Issue link: http://read.dmtmag.com/i/59015
HME NEWS / APRIL 2012 / WWW.HMENEWS.COM Garbage in, garbage out: Bill right from the get-go By implementing better training for intake personnel and integrating the right technology, efficiency and productivity can be improved while decreasing errors and audit exposure BY GREGG TIMMONS I N ANY chain of events, the first link is generally the most impor- tant. If something goes wrong there, it can impact every other step in the process. This is particularly true with HME providers, which rely on intake coordinators to get a complicated billing process ini- tiated properly. Starting off on the wrong foot wastes time and money, and opens the provider up to deni- als and, even worse, a potential audit. How can a provider ensure intake coordinators are doing the best pos- sible job? First, make sure intake coordinators receive instructions and tools to improve their efficien- cy and accuracy. Second, go digital. Too many providers rely on worn books and tattered printouts as ref- erence points to align items such as diagnostic codes with HCPCS codes. Since paper-based reference materials are not integrated into the billing system, these become hard to use and difficult to keep up. CODING AND DOCUMENTATION An important component of proper intake is having a keen understand- ing of the relationship between ICD-9 codes, HCPCS codes and how these are to be applied based on LCD and NCD guidelines. These codes guide product selec- tion and are critical to the proper submission of a claim. When the wrong code is assigned, the claim is denied. Beyond that, applying the wrong HCPCS code also can become costly when a provider has to recover and replace a product that was incorrectly assigned. Add BAIRD CONTINUED FROM PREVIOUS PAGE as the basis for denial; or (ii) in instances of medical impossibility. ADDITIONAL DOCUMENTATION REQUEST (ADR) A contractor may request additional docu- mentation from a supplier by issuing an ADR. The ADR must specify the pieces of documentation needed to make a cover- age or coding determination. The purpose of such documentation is to support the medical necessity of the item or service provided. The treating physician, another clinician or provider, or supplier may sup- ply this documentation. This documenta- tion may take the form of clinical evalua- tions, physician evaluations, consultations, progress notes, physician letters or other documents intended to record relevant those costs to already-reduced com- petitive bid reimbursements, and a provider's cash flow can quickly be squeezed. This can be compounded if an error is unknowingly repro- duced on multiple occasions. In addition to coding, intake coordinators also are responsible for gathering the necessary docu- mentation to file the claim, includ- Gregg Timmons ing verifying eligibility and pro- viding back-up documents such as a certificate of medical neces- sity. Failure to include the correct documentation also can result in a claim denial. And the risk only goes up from there—once a provider is determined to have too many deni- als, an audit can be initiated. PROPER EXECUTION Trained intake coordinators using business management software can help solve this problem and miti- gate the risk by fully automating the intake process. A comprehensive software package with end-to-end coverage ensures that LCDs and NCDs are tied directly to inven- tory items and provides reference information alongside each prod- uct to easily interpret the diagno- sis. In addition, through constant, web-based updating, a software provider can automatically keep intake coordinators up-to-date on the latest code or policy changes. Other critical steps at intake are eligibility verification and making certain all documentation required for a claim is attached to each order. There must be processes in place to reduce the level of human error by hard coding a document checklist into the intake process; intuitive software can fill the void. LEVERAGING TECHNOLOGY To streamline the billing process while maintaining strict quality control standards at intake, busi- ness management software can be beneficial. It's important to avoid implementing technology for the sake of having technology. It's criti- cal to understand whether or not the software being considered will save time and money while enhanc- ing productivity and workflow. In the end, it's really about the beginning of the process that requires the greatest focus and attention. The old adage of "gar- bage in, garbage out" applies to the HME billing intake process just as it would with any other industry that relies on quality control of data management. By implementing better training for intake person- nel and integrating the right tech- nology, efficiency and productivity can be improved while decreasing errors and audit exposure. HME Gregg Timmons is president and CEO of MedAct Software, which provides medical billing and inventory manage- ment software solutions for the HME/ DMEPOS industry. For more informa- tion, visit: www.medactsoftware.com. information about a patient's clinical con- dition and treatment. In instances where documentation is provided in lieu of con- temporaneous physician progress notes, the contractor will determine if the docu- mentation is sufficient to justify coverage. If it is not, the contractor will deny the claim. COMPLEX MR TIMELINESS REQUIREMENTS When the contractor timely receives docu- mentation it requested by ADR, the con- tractor must make a medical review deter- mination and mail a notification letter to the supplier within 60 days of receiving the documentation. LATE DOCUMENTATION AND REOPENING OF CLAIMS If a contractor receives the requested infor- mation from a supplier after a denial has been issued but within a reasonable num- Commentary 15 LETTERS TO THE EDITOR Crisis averted but work not done C MS ANNOUNCED, in the fall of 2011, the launch of com- petitive bidding in 91 of the largest U.S. metropolitan areas and their intentions to bid manual wheelchairs and items deemed accessories. This created new challenges, and more com- plex accessories and items were assigned to under-defined cat- egories (Medicare codes), with one group being adjustable skin protection cushions. Amidst a major crisis within the funding system for wheelchair cushions, the opportunity arose for substantial change to the way adjustable skin protection cushions were classified. The argument was made that the codes needed to be fixed before competitive bid- ding began, or excluded. I am pleased to say that our efforts have been heard. On Dec. 27, 2011, CMS announced the exclusion of the adjustable skin protection cushion codes, E2622, E2623, E2624 and E2625, from Round 2 of competitive bidding. The decision to pull adjustable skin protection cushions is a vic- tory for beneficiary access, but it is only the first step in a longer process. Now we have additional time to insure the coding and reimbursement structure are enhanced to ensure these products are classified and assigned to clinically homogenous groups. Numerous individuals and groups contributed to this successful outcome. Representing over 40 of the nation's leading beneficiary advocacy groups, substantial support came from the Independence through Enhancement of Medicare and Medicaid Coalition. Addi- tionally, strong support came from Congressional members, led by Reps. Jerry Costello, John Shimkus and James Langevin, and Sen. Richard Durbin. The efforts of the stakeholders and sympathetic members of Congress made the difference. Roho is committed to this effort and intends to give freely of our time and talent to achieving this goal. —Dave McCausland, senior vice president of planning and government affairs, The Roho Group If worked fairly, we can make it T HANK YOU for this article ("The Diabetic Shoppe's suc- cess—or failure— affects local community," March 2012)! Mr. Salmon, (my Daddy) headed to Washington, D.C., (Feb. 14), staying through Friday, to fight for the DME/HME industry and our company. Our employees thank him for everything he is doing to keep this business and industry on a level playing ground, because we know that if the bid is worked fairly, then we can make it. We have a wonderful group of people working here and we want to keep each and every one of our employees. We are fighting for what we have worked so hard to create (The Diabetic Shoppe) and we all need to join the effort to save this industry. We are working on it, and I believe that if anybody can do it, we can. Thanks for all you have done and continue to do. Thanks from "The Diabetic Shoppe" family! —Peyton Boone ber of days (generally 15 days after the denial date), the contractor may reopen the claim. RESPONDING TO POST-PAYMENT AUDIT The ADR will generally provide informa- tion on the type of documents a supplier is required to submit. The documents gener- ally include patient medical records; supplier records; detailed written order; dispensing order; certificate of medical necessity; and delivery tickets. Suppliers must provide a copy of doc- umentation from the patient's medical record that identifies the condition/diagno- sis for which the item is being ordered and other pertinent information relating to the medical necessity for the item. The date of the visit must be noted in the record and must be prior to the date of service on the claim. For items addressed in LCDs, there must be information to document that all coverage criteria specified in the medical policy have been met. The medical record must be in the usual format for that phy- sician's/provider's medical records. Suppli- er created forms, attestations, or similar documents are not sufficient to document medical necessity, even if completed and signed by the physician. The records should be organized by claim or patient. The supplier should include the following along with the records: (i) a copy of the request letter, including the patient list; and (ii) a cover letter detailing the docu- ments being submitted and a summary of the medical records (the summary should briefly discuss how medical necessity is established for each claim). HME Jeffrey S. Baird, Esq. is chairman of the Health Care Group at Brown & Fortunato, P.C., a law firm based in Amarillo, Texas. He can be reached at (806) 345-6320 or jbaird@bf-law.com.