Consider consequences over costs

Monday, April 25, 2011

A. Deciding to obtain professional assistance with an appeal is definitely an economic decision. However, many suppliers are unaware of the far-reaching consequences that can occur from losing an appeal. For the past 16 years, I have seen suppliers with either a local or national presence lose appeals because of a lack of expertise. Hiring a professional is often cost prohibitive because of the claim amounts.  Over the years, I have learned that Medicare has an unspoken protocol to increase audits when a supplier does not successfully defend claims in an appeal. This means paying $5,000 to defend a $15,000 appeal is worth it to prevent the audit of additional records, which could result in a large overpayment. 

To determine if you need professional assistance, you have to honestly evaluate your company's ability to 1) understand the Local Coverage Determination (LCD) and 2) verify that medical documentation meets the LCD requirements. A professional's expertise will certainly make a difference when you have a claim that is less than perfect. In the event the documentation is lacking, a professional can provide advice on how to legally obtain the required documentation prior to the appeal. For example, hire a physician as a medical expert. The best-case scenario is to obtain professional assistance prior to delivering products. But in the real DME world this is seldom done. 

If you can afford it, I recommend obtaining professional assistance from the very beginning. The documentation submitted at the first level of appeal is critical to the foundation for the next level of appeals because it is hard to introduce additional documentation in subsequent appeals. 

If you can't afford an attorney, hire a consultant who understands the claim requirements for your product and have the documentation reviewed prior to submission.

Cheryl Ward is CEO of Agape Medical Management. She can be reached at 951-680-1640 or