Auditor makes over-the-top request

YARMOUTH, Maine - A semi-automated review of certain CPAP claims in Jurisdiction C could be a waste of time and energy for HME providers--and auditors, say industry sources.

Connolly Healthcare, a recovery auditor contractor (RAC), has been asking for proof that patients have had a qualified sleep study in cases where Medicare did not pay for the study. That's basically any patient whose study was paid for by a private insurer or who paid out-of-pocket--not uncommon for a condition that is often diagnosed before patients reach Medicare age.

"It's very far-reaching," said Andrea Stark, a reimbursement consultant with MiraVista in Columbia, S.C. "It's a lot of work to be able to pull all these patients, get the sleep studies that may be very old and produce that information."

Particularly vexing: There's no proof that there is even a problem, she says.

"Do they really think that most of these patients didn't get a study--that providers are just randomly billing?" Stark said.

Some providers have been lucky enough to receive only one or two requests like this.

"If we get an order for supplies or device replacement, we won't dispense it until we have our hands on a copy of that sleep test," said Scott Lloyd, president of Extrakare in Norcross, Ga. "We've had a number of these requests, but it hasn't been a huge challenge."

But for provider Kim Brummett, the "onesies and twosies" have snowballed into 1,900 requests.

"The flood gates just opened," said Brummett, vice president of contracting and reimbursement for Greensboro-based Advanced Home Care and a member of AAHomecare's Audit Task Force. "I have four people doing nothing but pulling sleep studies."

Because the requests are semi-automated, technically, providers don't have to respond. But when they do, it proves there isn't a problem, says provider Eric Parkhill. He always responds to requests, and in return, he has received confirmation letters from Connolly that it would no longer pursue the "attached claims."

"Obviously what we submitted very much hit all the requirements," said Parkhill, vice president of clinical operations/corporate compliance for Home Medical Professionals in Gainesville, Ga.