Issue link: https://read.dmtmag.com/i/48253
10 News Use ABNs, don't get 'punked' on audits BY JOHN ANDREWS, Contributing Editor ATLANTA – With the elimination of Medicare's least costly alternative option earlier this year, CMS is now denying claims instead of downcoding them. This develop- ment makes the advanced ben- eficiary notice (ABN) option more critical than ever for HME providers, says con- sultant Andrea Stark. "ABNs are a mon- ey-making tool in an environment where few exist," Stark, with Columbia, S.C.- based Mira Vista told Medtrade attendees in October. "It can be used to empower consumers to spend more cash." Since CMS terminated down- coding last February, the agency has been issuing outright denials for claims instead of paying for lower-level items. Numerous cat- egories are affected by this policy change, including manual and power mobility, hospital beds, orthotics, patient lifts, CPAP devices and nebulizers. Even so, providers can pivot off of claims denials that state an item is "not reasonable and necessary" as a way to trigger the ABN, Stark said. Proper use of the "hardwork- ing" GA and GK modifiers are Andrea Stark essential, as are precise, descrip- tive narratives when required. Language makes a huge difference, she said, and generic statements like "Medicare may or may not cover this item" are not sufficient. "ABNs are under an audit micro- scope and providers are getting 'punked' on audits for making vague descrip- tions," she said. Providers also need to know what collec- tion recourse they have for beneficiaries who refuse to return products or pay for services. To illustrate, Stark said there are instances where a fam- ily won't return a sup- port surface because even though the patient's wound healed—ceas- ing Medicare coverage—they are afraid the wound will return with- out it and won't let the HME pro- vider reclaim the product. "And they won't pay the $400 to $500 a month for the support surface, so what can you do?" she said. For those who accepted assignment on the patient, pro- viding an annotation that shows the patient wanted the product or service but refused to pay should effectively "transfer lia- bility from the provider to the patient," Stark said. HME Granite state providers battle double whammy State's considering fee schedule cut, managed care program BY THERESA FLAHERTY, Managing Editor CONCORD, N.H. – HME provid- ers here got no resolution when they met with Medic- aid officials in September to discuss potential reimburse- ment cuts. "We are still going back and forth and waiting to see how it's going to shake out," said Tamme Dustin, director and CFO of Herron & Smith in Hooksett. In June, providers learned that the state was seeking to implement a fee schedule for durable medical equipment that is 60% of the current Medicare allowable. The cur- rent fee schedule is all over the board, said Dustin. At the meeting, providers highlighted certain products, like rehab, that, if the cuts were implemented, could lead to access issues. "They are running more analysis," said Dustin. "And we asked for better utilization numbers so we could offer more suggestions on what we could do to save money." It may all be for naught, though. State lawmakers recent- ly passed a law requiring that the state have a managed care/ Medicaid program in place by July 2012. "Why try to implement (a new fee schedule) that's going to create an access issue in the interim?" said Dustin. "Just leave it alone and then we'll work with you on man- aged care." HME WWW.HMENEWS.COM / DECEMBER 2011 / HME NEWS Industry attorney talks audits with CMS official Edward Vishnevetsky hopes recent panel discussion will 'effectuate change' BY LIZ BEAULIEU, Editor WASHINGTON – CMS officials know that audits are put- ting HME providers, good and bad, through the ringer and the agency is working on improving the process. That's the message Edward Vishnevetsky, an industry attorney, took away when he participated in a panel discussion on audits with Ted Doolittle, deputy director of policy for the Center for Program Integrity at CMS, during the Ameri- can Bar Association's Wash- ington Healthcare Sum- mit in October. Here's what Vishnevetsky, an associate at Munsch Hardt Kopf & Harr, told HME News about this hour-and-a-half discussion. HME NEWS: How is CMS trying to improve the audit process? Edward Vishnevetsky: They're working on some new, proac- tive data analysis. They under- stand the plight of the DME providers; they're aware that a lot of companies are shutting down because of the time- frame for these audits. He said, "We're trying to make it harder for the bad guys and shorter for the good guys, but we just haven't been able to come up with the algorithms Edward Vishnevetsky yet to discern that." They're trying to put algorithms into computers that, hopefully, dis- cern between different types of providers. HME: It sounds like they want to be able to use a scalpel instead of an ax. Vishnevetsky: That's pretty much it. The purpose of the audits is good, but this is what's hap- pened: To make an omelet, you have to crush a few eggs, but here they've crushed a lot. They're trying to get better. HME: How did you communicate the DME industry's frus- tration with the audit process? Vishnevetsky: I said the DME industry agrees that fraud needs to be curbed, but this process has had some grow- ing pains, especially related to the timeframe that the ZPICs have to respond. That's real- ly been the biggest problem. Everything just gets sent up to the next level, and pro- viders get caught up in that. That leads to loss in revenue, an increase in bankruptcy fil- ings, loss of referrals and, ulti- mately, just a decrease in the number of companies that are out there. HME: Did you learn anything new about the process during the discussion? Vishnevetsky: We thought the ZPICs got bonuses if they find more instances of fraud and they don't. The RACs do, but not the ZPICs. HME FRONT OF MIND CONTINUED FROM PAGE 4 register to submit the bid now, even though regis- tration isn't open yet. Higley said some providers submitted "panic bids" because they waited too long to make these decisions. Other tips Higley shared with the audience: Down- load the affected zip codes (the metropolitan statistical areas and the competitive bid areas don't match up exactly, he said); learn the licensing requirements in the bid areas ("Licensure was a killer in the first round, especially respiratory licensing," he said); and submit only the required financial documentation—nothing more, nothing less ("Don't do anything to confuse conference APPLETON, Wis. – ThedaCare At Home earned the HME Provider of the Year Award from the Wisconsin Associa- tion for Medical Equipment Services (WAMES). It's the second year in a row the pro- vider has earned the distinc- tion, which is based on things like legislative activities, lob- bying, public relations efforts and overall commitment to improving the HME industry. The award was presented at the WAMES 28th Annual Conference in September. Also at the conference, Sha- ron Suchomel, an optimiza- tion specialist with Theda- Care, received the WAMES President's Award for "going above and beyond," accord- ing to a press release. ThedaCare honored at CMS upgrades enrollment BALTIMORE – CMS is imple- menting improvements to the Provider Enrollment, Chain, and Ownership System (PE- COS) that will make it easier for providers to update their enrollment information and submit applications. The improvements include a streamlined application pro- cess and the ability to pay applicable fees during the online submission process. In the works: view all applica- tion data on a single screen. To access Internet-based PECOS: http://pecos.cms. hhs.gov. 5010 testing: 'No significant errors' WASHINGTON – CMS released the results from the second National Testing event in Oc- tober: 1,252 trading partners submitted a total of 67,782 test files and no significant error scenarios were report- ed. All covered entities are required to use the Version 5010 format beginning Jan. 1, 2012. Download zip codes, get licensed, and submit only required financials. these poor people," he said). As for where the Round 2 single payment amounts will fall, Higley said he doesn't think there'll be as big of a reduction this time around. The original Round 1 came in at 26% below the current fee schedule; the red-bid came in at 32%. "Will we get to 32% this time?" Higley said. "I don't think so. This is opinion only, but I think we'll see 25%. (But) it's not my suggestion that you bid that." HME