process, and this terrible cycle would be broken.

Unfortunately, most providers are continuing with business as
usual until they are hit with an audit, and by then it is usually
too late. We are now hearing the horror stories about DME companies
in business for 20 years going out of business because of
hard-hitting audits, but the truth is that this industry and is not
prepared as well as other industries, and the results have had a
more devastating impact.

Question: Can I have the physician complete a form to
document medical necessity?

Answer: The use of supplier-generated forms in
this industry has been a major culprit in the closure of good
companies as well as the loss of business for companies looking to
obtain more appropriate documentation. If you are using “forms” in
your company, you are doing more harm than good.

This may seem extreme, but forms are never accepted by an
auditor as documentation of medical necessity.

If you send a form to physicians to complete, they do so
thinking that is all that needs to be done. As a result, they do
not document anything further in their progress notes. So, in
essence, using forms is actually detrimental to obtaining the
documentation you will need to support an audited claim. The
support must be documented in the physician’s progress notes, which
is where it needs to be. I highly recommend against using any type
of forms unless they are specifically permitted in the policy.

Question: What kind of documentation are the auditors
looking for?

Answer: For each service that you provide for
which there is a Local Coverage Determination (LCD), the auditors
are looking for documentation to show which criteria for coverage
is met. These criteria are listed in the “Indications and
Limitations of Coverage and/or Medical Necessity” section of the
policy.

Essentially, the patient’s condition has to be documented
clearly enough for the auditors to determine that the coverage is
acceptable according to the medical policy. Unless you have someone
reviewing documentation and communicating with your referral
sources before providing services, then this is most likely not
present.

The problem is that physicians do not know what the policies
state in most instances. So, unless you educate them on the policy
requirements, chances that the documentation is sufficient are very
slim.

The supporting clinical documentation is the most difficult to
obtain and the biggest issue for most companies being audited now.
If the service is an ongoing rental or supplies, the auditors are
looking for documentation of ongoing medical necessity and that
appropriate refill policies were followed.

Each policy also contains a “Documentation Requirements”
section, which lists other documents, such as a Certificate of
Medical Necessity (CMN) that may be required. These documents are
usually unique to each individual policy.

You should also review the Supplier Documentation chapter of
your DME MAC supplier manual to remind yourself of the normal
requirements such as order, proof of delivery, beneficiary
authorization and Advance Beneficiary Notice (ABN).

Question: Do you have any tips for providers trying to
obtain better documentation?

Answer: Rather than forms, suppliers should
start using cover letters educating physicians on the policy
requirements. If you receive a referral and are faxing over a
detailed written order for the physician to sign, then attach a
cover letter explaining what needs to be documented in the
physician’s progress note and requesting a copy.

Many HME companies think that the more documentation you have,
the better it is. That is not the case. Just one progress note may
be sufficient to support the need for an item billed as long as it
addresses Medicare’s indications for coverage. Section 5.3.2
specifically states: “Cover letters can be used by a supplier as a
method of communication between the supplier and the physician. It
is not CMS’s intent to restrict necessary communication between the
supplier and the physician.”

Whether we like it or not, CMS has put the responsibility of
educating physicians about DMEPOS coverage criteria on the
supplier. So, these cover letters are one way to accomplish that
education.

I recommend building an open and collaborative relationship with
your referral sources and providing them educational material. If
possible, try to do an in-service with some of your referral
sources to educate their staff on the coverage criteria and
documentation requirements. The physician and supplier should be
partners in caring for their patients, but you can only accomplish
this if you follow through and provide resources and materials to
help physicians understand the process.

Other good tools are the physician letters posted on the DME MAC
websites by the medical directors. These letters outline the
physician’s requirements to provide the documentation; physicians
may be more inclined to respond because the direction is provided
by another physician. The medical directors have also drafted more
specific letters for certain coverage policies, such as power
mobility.

Several of the DME MACs have also provided checklists for your
staff to use internally. These checklists provide good information
on what needs to be contained in the patient’s file in order for
the equipment to be considered reasonable and necessary. I would
recommend having reliable and educated staff review the
documentation that comes in from physicians’ offices. Remember,
having the documentation in the file means nothing if it isn’t
sufficient.

In situations where you are having difficulty with a specific
physician, attempt to get the patient involved. Explain what is
needed to the patient and advise them that if you don’t obtain
sufficient documentation, they may be liable for payment. You have
the right in these instances to obtain an ABN because the
documentation does not support that the coverage criteria has been
met. Once patients realize they could be liable, they may get more
involved in getting their physician to cooperate with you.

All suppliers should implement processes to obtain supporting
documentation up front. Doing so will provide better security for
your business and help the industry as a whole better prepare and
respond to audits

Author and consultant Wayne van Halem, president of The van
Halem Group, Atlanta, has worked as a fraud analyst, Medicare fraud
information specialist and senior investigator. An Accredited
Healthcare Fraud Investigator and Certified Fraud Examiner, van
Halem has also served as the appeals manager for Medicare Part B
second-level statutory appeals nationally. Currently, he provides
counsel to all entities involved in the participation,
administration and oversight of public and private health care
plans. You can reach him at 404/343-1815 or [email protected].

For more on getting prepared for and responding to ZPIC
audits, see Wayne van Halem’s article called CMS Turns Up the
Heat in HomeCare’s April 2010 issue.