Audit Situation: ‘Worst I Have Ever Seen’

ARLINGTON,
Va.—AAHomecare’s Regulatory Council has its hands full
this year. With ZPIC, RAC, CERT and medical review audits in play,
oversight has never been so intense.

“It
is the worst I have ever seen,” said Kim Brummett, Regulatory
Council chair. “We have auditing bodies tripping over each
other.”

The
council met March 31 to focus specifically on audit activity and
has identified inconsistencies in documentation requested by
various Medicare audit contractors, Brummett said. Council members
are currently developing recommendations on exactly what
documentation should be requested by auditors for several product
categories, including oxygen, CPAP, diabetic supplies, enteral
nutrition, nebulizers and power mobility devices.

The
goal is to ensure that all audit contractors request consistent
documentation that is appropriate and specified under each Medicare
coverage policy, said Brummett, vice president, contracting and
reimbursement, for Advanced Home Care, High Point, N.C.

With
no relief yet, Brummett said, the association is continuing
education efforts with members of Congress, staff at CMS and the
Office of Inspector General about the problems stemming from
“unclear, inappropriate and overly complex” regulatory
requirements.

“Instead
of just fixing what we have, they just keep piling it on,”
said Brummett, a 24-year veteran of the HME billing world. She
noted proliferating medical reviews from the DME MACs and audits
from CMS’ Program Safeguard Contractors/Zone Program
Integrity Contractors, CERT (Comprehensive Error Rate Testing),
RACs (Recovery Audit Contractors) and others. Where the ZPICs are
concerned, she said, these contractors have the authority to look
across a wide spectrum of services, and in many cases they are
looking for indictments.

In
some cases, providers may be subjected to pre-pay audits that can
equal a near-death sentence, Brummett said.

“If
an error rate is over a certain percentage, the carriers are going
to do 100 percent pre-pay audit,” she said. “When
providers get into 100 percent pre-pay audits, they can’t
survive. Even the ZPICs are doing some 100 percent pre-pay audits,
and in the next six months we will start to see people who are just
closing their doors.” Brummett added that was already
happening in some areas, including her own backyard in Charlotte,
N.C.

Meanwhile,
Brummett said the association council is also monitoring
implementation of new anti-fraud provisions enacted under health
care reform. These include additional provider screening measures
such as application fees, licensure checks, site visits,
fingerprinting and criminal background checks, as well as mandatory
face-to-face exam requirements for DME.

There’s
no shortage of additional topics on the watch list, she said,
including modifications to the DMEPOS supplier standards, changes
to coverage policies based on elimination of the use of least
costly alternative, oxygen and CPAP policy and, of course,
competitive bidding.