Audited providers fight fire with fire

Wednesday, July 24, 2013

Faced with more audits for power mobility devices than ever, providers are taking drastic measures to appeal denials. 

“I’m going to interview patients on video and bring it to the administrative law judge,” said Cory Baker, compliance officer at Abilene, Texas-based Choice Medical Supply. “I don’t see how they could see this video and say the patient doesn’t need it.”

Baker says 45 of his company’s claims have been audited.

“None of these claims were denied because of medical necessity,” said Baker. “It’s no longer about medical necessity. It’s about how you play their games.”

Claims for power mobility devices are under constant scrutiny—and prepay reviews result in consistently high error rates. For example, the most recent report from National Heritage Insurance Company, the Jurisdiction A DME MAC, reported an error rate of 80.6% for K0823, one of the most common power wheelchairs, from Jan. 1, 2013, through March 31, 2013.

Adding to the problem: Auditors are targeting old claims, in some cases, all the way back to 2008—a year after Medicare changed its documentation policy. That means a higher likelihood of errors, and makes it more difficult to get documentation from physicians.

“We’re getting RAC audits on dead people,” said Chris Limbeck, owner of Bloomington, Minn.-based Metro Medical. “(The claims) are from 2008, and it’s taking us six hours per audit to get the information together.”

Championing claims is key if a provider wants to stay in business, says Susan Siders, who has 10 claims under audit, putting $30,000 in jeopardy. 

“I’m a small business,” said Siders, owner of Mullins, S.C.-based Home Therapy. “And it’s not just me—everybody and their brother is closing.”

Siders plans to get patients to sign releases allowing her to share their stories with state senators and representatives. She plans to give specific examples of why the power wheelchairs she provided were medically necessary.

“Every wheelchair was needed, and we put it out in good faith,” she said.


Saying that the audit process is a paperwork game is exactly what it's all about.  Without actually knowing who or what is involved, I'd say it's safe to bet that the 'auditors' have a checklist of items --especially checks for document flaws, such as stamp or signature issues.  It's NEVER about medical necessity.  Of all the ones I've sent to ALJ, I've had more than 50% of them overturned at the ALJ level.  What's worse is by the time ALJ reviews it, the HME provider has already lost money, which is an outrage.  The provider is mandated to submit all documentation within a limited timeframe, but ALJ can take as long as they want. The QIC's/ZPICs/ALJs don't give a dang about how 'backlogged' we are--we still have to get our requests in their required timeframe.  If ALJ is going to take more than 4 months for a decision, then the government should have to pay interest PLUS a penalty. Oh wait, sorry....that's not reality now is it?