CMS gets contractors to relent on technical errors

Friday, May 2, 2014

WASHINGTON – HME industry stakeholders are seeing their first real sign of relief in the fight against audits.

As a result of discussions with the Jurisdiction D DME Advisory Council (DAC), CMS has reminded its contractors that their “scope of services” includes reopening cases where claims have been denied due to technical reasons. That has opened the door for council members Peggy Walker and Mary Stoner to get more than 70% of the denied claims they submitted for reopening overturned.

“This is huge,” said Walker, a billing and reimbursement advisor for The VGM Group’s U.S. Rehab, who continues to collect documentation from providers to submit to contractors for reopening.

Traditionally, when providers contact contractors such as C2C Solutions, which handles the second level of appeals, to reopen cases, they’re told to take it up with the contractor at the next level of appeals.

But with mounting pressure from the industry and CMS, and a high-profile forum* in February on the huge backlog at the administrative law judge level (ALJ), the third level of appeals, these contractors are now more willing to take a second look at claims denied due to technical reasons.

“Providers need to be more aware of their options,” Walker said. “Mistakes happen and they can be corrected before they get to the ALJ.”

Of course, not all denied claims are overturned. First of all, the denial has to be for a technical reason, such as not including pricing on a detailed product description, something that hasn’t been required since 2011. It can’t be for lack of medical necessity, Walker and Stoner say.

“You have to know what the rules are when you put your documentation in,” said Stoner, chairwoman of the Jurisdiction D DAC and president of Electronic Billing Services. “The contractor can’t fix if it if you didn’t provide proper documentation.”

Members of the Jurisdiction D DAC aren’t stopping at audits, either. They’re also discussing with their contacts at CMS issues with PECOS and the face-to-face requirement.

“They’re not just this big cloud hovering over us throwing down lightning rods,” Stoner said. “They’re people and they’re willing to engage with us.”



The bigger issue is the shear volume of the audits. There is no reason why a provider should be audited on every hospital bed, Wheelchair, oxygen unit, urilogical supply etc.. that they deliver.   As a billing service we a seeing dozens of audits every week on our clients claims.  It seems like auditing a percentage of the claims would be just as effective.