Auditor makes over-the-top request

Thursday, February 9, 2012

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.



It is simple!! I suggest, if you haven't, you follow the Nichole Medical Case currently before The Third Circuit Court in the eastern district of Pennsylvania. Currently, without protection from the Courts for Auditors unsubstantiated, harmful and negligent actions every medicare Provider is an "unarmed opponent in a gunfight with a gunslinger!" The Nichole Medical Case is NOT a Maximum Comfort Case. If The Nichole Medical Case is not successful every RAC, MAC and PSC Auditor will wreak havoc on the entire industry. Their actions can make the Competitive Bidding issues seem like a walk in the Park! Sadly, impeccable records are NOT a weapon against this enemy that neither has or knows any boundries!

In the legal system there is a presumption of innocence. Too bad that doesn't apply to providers.

Frank, while your scenario is correct it implies in the legal system which is overseen by the Judicial Courts. That is all the more important reason for the Nichole Medical case to be successful. Medical providers NEED the protection from the civil Judicial Courts to safeguard the services and availability for ALL Medicare Beneficiaries. Decisions not driven by dollars and cents!

I agree 100% Dominic. RAC contractors have been playing the same scam for years now. Throw everything against the wall just to see what sticks. If you gave me a 20 year old who was capable of programming in visual basic and a data dump from the CMS transactional files then I could find you massive fraud in a very short amount of time. For example, how many diabetic shoe providers only see the patient once to measure the patient's foot, order custom molded inserts and mail them to the patient? I would look for every diabetic shoe provider that had more than half of their patients in custom inserts and I would audit their files for delivery paperwork showing they went out to the patient's home and actually did a shoe fitting. And then I would call the patients to corroborate the story. Also, in licensure states like Texas or California I would cross reference their files to make sure they had a pedorthist on staff and then I would make sure that was the actual person on the assessment and delivery paperwork. That one little trick would net several million in remibursement recoveries by itself.

Thank you! Now follow and support the case; inform every industry Provider and advocate you know to do the same. It may become the most influential piece to the case. More than all the legal arguments currently filed with the Court that being a solidarity among health care Providers pleaing with the Federal Courts for civil protection currently controlled by an autonomous CMS.