Documentation Dilemma

The relationship between home medical equipment companies and referring physicians can be testy at times. This is especially so when a supplier must rely on the physician to complete a medical chart or a form with all the substantive indicators of medical necessity and correct terminology required to entitle the supplier to payment on a claim.

It is not enough for a physician to believe a piece of equipment or therapy is appropriate for the patient. The physician must also articulate why the item satisfies the insurance requirements for entitlement clearly and precisely. Just because the physician has made a referral to an HME company does not mean that the company will be entitled to reimbursement after the medical record is reviewed.

Many companies have tried to address this problem by helping physicians complete their necessary documentation. Some state medical societies have tried to ease the physicians’ burden, giving them preprinted forms to help justify a patient’s entitlement. These forms come complete with boxes to be check-marked and other shortcuts designed to alleviate the physician’s workload.

CMS has pushed back against many of these efforts to assist physicians and reduce their paperwork requirements. HME companies are not permitted to complete the physician’s paperwork and then have it signed by the doctor. CMS has further rejected fill-in-the-box forms, holding that such forms are not credible evidence of the physician’s diagnoses and justification for prescribing certain equipment or therapies.

CMS says its concern is that forms channel the physician toward expediency rather than an accurate reflection of medical judgment, and that substituting the form’s verbiage for what the physician may otherwise have written casts doubt on whether the words reflect the physician’s medical judgment accurately and precisely.

One problem, of course, is that an HME company can’t simply say to the physician, “We can’t give you a form to use, because CMS says it is bad.” Too many physicians will respond, “Well, Brand X Homecare says they will give me a form, even help me fill it out, and that’s all I will need to do. Why should I refer patients to you, when Brand X will do this for me?”

I have several responses to this sort of comment. First, alerting the physician that Brand X may not be following the law, and that the physician himself could come under scrutiny if repeated violations are noted will often help. (The physician’s vulnerability comes from the suggestion that repeated use of such forms casts doubt as to the physician’s full determination of medical necessity; this doubt, in turn, suggests that the physician’s own billings may not be supported by clinical decision-making.)

Second, sometimes you can challenge the competitor’s activity. The competitor’s president, compliance officer or other senior decision-maker may not be aware of the form-filling practice or its noncompliance. Exposing it to the light of day may cause the competitor to reevaluate its bad behavior. At a minimum, it can help prompt the feds or the DME MAC into action if you can demonstrate that Brand X Homecare knew of the violation (as evidenced by your letter) and willfully ignored it.

Finally, and most important, there are steps you can take within the confines of the law and reimbursement rules to make the physician’s life easier. An HME company is permitted to fill out the portions of physician paperwork that don’t deal with medical observations and judgment. This includes physician information as well as administrative details relating to the patient, such as name, address, date of last visit, etc. An HME company is also permitted to instruct the physician as to what type of information CMS requires to demonstrate reimbursement entitlement, what phraseology CMS believes best satisfies its criteria and what sort of information to emphasize or de-emphasize, etc.

For example, an instruction letter could alert the physician to Medicare’s specific requirements for reimbursement entitlement. It might say: “Medicare requires that a patient receiving a power mobility chair must be unable to navigate in the home without the chair.

If this navigation problem is part of your diagnosis, please say so clearly, and also state clearly why the patient cannot use a manual wheelchair.”

An HME company may remind the doctor of some of the clinical conditions that would require a patient to need certain equipment, and may advise the physician to state those reasons clearly and directly. Mind you, CMS has never come out with any precise, detailed guidance on how much assistance is “too much.” So, I would avoid offering much in the way of exact language. For example, an HME company should not say, “If you conclude that your patient cannot navigate her house without a power chair, you should write these words in your medical chart: ‘The patient has no leg or arm strength, as well as vertigo problems, and therefore cannot ambulate without the assistance of a power mobility device.’”

Absent conflicting commentary from CMS, it may be acceptable to alert the physician to some of the diagnoses that would result in the patient’s being unable to navigate her home without a power device. It would probably be acceptable to remind the physician that, for example, if vertigo was part of the patient’s pertinent diagnosis, the physician would need to make sure that the rest of the medical records supported that diagnosis.

There are many different options for formatting these instructions, and you will want to consider how best to support the particular desires and preferences of your referral sources. Regardless, many physicians may resist using your services without such help. It may, therefore, be wise to guide your referral sources as thoroughly as you can while still staying on the right side of the regulatory waters.

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Neil Caesar is president of the Health Law Center (Neil B. Caesar Law Associates, PA), a national health law practice in Greenville, S.C. He also is a principal with Caesar Cohen Ltd., which offers compliance training, outsourcing and consulting and the author of the Home Care Compliance Answer Book. You can reach him at 864/676-9075 or [email protected].

Materials in this article have been prepared by the Health Law Center for general informational purposes only. This information does not constitute legal advice. You should not act, or refrain from acting, based upon any information in this presentation. Neither our presentation of such information nor your receipt of it creates nor will create an attorney-client relationship.