Audits: They’re coming from every direction

Friday, August 17, 2012

YARMOUTH, Maine – Commercial payers are stepping on the gas on post-payment audits for home medical equipment, industry stakeholders report.

In a Form 10-Q filed last week, Apria Healthcare reported an increase in post-payment audits by commercial payers this year. But the national provider, which has a national contract with Humana, isn’t the only one, stakeholders say.

“The biggest ones have been Humana and United Healthcare,” said Roni Pidcock, vice president of Quality Healthcare Systems, a High Point, N.C.-based billing service. “We call to verify benefits and bill, and they send us a denial. We send the records in and they send us a letter for additional documentation. We’re definitely seeing them across the board.”

Blue Cross Blue Shield is often cited by stakeholders as another commercial payer that’s following Medicare’s lead on audits.

The good news is that commercial payers, for the most part, are conducting audits for the right reasons, stakeholders say: to check on utilization, not to question medical necessity.

“Medicare will deny for a technical detail,” said Roberta Domos, who owns Domos HME Consulting Group in Redmond, Wash. “We’re not seeing that, but they do want to look at the progress notes.”

Stakeholders also say responding to and appealing audits from commercial payers is a cakewalk compared to Medicare.

“Compared to Medicare’s highly inefficient method of mailing out a single four-page letter at a time for each and every patient, at least the private sector issues one electronic spreadsheet with the list of patients on it and manages the whole process much more cost-effectively,” said Lisa Getson, executive vice president, government relations and corporate compliance, at Apria. “The appeal process is also much more streamlined, includes fewer administrative layers and is resolved 10 times more quickly.”

But while commercial payers have increased their audit activity, some stakeholders don’t see them going crazy like Medicare. Instead, they believe commercial payers will limit their networks to a smaller and smaller group of trusted providers, eventually eliminating the need for such audits.

“I don’t think we’re going to see a ton more, unlike on the Medicare side,” said Kim Brummett, vice president of contracting and reimbursement at Advanced Home Care in Greensboro, N.C., and a member of AAHomecare’s Audit Task Force.

Other stakeholders aren’t so sure.

“We haven’t seen anything material yet, but I wouldn’t be surprised if this is the next wave,” said Rick Worstell, CEO of Harrington Management Group, also known as The Audit Team, in Canton, Ohio. “We have clients tell us that more and more commercial payers are following Medicare guidelines to the T, to the extent that they’re reciting the LCD.” 



Maybe, just maybe!! It's a different world when immunity is off the table for inferior work!!!???