High error rate points to 'systemic' problem at CMS
BALTIMORE – CMS's announcement last week of a 61% improper payment rate for home medical equipment points to the need for the agency to take a closer look at its own policies and procedures, say HME industry stakeholders.
"It points to a systemic problem," said Walt Gorski, vice president of government affairs for AAHomecare. "If 61% of the class is failing, you need to look at the teacher."
Other claims types, like inpatient hospital and physician/lab/ambulance, have error rates in the single digits. The overall error rate for Medicare fee-for-service is 8.6%.
There are several key factors pushing the error rate for HME so high, say stakeholders. Chief among them: unclear and inconsistent medical policy.
"Suppliers are filing claims based on the requirements that are set by Medicare," said Wayne Stanfield, president and CEO of NAIMES. "Is it so convoluted and overburdensome that no one can get it right? If I was Medicare, this would be embarrassing."
Adding to the problem: Providers are dependent upon physician documentation.
"Not only do we have to make sure our documentation is in order, but make sure the physician's is, too," said Gorski. "If you are not going to hold physicians accountable, you are not going to effect change."
Gorski also pointed out that auditors have too much free rein when it comes to interpreting coverage policy.
"Policies are subject to auditor interpretation," he said. "Sixty-one percent of the time, federal auditors are overruling the clinical decision making of physicians.”
CMS last week also announced a three-year demonstration project to expand prepay reviews by Recovery Audit Contractors (RACs). Under the demo, auditors will identify improper claims before payment is made. They will be paid contingency fees from the money CMS saves by denying improper claims.
"AAHomecare has made a number of recommendations to prevent bad claims from being paid at the outset," said Gorski. "But if you allow independent contractors to get a piece (of the Medicare pie), that is only going to hurt the providers and, in turn, the beneficiaries."