ARLINGTON, Va. — After tracking the impact of increasingly tough and proliferating audits on HME providers, officials at the American Association for Homecare say it's time for CMS to rein in its Medicare audit contractors.
Formed last year, the association's audit task force has looked at "dozens of sample audit letters that are typical of the ones HMEs receive from Medicare contractors nationwide," said AAHomecare President Tyler Wilson in a column for HomeCare's January issue. He added that CMS contractors "are routinely denying or requesting refunds" for medically necessary HME that is clearly covered by Medicare.
"Some of the audits are not just unfair," Wilson said, "they are contrary to coverage criteria and do not comply with applicable laws and regulations …
"Contractors are either refusing to pay for services or are requesting refunds for claims, in spite of the treating physician's determination of medical necessity and patient records that further demonstrate legitimate medical need for an HME item," Wilson said. "Our review shows that Medicare contractors often deny claims for reasons that are not specified in a controlling NCD or LCD or impose new documentation requirements without notice to providers."
In particular, Wilson continued, CMS' Zone Program Integrity Contractors (ZPICs), Program Safeguard Contractors (PSCs) and DME MACs — all of which can perform both pre- and post-pay audits — are performing "non-random prepayment complex medical reviews that include patently unfair requests for additional documentation and give providers little guidance about what they must do to terminate the prepay review."
In addition, he said, Comprehensive Error Rate Testing (CERT) contractors have recently been disregarding documentation created at the time of the initial order and are asking for patient records that explicitly document medical necessity on the date of service the CERT is auditing.
Wilson pointed out, however, that providers don't have and usually can't get — because the doctor doesn't have them, either — medical records that satisfy the CERT's request. "The result is that providers must refund the claim despite the presence of medical records that would have established medical necessity only a few months ago," he said.
The task force also found that some providers are being placed on 100 percent prepayment review and are getting additional documentation requests from the ZPICs on hundreds of claims, which means they have to spend an "enormous number of hours" obtaining clinical documentation. Because of the volume of requests, a provider's cash flow can be cut off for an extended period.
Wilson said association representatives would meet with regulators and members of Congress to address the "severe problems." Specifically, according to the task force recommendations, CMS should:
- Not permit contractors to apply new audit strategies retroactively;
- Establish clear, consistent rules on the medical necessity criteria and documentation that contractors may request in an audit;
- Publish the criteria for comment and include HME providers and physicians in this process. Once there are clear guidelines, contractors may enforce them prospectively;
- Establish parameters on the manner in which ZPICs perform audits;
- Place limitations on the number of additional documentation requests a ZPIC can issue to any one HME provider; and
- Limit ZPIC audits to situations where CMS or the ZPIC has credible evidence of serious wrongdoing on the part of a home care provider.
"Our goal is to ensure fair treatment by CMS staff and its contractors. We need unambiguous guidance that clearly defines what is required of HME providers. Contractors must also play by the established rules and need detailed instructions from CMS," Wilson said.
"Auditing cannot be a game of 'gotcha.'"
AAHomecare is asking providers with audit "horror stories" to contact Walt Gorski at waltg@aahomecare.org.