Aggressive audits rankle providers

Tuesday, April 30, 2002

WASHINGTON — If the DMERCs have become hyper-aggressive in their auditing tactics, as industry watchers claim, it's news to the medical directors.

"Many suppliers are surprised to find out that we are interested in the patients' medical records in order to evaluate whether the patient's disease or medical condition or need for the item is properly documented," Region A Medical Director Dr. Paul Hughes told HME News last month. "The Social Security Act authorizes Medicare to gather whatever information is necessary."

Nevertheless, for the past year to 18 months, the DMERCs have become "more aggressive in their auditing than ever before," said healthcare attorney Elizabeth Hogue and others.

That's been particularly true when it comes to power wheelchairs, but the DMERCs, ever attuned to high utilization, have recently begun auditing providers who traffic heavily in high-end support surfaces, another high ticket item.

The audits themselves don't irk providers and industry officials, but delving unnecessarily into medical records and other data providers don't possess does. At one time, auditors asked for this information (information above and beyond the CMN) only when they strongly suspected fraud or some major billing snafu. Now such requests have become routine upon a first visit.

"It's not an attempt to confirm that coverage exists," said Asela Cuervo, AAHomecare's vice president of government relations. "What they are doing is trying to find some way to undo coverage that was appropriately put in place."

What's "really troubling," Cuervo continued, is that the CMN is not considered part of the medical record. That means if an auditor's on the look out for information in a patient's medical record that documents medical necessity, the CMN won't do it. Unfortunately, doctors often don't include additional supporting data in exactly the language auditors want to see, which makes it easy for the auditor to deny a claim, Cuervo said.

"I'm all for auditing and getting rid of sleazy dealers, but they're using unfair criteria to make us all look bad when we haven't done anything wrong," said Tyrrell Hunter, owner of Majors Mobility in Topsham, Maine.

AAHomecare's met with CMS several times to discuss developing limits on what kind of information DMERC auditors can request.

"When you have limitless authority to get whatever, than it really is just a fishing expedition," Cuervo said.

Until CMS changes the audit process, providers will have to aggressively contest what they consider unfair recoupments, said Cara Bachenheimer, healthcare attorney with Epstein Becker & Green in Alexandria, Va.

"You have to be aggressive about it," Bachenheimer said. "Otherwise, they'll run roughshod over you." HME
Related story: Region D Medical Director Dr. Robert Hoover discusses auditing protocol. Read the interview.