Saturday, July 31, 2004

Change is on the horizon
with Seth Johnson
Q. Now that a U.S. District Court Judge has ruled that CMS can’t require a provider to furnish documentation beyond the CMN to prove medical necessity, does that mean that the DMERCs can no longer require chart notes?

A. The recent ruling from the U.S. District Court for the Eastern District in California is the most positive development for the industry in quite a few years. While this case specifically impacts claims processed within the court’s jurisdiction, the precedent that it sets is significant.

In light of the limited application of the ruling, providers should continue to document and supply the DMERCs with all requested information until they withdraw such requests. CMS will likely appeal this decision, which could lead to a broader national application of the ruling. The ruling also calls into question whether CMS should continue seeking additional documentation in other areas of the country, now that the court has ruled it illegal. The judge pointed out one solution, which is to require the physician to include all relevant medical information on the CMN. Changes to the CMN are currently under way, and the industry will provide input into these revisions.

As an industry we should share this court ruling with Congress, consumers and other local stakeholders to highlight the flaws with the current Medicare claims process and coverage policy. This court decision will be helpful in moving CMS in the right direction toward a clear and concise Medicare coverage policy.

Seth Johnson is the director of government affairs at Pride Mobility Products. He can be reached at 1-800-800-8586 ext. 1480.