AOPA on audits: 'Claw backs' harm patient care

ALEXANDRIA, Va. - With DME MACs and RACs training their sights on prosthetists, the American Orthotics and Prosthetics Association (AOPA) took CMS to task recently on what it calls the “egregious behavior” of auditors.

“This is a problem that is putting people out of business in the O&P field,” said Tom Fise, executive director. “RAC auditors who have a stake in the action are trying to claw back as much money as possible on claims from small businesses.”

AOPA recently sent four separate letters to CMS asking the agency to intervene on a host of audit-related issues.

The biggest issue: Even though prosthetists' notes must be included within the physician notes, they are no longer considered part of the medical record. That's a complete reversal from how prosthetists have traditionally filed claims, they say.

“In the past, physicians relied upon the prosthetist to help them make those calls,” said James Rogers, owner of PPS Orthotic and Prosthetic Services in Chattanooga, Tenn. “The negative is that for the O&P company, if the physician is not documenting properly, there could be a denial there.”

AOPA is also taking issue with auditors overturning the professional determination of prosthetists to fit patients with more sophisticated—and pricier—K-level devices; increasing the number of prepay reviews; and applying methodologies that inflate the number of additional documentation requests.

“You are going to think twice about putting out high-end devices,” says James Newberry, CEO and director of orthotic patient management at Mahnke's Orthotics-Prosthetics in Oakland Park, Fla.

Sadly, the biggest impact of the audits is on patient care, says Fise.

“If you set a policy, as Jurisdiction D has, stating they are going to review every claim for higher-cost prosthetics but not on lower and less advanced prosthetics, are you really auditing or are you trying to change behavior?” he said. “You are setting a different standard of care for Medicare beneficiaries than for the rest of the population.”