Audits Run Amok

Yep. “Amok” is exactly the word AAHomecare used to describe the growing onslaught of Medicare audits. Many are not only unfair, an association task force discovered, but in some cases the audits go against coverage criteria and don’t comply with laws or regulations.

After looking at dozens of sample letters received by HME providers nationwide, a task force report found government contractors “often deny claims for reasons that are not specified in a controlling national or local coverage determination or impose new documentation requirements without notice to providers.”

When we asked members of HomeCare’s Editorial Advisory Board to name the industry’s biggest challenge, in fact, consultant Sarah Hanna chose audits over the devastating competitive bidding program. While providers are getting hit from all sides and it is a toss-up between the two, she said, where audits are concerned “it’s hard to prepare for the attack.”

I’m hearing the same thing from a number of providers. Pre- or post-pay, RAC, CERT, ZPIC, DME MAC, you name it. Somewhere at some HME company, some auditor is looking.

The ZPICs in particular seem to be creating a new sort of HME hell.

Recently I got a call from Ricky Burge, a provider in Oxford, Miss., whose small company has been on 100 percent pre-payment review since October — of 2009. That’s 16 months. But he didn’t find out until February of 2010. Even then, Ricky said, he had to get his senator (Roger Wicker, R-Miss.) involved to find out why.

He was told the company had been identified as a “high-risk supplier,” but he’s still not sure what triggered that. Although he’s received many additional documentation requests, Ricky said he doesn’t have a single piece of paper from AdvanceMed, the ZPIC for Zone 5, about the reason for the audit. And after 20 emails and three written requests asking for feedback on his claims, he hasn’t gotten any answers.

“If you can send an ADR to my address and I get it, why can’t you send an education letter to my address and I get that?” Ricky wondered. His brother Vernon, co-owner of the business, went to the CMS contractor’s office in Nashville to see if he could pick up such a document, “but they wouldn’t let him talk to anyone who was involved,” Ricky said.

What’s more, even though the small company serves only about 40 Medicare patients a month, it’s vital to the community, Ricky believes, and he hates that his customers are being inconvenienced. “I see them at church and Walmart,” he told me. “We’re the only power mobility provider in a four-county radius.” He is also a certified orthotic fitter, and some of his patients don’t have other options for 20 miles.

The company is beating the ZPIC decisions on appeal. “But we’re still on 100 percent review,” Ricky said.

His goal, of course, is to come off the review, and he continues to work at it. He acknowledges his claims weren’t all perfect. But after months of fighting through what is a “very, very slow-moving process that takes up every bit of your time,” he said, “we’re only hanging on by a thread. It’s crippled our business. I don’t think we can ever build it back.”

When we spoke, Ricky was in the process of completing a formal complaint to CMS about the entire ordeal — he’s kept a diary documenting the audit since it began — and he is keeping Sen. Wicker in the loop.

AAHomecare is also planning to meet with members of Congress about its findings, and Ricky is hopeful they will help. “This is a classic example of Washington over-regulating an industry,” he said. “If the ZPICs treat companies that are trying to get it right like this, many companies in the industry won’t be able to survive.

“There’s no way you could plan for anything like this,” he said. “It came out of the blue.”

Ricky warned all providers, big or small, to prepare for a ZPIC audit. If it does happen, he said, “Surround yourself with people who can be a source of support and other providers who have gone through this. You’ve got to have somebody to lean on.”

After all, isn’t having HME providers to lean on the reason this industry exists?