Free association with Dr. Hughes

The buzz word among rehab providers these days is audits. Mostly, they're dreading the day that the DMERCs begin auditing claims that were submitted under the new documentation requirements for power mobility devices. Providers don't have all that much to worry about, if they have all their ducks in a row, says Dr. Paul Hughes, the medical director for regions A and B. Here's what he had to say. A PRESCRIPTION IS NOT ENOUGH A prescription is not enough for an audit, because in an audit, we go back to the basic set of medical records. We look to see what, in the doctor's records and the therapist's records, shows that the patient meets the policy criteria. THEY'RE LIKE TAXES How well do you keep your records for your income taxes? Some people are fast and loose in the chance that they won't be audited. Some people only claim the stuff they have 22 receipts for. That's your judgment. But if you get audited, the IRS standard doesn't change. It's no different in our audits. THERE IS NO ONE PIECE OF PAPER Because they're business people, suppliers say, 'Just tell me what paper you want to get.' They want to be efficient. I understand that, but there is no one piece of paper. The Paper Reduction Act prevents me from saying, 'Go get this piece of paper.' You, as a supplier, then need to be knowledgeable about the policy criteria and have some sense of the basic medical concepts so that you can screen the information and make determinations. BUT WE'RE NOT CLINICIANS They say, 'We can't be clinicians.' I say, 'What do you do when you decide whether to use an ABN?' You do exactly the same thing--you ask yourself what are the policy criteria, does the patient meet the policy criteria, do I have information about their medical condition? If they don't meet the criteria, you don't use an ABN. They've been doing that for years. This is not a check-off production If we say left-handed smoke shifter is good, then they will go and tell doctors to write left-handed smoke shifter in red ink on the side of the paper. That's not what this is about. What's complex medical review? It's done largely by nurses--they're supposed to know the policy criteria and they're supposed to use their medical knowledge, experience and judgment to determine whether the information in the medical record shows that the patient meets the criteria. This is not a check-off production. How they write it almost becomes as important as what they write. We train our people to read everything and get a picture of the patient and then give the benefit of the doubt to the patient so we can get them what we need. But what we see most of the time is nothing.