Audits Go Beyond Unfair, AAHomecare Says

ARLINGTON, Va. — After tracking the impact of increasingly
tough and proliferating audits on HME providers, officials at the
American Association for Homecare say it’s time for CMS to rein in
its Medicare audit contractors.

Formed last year, the association’s audit
task force has looked at “dozens of sample audit letters that
are typical of the ones HMEs receive from Medicare contractors
nationwide,” said AAHomecare President Tyler Wilson in a column for
HomeCare’s January issue. He added that CMS contractors
“are routinely denying or requesting refunds” for medically
necessary HME that is clearly covered by Medicare.

“Some of the audits are not just unfair,” Wilson said, “they are
contrary to coverage criteria and do not comply with applicable
laws and regulations …

“Contractors are either refusing to pay for services or are
requesting refunds for claims, in spite of the treating physician’s
determination of medical necessity and patient records that further
demonstrate legitimate medical need for an HME item,” Wilson said.
“Our review shows that Medicare contractors often deny claims for
reasons that are not specified in a controlling NCD or LCD or
impose new documentation requirements without notice to
providers.”

In particular, Wilson continued, CMS’ Zone Program Integrity
Contractors (ZPICs), Program Safeguard Contractors (PSCs) and DME
MACs — all of which can perform both pre- and post-pay audits
— are performing “non-random prepayment complex medical
reviews that include patently unfair requests for additional
documentation and give providers little guidance about what they
must do to terminate the prepay review.”

In addition, he said, Comprehensive Error Rate Testing (CERT)
contractors have recently been disregarding documentation created
at the time of the initial order and are asking for patient records
that explicitly document medical necessity on the date of service
the CERT is auditing.

Wilson pointed out, however, that providers don’t have and
usually can’t get — because the doctor doesn’t have them,
either — medical records that satisfy the CERT’s request.
“The result is that providers must refund the claim despite the
presence of medical records that would have established medical
necessity only a few months ago,” he said.

The task force also found that some providers are being placed
on 100 percent prepayment review and are getting additional
documentation requests from the ZPICs on hundreds of claims, which
means they have to spend an “enormous number of hours” obtaining
clinical documentation. Because of the volume of requests, a
provider’s cash flow can be cut off for an extended period.

Wilson said association representatives would meet with
regulators and members of Congress to address the “severe
problems.” Specifically, according to the task force
recommendations, CMS should:

• Not permit contractors to apply new audit strategies
  retroactively;
• Establish clear, consistent rules on the medical necessity
  criteria and documentation that contractors may request in an
  audit;
• Publish the criteria for comment and include HME providers and
  physicians in this process. Once there are clear guidelines,
  contractors may enforce them prospectively;
• Establish parameters on the manner in which ZPICs perform
  audits;
• Place limitations on the number of additional documentation
  requests a ZPIC can issue to any one HME provider; and
• Limit ZPIC audits to situations where CMS or the ZPIC has
  credible evidence of serious wrongdoing on the part of a home care
  provider.

“Our goal is to ensure fair treatment by CMS staff and its
contractors. We need unambiguous guidance that clearly defines what
is required of HME providers. Contractors must also play by the
established rules and need detailed instructions from CMS,” Wilson
said.

“Auditing cannot be a game of ‘gotcha.’”

AAHomecare is asking providers with audit “horror stories”
to contact Walt Gorski at [email protected].