Auditors want to see those MDIs

Tuesday, December 31, 2002

WASHINGTON - A new wrinkle has reportedly been added to the Medicare post-payment audit process for nebulizer provision - checking the physician’s files for evidence that non-covered treatments were considered first.

Industry observers are expecting CMS to turn post-payment audits for nebulizers into something of a crusade. And though questions exist about the kinds of details agency officials might be looking for, there is speculation that they’ll be reviewing physician notes for signs that metered dose inhalers were considered before a nebulizer prescription was issued.

If true, it is a practice that has respiratory medications supplier Mickey Letson concerned.

“What’s bothersome is that the provider is liable for what’s in the physician’s file, and it’s beyond our control,” said Letson, president of The Letco Companies in Decatur, Ala.

Based on the experiences of two providers represented by the healthcare law firm Brown & Fortunato, Letson’s suspicions may indeed prove right, said attorney Lisa Smith.

“In both cases, the focus has been on the coverage criteria requirement that an MDI be tried and ruled out for medical reasons,” said Smith, of the law firm’s Kerrville, Texas office. “In those instances, physician records were checked for documentation.”

What is triggering the post-payment audits now? Historically, radical spikes in billing for particular items have caught the Medicare administrator’s attention. While Letson won’t deny that nebulizer claims could be up, he suspects that the agency is on a fishing expedition.

“There are no red flags that I can see,” he said. “There is no clinical basis for it other than they simply don’t want to spend the money. They’re using it as an excuse to see what they can dig up.”

Smith contends the audits could set a precedent that further strains an already tenuous relationship between providers and physicians.

“Providers will feel compelled to ask physicians for copies of their notes in order to have adequate documentation,” she said. “Physicians won’t stand for that.” HME