The Audit Mess

Complaints are mounting by the week about the number, magnitude and scope of audits hitting the HME community.

Home care companies across the country are finding themselves subjected to 100 percent prepayment review. Over-reaching by audit contractors within Medicare coupled with glaring mistakes and denials of claims at alarming levels are hampering the ability of providers to supply medically required care and equipment to patients. Reports are coming in that some providers are scaling back operations and some even closing their doors because of the massive pressure of denials and recoupments.

AAHomecare has been telling CMS and its contractors that the bombardment of audits — now including MAC, RAC, ZPIC, PSC and CERT — must end and the current approach must change. The auditing strategy underway right now is expensive, inefficient and distorts the Medicare claims error rate for at-home care products. The process is unreasonably burdensome to providers and is disrupting the service and care provided to patients.

Here are just a few consequences:

• Data regarding fraud is being distorted;
• Eligible Medicare beneficiaries are not receiving medically necessary and covered benefits;
• Auditors for CMS are misinterpreting and then misapplying Medicare rules and regulations, sometimes on a retroactive basis, leading to inaccurate error-rate data;
• Legitimate providers are being hurt by unjustified monetary recoupments; and
• CMS will not be able to achieve the Administration’s goal of reducing the error rate until it modifies its current audit policies.

The Association has been working with CMS officials for over a year to get the agency to refine its approach. Common sense and accountability need to become two of the parameters guiding the audit process.

CMS is just now beginning to respond; some incremental progress has occurred. Much more work will be needed by AAHomecare and the state organizations, however, before the onslaught of audits is likely to get scaled back in any meaningful measure.

In late June, CMS announced it will conduct an “audit audit” following a long line of complaints about overzealous auditors. CMS Administrator Donald Berwick recently admitted that audits are “a blunt tool.” Often linked to fraud prevention, as was the case at a June federal fraud-prevention summit in Philadelphia, audits continue to choke legitimate home care providers and cause millions of dollars in withheld payments.

If there was any good news to come from the summit, it might be in the fact that references to HME were conspicuously minimal. Dozens of government and law enforcement experts who presented at the Philadelphia conference focused their attention on pharmaceutical companies, dentists, physicians, hospitals, physical therapists and other types of providers and suppliers in other health care sectors.

Members of AAHomecare’s Regulatory Council continue to push CMS on the audit issue. Fighting overzealous auditing practices is the highest priority for the Council. A meeting in June with Medicare officials was a follow-up to an initial meeting in January when the agency asked the Association what documentation it thought should be requested in audits for CPAP, oxygen, enteral nutrition, diabetic supplies, power mobility devices and nebulizers.

AAHomecare provided CMS with its recommendations on documentation and offered other guidance to help clarify how CMS auditors conduct audits. For example, the Association believes auditors should not deny claims simply because saturation levels were written on a desktop prescription or because the auditors did not like the documentation form used by hospitals.

Over the past couple of years, audits have created one more significant obstacle to providing high quality home medical equipment to America’s seniors and people with disabilities. AAHomecare understands the problem, shares the urgency and is committed to clearing the path so the HME community can once again focus on providing good products and service.

Read more AAHomecare Update columns.

Tyler J. Wilson is president and CEO of the American Association for Homecare, headquartered in Arlington, Va. You can reach him at [email protected]. For more information on critical home care issues, visit the association’s Web site at www.aahomecare.org.