Medicare sees a number, not a mother

Friday, February 20, 2015

By Gary Rench

I need to call a patient’s family and tell them that I either have to pick up the hospital bed they are renting from me, or they have to sign a document that states they are willing to pay privately. 

I provided them a bed and the claim for that bed was randomly picked by the Medicare contractor Noridian to be audited. An audit of a claim should not scare anyone—you would expect that they look at the documentation and see if the patient needs the equipment. Well it does not work that way.

Medicare first goes through every piece of paper looking for a mistake. When there is a mistake, it is an all-or-nothing mistake. It finds any type of mistake and the DME company gets its money taken back. It could be something like a doctor signing an order, but not dating his signature. Not fixable, not payable. Noridian states a 91% denial rate for three quarters in 2013. 

DME companies are not dumb. We have had to figure out what words Medicare needs to see to cover equipment and make sure the doctors say something along those lines. You see, we have clients who need equipment and the doctors want to know what has to be done to accomplish that. Medicare will not make sure the doctors are educated; we are forced to. 

Most DME companies are not crooked. I am definitely not a crooked person and Sandcreek Medical is not a crooked company. We fight every claim we are denied and we win most times. In fact, most of the DME companies have started fighting every claim and that has created a new problem. The final level of appeal, alone, is out 27 months to 12 years, depending on who you ask. Either way, you cannot afford to work your way through the appeals process anymore.

This particular claim is for a bed needed to take a patient home from the nursing home. The patient’s daughter asked us about procuring a bed and we explained we needed chart notes from the doctor stating the need. She said that her mom had seen the doctor, so that part should be taken care of. 

I explained that very few doctors will document the need for medical equipment without someone pushing them on how much documentation there needs to be. As usual, when we received the documentation from the doctor, there was no talk of needing a hospital bed, let alone the required phrases Medicare wants to see in the notes, i.e. “frequent changes of body position” “alleviate pain” and “immediate change of body position”

So this family had to take their mom back to the doctor for a visit that would document the need for the bed. I provided them with a sheet that explains the basic rules of Medicare and that there needs to be talk of the reasons she needs the bed. Well, this doctor did a fair job. I would have liked a little more detail, but I did not get it. I believe in my heart that she needed and still needs the bed. Then I did what every DME company in America does: hope that this claim will not be chosen for an audit.

Here is the real problem. Medicare has changed the rules of the game. According to its own statements, the agency cannot use clinical inference to say, “Oh yeah, this client really does need a hospital bed.” Instead, it has to go to the Local Coverage Determination or LCD for the rules and it sticks to the letter of the rule. Hence, a hospital bed will not be covered if a doctor did not have a statement like this: “This patient needs positioning in ways not feasible in an ordinary bed. This patient needs frequent changes in body position in order to alleviate pain.” If those words are not in the chart notes, then Medicare will deny the claim. In the real world, that means one of three things: 1) The DME company is going to lose money, 2.) the patient is not going to get the equipment they need, or 3.) the patient will have to pay privately. With the tighter profit margins, and amount of time and money it takes to fight claims, many times we are forced to tell the patients they have to pay. 

Back to changing the rules of the game. I believe that Medicare started to see the words it wanted to see in the chart notes. It saw the word “frequent” and it saw the word “alleviate.” It should be happy, but instead of quoting the LCD verbatim, we have a new weapon called the PIM 5.7. Now Medicare is going to focus on the statement, “For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable).” What is sufficient enough and when is it inapplicable—that is up to Medicare and its auditors.

Medicare still wants to know that it is frequent, but how frequent. It wants to know not only that it will alleviate pain, but also what are the levels of pain, and the frequency of that pain, or how the bed is likely to alleviate that pain. It wants to know if the patient has had experience with this equipment before. It wants to know if the patient has had any therapeutic interventions. Most importantly, it wants it detailed and it does not want any vague answers. 

Unfortunately, in our business we deal with real people in their worst part of life. Some times a hospital bed is needed for someone who is dying and the doctor does not really know that the hospital bed will alleviate his or her pain. The doctor knows that the patient is in pain, and the patient needs a hospital bed to be able to be at home with family. The doctor is sometimes just hoping that the bed will alleviate pain. Sometimes morphine will not alleviate the patient’s pain.

Below is Medicare’s answers to why this patient does not meet the medical criteria for the bed. As you read these statements, remember that the doctor is required to document this in his normal chart notes. Even if he wanted to write a letter or a 500-word essay stating why this client needs a hospital bed, the letter or essay would not be considered part of the medical record. The documentation must be in the doctor’s normal chart notes. This particular doctor has a unique way of doing his chart notes. He has forms where he will X out words and circle others. He will write little statements to the side and makes notes that tell him how the patient is doing. These same chart notes have been used for years and used to document conditions that are more complex than a hospital bed referral. I do not believe that his chart notes could ever get a hospital bed covered and that is sad.

As you read the statements from Medicare, pay close attention to this: “Verbiage such as pain is vague, subjective, and insufficient. Clear objective documentation and quantifying information is lacking.  This type of verbiage does not provide a clear picture of the beneficiary’s pain.” Then keep in mind that Medicare does not have objective rules on what frequent is. It cannot tell you what level of pain is acceptable. It cannot tell you what functional limitation it is looking for, or what therapeutic intervention is acceptable. It will not tell you exactly why the documentation does not support that the beneficiary requires frequent changes of body positioning and it will not say exactly what part of pages 5-8 are illegible, just that they are partially illegible. 

What Medicare is really saying is, do as we say, not as we do. It is saying that we must provide clear, objective data, written in the doctor’s normal chart notes, and only the agency can be subjective on the reasons it denies the equipment. It says that verbiage such as pain is vague, subjective and insufficient—the doctor used the words severe pain. Maybe that was one of the illegible words; I do not know because Medicare does not have to be clear, objective, or quantified. 

I now have to do the part of the job I do not like. I am going to have to call the family and give them a choice between paying privately for the bed, or having me pick the bed up. I no longer can fight a bed like this through the appeals process. Money is too tight and the time it takes is too long. You see, you would think that the requirement of an Administrative Law Judge hearing your case in 60 days would happen within 60 days. Somehow that has turned into a minimum of 27 months and a letter asking us to be patient, but that is a different issue.

I now have to do the part of the business that I do not like and I have to call this patient and say that the bed is not covered. I am also going to say that until patients start contacting their elected officials, these are only going to be seen as numbers and not as someone’s mother.

Gary Rench is the owner and manager of Sandcreek Medical in Sandpoint, Idaho, a small DME and respiratory company started in 1989. He can be reached at