Let's put a stop to the government's game of 'gotcha'

Sunday, September 25, 2011

Recent government reports highlight high error rates and levels of improper payments related to claims for power mobility devices (PMD). Subsequent news coverage lays the blame squarely on durable medical equipment (DME) suppliers, while ignoring the real cause, the government itself. CMS has for many years ignored pleas from physicians and the PMD industry to provide a clear objective standard for documenting medical necessity and a multi-page clinical guide to assist physicians in satisfying documentation requirements in a uniform manner. This strategy enables CMS and its contractors to apply confusing subjective policies to deny legitimate PMD claims either upon initial filing or via multiple post-pay audit cycles. Subsequently, misleading reports are issued using deceptive data that results in new levels of Congressional legislative action. As an industry, we should expect more from our government and its agencies. 

In late 2003, the Medicare Prescription Drug, Improvement, and Modernization Act was signed into law. As part of that law, a face-to-face mobility examination was required for power wheelchairs, which was intended to put the physician in control of patient care and to help address fraud, waste and abuse. Fast forward to the present day, and the Patient Protection and Affordable Care Act requires a face-to-face examination for all DME. If history is any indicator of the impacts of the face-to-face requirement, suppliers should be very concerned. 

In 2009, over 200,000 Medicare beneficiaries required a PMD to conduct their activities of daily living (ADL). Statistics show that an estimated 75% of physicians prescribe just one PMD per year; and roughly 15% prescribed two per year. The physician's goal is simple--prescribe what is medically necessary to improve the patient's quality of life. However, physicians are concerned that their medical expertise is being routinely overridden by auditors who have never seen their patient. Since the elimination of the certificate of medical necessity (CMN), CMS has merely issued educational guidelines through a series of MedLearn Matters articles. In each instance, the policy has shifted further away from using the medical information gathered by the physician at the time of the examination. Today, audits are being conducted in a manner that emphasizes a patient's entire longitudinal medical history appearing in chart notes, discounting the mandated face-to-face physician examination findings and documentation. These audit practices do not follow evidence-based medicine and can adversely affect quality and comprehensive care for patients needing power mobility assistance. 

The government's ongoing game of "gotcha" is leaving suppliers caught in the middle, between the way physicians normally document their encounters with patients and the unrealistic expectations of CMS. Because CMS has not provided a clear objective standard, physicians across the country have relied heavily on medical organizations and the supplier community to fill that void. Some physicians are reporting that they are being told that the requirement is simply a letter of medical necessity. Other physicians are using forms endorsed by state physicians associations; some eschew forms altogether and provide clinical information in chart notes, only to learn that it is not enough. There are even reported instances where physicians receive paperwork already pre-filled, simply in need of a signature. It's no wonder physicians are confused.

As an industry, it is time we unite and ask Congress to hold CMS accountable for their actions. We should support legislation that mandates the creation of a government issued, multi-page clinical guide and instructs the agency to stop routinely denying PMD prescriptions by second guessing the clinical judgment of physicians unless there are glaring contradictions or evidence of fraud. Such legislative measures will improve quality outcomes, reduce error rates, and eliminate unnecessary and burdensome paperwork while ensuring that beneficiaries receive the necessary products and services they require. 

Congress is faced with serious budget issues that need serious answers. Recent legislative measures have already punitively and financially harmed legitimate suppliers. And unfortunately, the bulk of the provisions in the Patient Protection and Affordable Care Act (ACA) have yet to be rolled out. We also face the unknown impact of a new congressional super committee as it endeavors to identify trillions of dollars in budget savings. Dedicated suppliers cannot continue to pay for the mistakes of others because we are an easy target. We must take a stand. If not, everyone will be facing "overpayment demands" as a result of CMS's refusal to come up with an approach physicians understand and will comply with.