High error rate points to 'systemic' problem at CMS

Friday, November 18, 2011

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."



Seriously sometimes i sit back and wonder who the hell makes all these decisions. How can you hire a company and tell them they would be paid based on the number of claims they deny. What do you think is going to happen? Every claim is going to get denied and they will leave a few claims out there to save face and not make it look so obvious. Case in point, if you are in business to make money and they only way to increase revenue is deny claims, what the hell do you think is going to happen. But wait, they will probably have them take a class that says "don&#39;t deny claims because it is how you get paid". These guys basically want HME providers to work for free. Excuse me, we are all enjoy helping others with their mobility needs but you simply cannot help others if you cant help yourself and we are not a bunch of non-profit, we are actually in business to earn money. <br />
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I just wish someone with adequate backing and financing can create a union for this industry and then force Medicare to change the way they treat HME providers or we are all going on strike until we get favorable deals. I mean majority of companies that service patients in HME are small businesses, how long are the rules and regulations going to take place until we all go out business.

Great article, Theresa! I see the latest is Glucose Test Strips. Ck this out:<br />
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"The National Government Services, Jurisdiction B Medical Review department continues to conduct a prepayment targeted medical review for overutilization of glucose test strips (A4253KS). This review is a selection of multiple supplier submitted claims based on a targeted service(s) that are reviewed for medical necessity.<br />
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As of September 30, 2011, a total of 3,685 claims with three to eight units of service (UOS) have been captured for review and developed for additional documentation. All of these claims have been reviewed and processed. Of these, 3,332 claims were denied accounting for a 90.40% claim error rate."

The crazy part is how many of these denials get overturned at the ALJ judge review point. This is why they fired trust solutions a few years back but it hasn&#39;t gotten any better since then. They apply inconsistent standards from one reviewer to the next. They are constantly looking for new immaterial technicalities like date stamps to deny payment. They go over their own tike requirements without consequnce. And don&#39;t even get me started on how often they "lose" your files or how much time you have to spend just confirming they received what you mailed. This is intended to create uncertainty and intimidation. They do not want you to see clear, bright lines because utilization will be lower when you are afraid to fill a valid order because there are a thousand ways to be wrong and maybe, possibly one way to be right.

The sad part is how CMS has taken things to the point of working against the interest of the taxpayers. I know there has been abuse of the standard power mobility codes in the past. But standard power mobility is a valid cost mitigation tool against what medicare pays for skilled nursing services in a nursing home. Virtually every new nursing home patient gets the maximum 100 days in skilled nursing when they are admitted to a nursing home because they get to bill medicare $500 per day instead of billing medicaid $150 per day. So when someone goes to a NH medicare pays about 40k in the first 100 days. On the other hand medicare pays about $3,200 for a K0823.

So if these people with severe chronic illnesses who qualify for powerchairs can stay in their homes until the disease finally takes them just one out of 12 times then it pays for the other 11. Never mind the back end medicaid costs or the hospitalization and therapy costs related to falls. It is just so stupid for CMS to deliberately try to kill the standard power mobility market by creating cash flow disruptions the small providers cannot handle because we are the ones who get this right. We don&#39;t advertise. We don&#39;t try to intimidate docs. We are the ones who put the process 100% in the hands of the physician. Therefore we are more likely to spend tax dollars well.

"I&#39;m done" you are absolutely correct. This whole process has gotten so ridiculous the only reason i maintain Medicare is because other reasonable insurance companies i deal with require that you have a valid Medicare provider number. Like I said before, these rules and regulations are in place to displace the operation of smaller firms. Even Scooter Store had to seek financing from a capital venture firm. Where is a small business going to get financing given the weak economic condition. But providers also make this easy for Medicare, until we start campaigning against these policies its only going to get worse. No one seems to care what we think, they go ahead and do whatever they please. To get started on the capped rental thing, i mean how can you treat power chairs and hospital beds equally and make them both RR. One is stationary and the other moves around from place to place. Common sense tells you pwc withstands more rigorous use than hospital beds. Then they put all the burden on you as the provider when someone is abusing your asset. <br />
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Then upon all these rules, these bums are still pushing competitive bidding. After CB whatelse is going to be there. Maybe they will introduce something that says providers with owners below the age of 40 cannot participate in Medicare. What a bunch of clowns

Chris, this is a dying industry because the government is going broke. Get out if you can. Start a business that does not rely upon the good faith of the government.