You’ve (Probably) Got Mail

Have You Received Your Audit Request?

If you have not received an audit request from AdvanceMed already, it is likely that you will.

AdvanceMed is an independent auditor hired to perform audits for the Centers for Medicare and Medicaid Services. The Comprehensive Error Rate Testing program, or CERT, allows CMS to monitor claims to ensure that they are accurate, and therefore, should be reimbursed.

Let’s review to make sure your documentation meets the requirements to pass these audits — and so that your claims will be reimbursed.

Physician Orders

Physician orders must be complete and accurate. A 3″×5″ prescription slip that reads “bedside commode, diagnosis: CVA (cerebrovascular accident),” even if it contains the patient’s name and the doctor’s signature, is not an acceptable order.

What does constitute a compliant physician order? Check your orders for the following:

• Patient’s name, address and Health Insurance Claim (HIC) number
• Physician’s name, address and UPIN
• Quantity of the item to be dispensed
• Frequency of use
• ICD-9 code or narrative diagnosis
• Specific type of equipment or supply ordered
• Date of the order
• Length of need
• Physician’s signature and date
• Medical necessity of the item

Certificates of Medical Necessity

CMNs must comply to Medicare guidelines; providers can face large fines if they are not. Check your CMNs for accuracy and completion. As a provider, you must complete Sections A and C of any CMN before it is delivered to the physician’s office for his or her signature and date.

In Section A, make sure to include:

• Patient demographics
• Place of service
• Provider’s information
• Physician’s information, including UPIN
• Patient’s date of birth, sex, height and weight

Section B must be completed by the physician or an employee of the physician. If someone other than the physician completes Section B, that person’s name, title and employer must be stated. Section B also gives the medical necessity qualifications for the equipment being ordered.

Section C, to be completed by the provider, must state the equipment, supplies and accessories being ordered, as well as the Medicare allowable and supplier’s charge.

Section D includes the treating physician’s signature and the date of the physician’s signature.

Remember to make sure the CMN retains its back section, which includes printed instructions for the physician on how to complete the CMN. Any changes made on the CMN must have the physician’s initials and date. Any electronic CMN that is transmitted to the DMERC must be a mirror image of the paper CMN.

Go through your CMNs thoroughly. If you find any that are not in complete compliance, obtain revised CMNs so that you will be prepared for auditing.

Written Order Prior to Delivery

For items requiring a written order prior to delivery (WOPD), verify that you have a signed, written order in your hands before the equipment is delivered or leaves your showroom floor. A WOPD is required for:

• Support surfaces
• Transcutaneous electrical nerve stimulator (TENS) units
• Seat lift mechanisms
• Negative pressure wound therapy (NPWT)
• Power-operated vehicles (POVs)

Before sending any audit to AdvanceMed or directly to your DMERC, it may be wise to have an outside review of the documentation to avoid an overpayment, or a possible denial of a pre-payment review. The saying “pay now or pay later” comes true all too often for many providers.

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 [email protected].