Patient uses fewer strips? Document it

Sunday, October 31, 2010

It's easy to understand why auditors might look askance at diabetes claims for more testing supplies than Medicare allows, but for fewer supplies?

Well, providers need to back that up, too.

"I think providers are surprised when they are asked for similar documentation for low-frequency testing," said Seth Lundy, a partner with Washington, D.C.-based law firm King & Spalding. "Ultimately, Medicare can require documentation for any claim because the basis for payment is medical necessity."

One national mail order provider has seen about 20% of its claims for fewer supplies than Medicare allows get audited since April.

"(The auditor) has denied huge numbers of claims for us for people who are under guidelines," said the provider. "The cash flow held back is several hundred thousand dollars at this point."

Medicare guidelines allow testing once per day for non-insulin treated diabetes and three times per day for beneficiaries on insulin.

Currently, providers aren't required to keep doctors' notes on file (see related story on page 37), but they must be able to produce them on request, usually within 30 days of the date of the demand letter.

"You spend most of the 30 days getting the documentation from the physician," said industry consultant Karen Kaczmarek, president of Boca Raton, Fla.-based KBK Consulting. "And, I have seen multiple cases where the postmark on the envelope is a week or more after the date on the (auditor's) letter, so suppliers are losing reply time."

That's when they can even get the notes. Lundy estimates that providers are successful only about 40% of the time.

Adding insult to injury: The notes don't always satisfy Medicare requirements.

"The biggest problem we have is trying to determine what they are looking for in the doctor's notes," said Kathy McKenna, billing supervisor at Carolina Diabetic. "If you call for guidance they can't tell you what they are looking for."

It's difficult, agrees provider Mark Gielniak.

"They want us to read the progress notes, which have to contain certain things," said Gielniak, vice president of Diabetes Plus in Warren, Mich. "I am not a medical professional who should make that judgment."