Audit relief: CGS explains denials, excludes certain providers

NASHVILLE, Tenn. - CGS Administrators has agreed to make two concessions that should make audits less hair-raising for HME providers in Jurisdiction C.

The first: In a June 3 bulletin, the DME MAC detailed its plans to start sending providers detailed written letters explaining why their claims were denied as part of prepayment or complex medical reviews.

“We're encouraged that they're taking our feedback and that we're finding those areas where collaboration is possible,” said Andrea Stark, a reimbursement consultant for MiraVista and chairwoman of the Jurisdiction C Council.

CGS started sending the letters on May 30, but only to providers that bill for oxygen and diabetes supplies. It will expand to other providers throughout the year. In addition to the reasons for denials, the letters also contain claim-specific information, such as dates of service and submitted charges.

Typically, providers that want more information about denials have to log in to myCGS, but they say the web portal doesn't always have what they need.

“We still find ourselves calling a lot and that's very time consuming,” said Sylvia King, general manager of Thrift Home Care, a member of the council, and vice president of the Mississippi Association of Medical Equipment Suppliers. “Anything that will save us time getting paid, especially with reimbursement cuts, is so valuable.”

With a written record of the reasons for denials, providers will also be better positioned to train not only their staff but also their referral sources, King says.

“We can tell our referral sources, 'This is what Medicare is telling us,' and it's on their letterhead,” she said. “That will be more real to them.”

Stark puts it this way: “It triggers a more direct response and intervention.”

The second concession: CGS has also started excluding providers with low error rates from service-specific audits.

“Exclusion from the edit is not forever, but it's long enough to catch your breath, pat yourself on the back and celebrate your success,” wrote Robert Hoover, the medical director for Jurisdiction C, in a letter.

While CGS doesn't specify what it considers a low error rate, Stark says 20% or less is a good goal for providers to have.

“That's a good place to start and fine tune from there,” she said. “Very few providers have 0% error rates. There are going to be things that happen.”

The two initiatives together should go a long way toward empowering providers to “get in front of what's impeding their reimbursement,” Stark says.

“A lot of times, I think providers have a high error rate because of the difficulty they have in tracking this process from start to finish,” she said. “Getting these letters is really going to allow providers to start managing this in a different way.”

As for whether or not other jurisdictions will follow suit: “I haven't heard any talk,” Stark said.