Contractor: CPAP claims get 'big F'

Sunday, September 26, 2010

NASHVILLE, Tenn. - More than half of all CPAP claims in Jurisdiction C--63.94%--failed in a recent widespread review.

"Obviously, that's a big 'F,' said Kelly Riley, director of The MED Group's National Respiratory Network. "Some of the things we should know at this point, but there's also still some confusion and cleaning up we need to do."

The review, conducted by Cigna, the Jurisdiction C DME MAC, looked at delivery documentation, detailed written orders, medical necessity, patient/caregiver education and proof of adherence to therapy. The report identified several troublesome areas.

Riley, who recently conducted a handful of audits herself, got a firsthand look at what providers are--and aren't--doing. Here's what she had to say about Cigna's most common findings.

"Confusion in the field"

Many providers don't understand what constitutes a face-to-face evaluation, said Riley. Often, they believe a face-to-face means the sleep study report along with physician notes about why the patient needs a sleep study.

"What (Medicare) wants to know is, 'How did the patient enter the system in the first place,'" said Riley. "Medicare wants proof that the patient had a comprehensive evaluation by their primary care physician prior to a sleep study. There's still confusion in the field."

"Is the damn thing signed?"

Signatures are another issue, said Riley. They are either missing from forms or they don't meet Medicare's signature guidelines. Providers really need to check to make sure any records they submit have appropriate signatures.

"You may get the report dictated and transcribed but it can take weeks if not months to get that physician signature," she said. "When you pull the records, ask 'Is the damn thing signed?'"

In cases where a signature is present but doesn't meet guidelines, providers often think that means that the signature is illegible.

Not necessarily true, said Riley.

"If the physician's name is typed under the signature, anything will fly," she said.

"Responsibility without authority"

One item in the report that Riley found particularly vexing: For proof of adherence to therapy, Cigna says the re-evaluation must show that the treating physician reviewed the evidence of adherence of the CPAP.

Medicare already requires that physician notes contain information to the effect that the patient is using CPAP and feeling better. Providers also submit downloads that show evidence of compliance, she said.

"Why on God's green earth do they have to have proof that the physician actually read that?" she asked. "Does that mean the DME has to send over every download to get a physician signature on that as well? You are holding somebody responsible that has no authority."