CMS, prosthetists at odds

Friday, August 23, 2013

BALTIMORE – CMS officials may have wanted to get feedback on the data points for a proposed electronic clinical template, but it was clear on a recent call that stakeholders remain frustrated with the agency.

“It’s all very well and good to make this template, but there’s absolutely no accountability to the physician if they either refuse or don’t document appropriately to support what it is they are prescribing,” said Joe McTernan, director of coding and reimbursement services, education and programming for the American Orthotic and Prosthetic Association during a July 31 Open Door Forum. “All of the liability falls back on the prosthetist to ensure that documentation is in the physician files.”

The template is meant to reduce high audit rates for certain lower limb prostheses—something that stakeholders welcome, they say. However, the most recent draft of the proposed template, posted July 24, contains several dozen data points that are meant to guide physicians through the required documentation.

That’s simply too much, say stakeholders.

“We need to simplify this into a system that is actually doable,” said one caller. “Otherwise, it’s going to be the kiss of death if it’s too big.”

The more data points required, the more opportunity there is for auditors to find something wrong, a problem that is already playing out, say stakeholders.

“It seems like the RACs are looking through claims point by point and if you miss a point, they deny it,” said one caller. “It’s a ‘gotcha’ situation, and that’s where a lot of the panic is coming in.”

One caller suggested CMS use prior authorizations instead of a template.

“If this could be decided in advance, Medicare saves money and we would be saved from carrying the burden that, subjectively, someone else might say, ‘I don’t know if this qualified,’” he said.