Issue link: http://read.dmtmag.com/i/59015
14 Editorial W e get emails all the time from HME providers and other stakeholders pointing stuff out. These emails often sit in my inbox for some time. They're interesting and note- worthy, but there's no way we can write stories about them all. So in an effort to clean out my inbox, I'm going to share a few of them with you here. Former provider Dominic Rotella recently pointed out to me that the government is being a bit of a hypocrite in its crackdown on health- care fraud. You remember Rotella, right? He fought an audit and won and is now suing TriCenturion, the CMS contractor that con- ducted the audit, for $10 million in damages. Rotella shared two announcements relat- ed to the government's healthcare fraud efforts. The first: The government announced recovering $4.1 billion in improper pay- ments to Medicare providers in fiscal year 2011. The release on this big news had "fraud and abuse" stamped all over it. The second: The government announced plans to save $370 million this year, and more over time, from improper payments to Medicare Advantage plans. The release on this big news had "prob- lem" stamped all over it, even though it was estimated to be a $12 billion "prob- lem" in 2011 alone. Note the difference in how the govern- ment views Medicare providers and pri- vate health plans? As Rotella points out, Medicare providers being paid improperly is "fraud and abuse;" private health plans being paid improperly is "a problem." Another provider pointed out a com- Post-payment reviews, step by step AUDITS: PART III BY JEFFREY BAIRD Editor's note: This is Part III of a five-part series. Part IV will compare post-payment audits and prepayment reviews conducted by DME MACs with those conducted by ZPICs, and Part B will discuss contractor abuses. in the interpretation and implementa- tion of Medicare policy. MR functions may include analyzing data; writing and review- ing local coverage determinations; reviewing claims and educating providers; comprehen- sive error rate testing; advance determina- tion of Medicare coverage; probe reviews; supplier education; and medical review of claims not for benefit integrity purposes. INITIATION OF POST-PAYMENT MR When initiating post-payment MR (either provider-specific or service-specific), the DME MAC is required to give suppliers written notice of the following: the specific reason for selection; if the basis for selection A CCORDING TO CMS, the Medical Review (MR) program is designed to promote a structured approach is comparative data, how the supplier's data varies significantly from other suppliers in the same specialty payment area or local- ity; the list of claims that require medical records; and the OMB Paperwork Reduction Act collection number. DME MAC DETERMINATION A contractor may review a claim regardless of wheth- er a national coverage determination (NCD), coverage provision in an interpretative manual, or LCD exists for that service. A contractor must first consider cov- erage determinations based on the absence of a benefit category or based on statutory exclusion. Next, a contractor then considers whether the claim was reasonable and neces- sary. A service is reasonable and necessary if the contractor determines that the service is (i) safe and effective; (ii) not experimental or investigational (with a limited exception); Jeffrey Baird and (iii) appropriate, including the duration and frequency that is considered appropriate for the service. A contractor must deny a claim (in full or part) whenever there is evidence that the item or service was not rendered or was not rendered as billed; was fur- nished in violation of the self-referral prohibition; was furnished, ordered, or prescribed on or after the effective date of the supplier's exclusion (unless an exception applies); or was not furnished or not furnished as billed. DOCUMENTATION FOR POST-PAYMENT MR The contractor may review any docu- mentation submitted with the claim and request documentation from the supplier or a third party. A contractor may, but is not required to, review unsolicited, support- ing documentation that is submitted with a claim. A contractor may deny a claim without reviewing such documentation in two instances: (i) when clear policy serves BAIRD SEE NEXT PAGE LIZ BEAULIEU ment made by Dr. Doran Edwards on a dis- cussion board for a LinkedIn group. You remember Edwards, right? He's a consultant and former CMS medical director. He wrote: Round Two absolutely must happen. Law requires the successful launch of two rounds of competitive bidding. Then the Secretary has the authority to apply an across the board cut to all DMEPOS in which significant sav- ings may be realized. By presidential mandate, competitive bidding for all HCPCS codes and across the US and all territories must be completed by 2016. With the mid-2013 launch of Round Two, there will not be suffi- cient time for subsequent rounds. So it appears that the present process will result in a successful launch of Round Two, a short period of experience and then a determination of a per- centage of savings. A rollout to all locations and WWW.HMENEWS.COM / APRIL 2012 / HME NEWS A hypocrite and a telling comment? the majority of HCPCS Level II codes will follow. Various estimates abound but most frequently heard is the figure that about 50% of the current suppliers will be eliminated or forced out of busi- ness. As time progresses, the results of healthcare reform, competitive bidding, ACOs and a host of other changes will become clearer. Wise use of resources, business sense and commitment to this segment of patient care will be required for the winners to survive and maybe even thrive. The provider wrote that he thought the most telling part of Edwards' comment was that competitive bidding will result in 50% of providers being eliminated. He sees that as proof that part of the government's goal with the program is job loss. To me, the most tell- ing part of Edwards' comment was the rally- ing call to providers for "wise use of resources, business sense and commitment to this seg- ment." He sees that, and I see that, as keys to the future. HME PUBLISHER Rick Rector rrector@hmenews.com EDITOR Liz Beaulieu ebeaulieu@hmenews.com MANAGING EDITOR Theresa Flaherty tflaherty@hmenews.com ASSOCIATE EDITOR Elizabeth Deprey edeprey@hmenews.com CONTRIBUTING EDITORS John Andrews Jennifer Keirn EDITORIAL DIRECTOR Brook Taliaferro EDITORIAL & ADVERTISING OFFICE 106 Lafayette Street PO Box 998 Yarmouth, ME 04096 207-846-0600 (fax) 207-846-0657 ADVERTISING ACCOUNT MANAGER Jo-Ellen Reed jreed@hmenews.com ADVERTISING COORDINATOR Heather Pagano hpagano@hmenews.com MIDWEST SALES OFFICE Steven Loerch 847-498-4520 (fax) 847-498-5911 PRODUCTION DIRECTOR Glen Halliday ghalliday@unitedpublications.com REPRINTS For reprint information on orders of 500 copies or more, please call David Einziger at PARS 212-221-9595 x.407, david.einziger@parsintl.com ART CREDITS Steve Meyers: cartoon SUBSCRIPTION INFORMATION www.hmenews.com/subscribe HME News PO Box 47860 Plymouth, MN 55447-0860 800-869-6882 Publishers of specialized business newspapers including HME News, Security Systems News and Security Director News. Producers of the HME News Business Summit. PRESIDENT & CEO J.G. Taliaferro, Jr. VICE PRESIDENT Rick Rector