These audits may seem inevitable, but denials do not have to be part of the equation
by Roberta Domos
December 31, 2014

The DME industry has been worn down for years by a relentless volume of Medicare audits in the form of additional documentation requests (ADRs). Worse yet, there are countless documented cases of incorrectly denied claims resulting from the audit process, and plenty of examples of redeterminations and reconsideration appeals that seem to be the MAC’s rubber-stamp approval of auditor errors. Sadly, all of this culminates in an ALJ appeal process so backlogged it can take years to get an independent review of an improperly denied claim. There is a sliver of hope that the quantity of audits will decrease now that CMS has agreed to send ADRs to providers in numbers proportionate to its ADR audit denial rate. It is now more important than ever not only to pass initial audits, thereby decreasing the number of ADRs received, but also to anticipate some of the more common “gotchas” auditors use to deny claims. In January, the new Medicare face-to-face rules added more than 160 big-ticket DME products to the previous list of items requiring a Written Order Prior to Delivery (WOPD). Technically, the DME provider is permitted to use the fax machine’s date stamp on the document header as proof that the prescription was received prior to delivery. However, do not count on auditors seeing it that way. If there is more than one date on the header because the document was faxed back and forth between referral source and provider, then the auditor may deny the claim even if one of the dates is prior to delivery. I have even seen an auditor deny a claim when the prescription contained only a single date stamp after making the incorrect assumption that it represented the date the DME provider sent it for signature, when in fact the prescription had originated from the physician’s office. The solution? Use an actual date stamp on the bottom of the page that states “received” followed by the receipt date. Also remember that if you get a WOPD for the DME device but the prescription also contains an order for supplies that Medicare considers a blanket order, such as the direction to fit the patient with any type of PAP mask that is most comfortable and effective for the patient, you will need to obtain a specific prescription for supplies received prior to billing the claim. Then you should submit both physician orders with your audit response. When you scan or copy documents in response to an ADR, always review before sending. Understand that the auditor is not likely to go out of the way to decipher writing on the pages you are sending. If the scan or copy is too light or too dark, or if any part is obscured or illegible, a denial is likely. Typically the same goes for the subsequent appeal even if the illegible portions are later cleared up. The same goes for physician notes. If necessary, create an enlarged copy of areas that are too small to be easily viewed and include the enlargement along with the full document. Avoid accepting home sleep study (HST) reports from companies that will not cooperate with the Medicare requirement to obtain documentation that the patient was trained in the use of the device prior to undergoing the HST. You also need to be aware that some auditors are now requiring that the proof of educational training document clearly delineate which type of instruction—face to face, video or telephonic—was provided, even though no such requirement to delineate the type of instruction received is required by the local coverage determination. Lastly, make sure your proof of delivery is spot on. Every item you plan to bill for should be included on the proof-of- delivery document and the description should be unambiguous. Don’t expect the auditor to know that something you have listed as “supersonic comfort fit” is actually a nasal PAP mask.