Providers, like pilots, need checklists
For years, physicians have drawn lessons from the aviation experience to create checklists called safety procedures that support essential clinical practice. In medicine, if you make a mistake, it can cost a life. In the DME industry, if you make a mistake, it can cost your business. Recent speculation by many industry experts forecast that in less than one year the number of DME companies currently operating in the United States will be reduced by one-third. If you don’t want to be one of the 7,666 locations that go out of business, get your documentation checklist in order. And check it twice before submitting to a payer source like Medicare.
The proof is in the data published quarterly by CMS. In April 2013, Medicare Administrative Contractors (MACs) released their K0823 power mobility device (PMD) prior authorization (PA) findings; More than 50% of paperwork submitted was incorrect. In many cases, the reasons for the non-affirmation could be easily fixed and paperwork was resubmitted for approval. It’s becoming increasingly clear that if the provider submitting the PMD documentation used a checklist to ensure medical justification is met and all required information is included, the percentage of denials could be reduced, just like the percentage of medical errors decreases every year.
If you haven’t already subscribed to an electronic template that can assist you and your referring physicians in obtaining accurate and complete PMD documentation, here are some tips to improve your approval rate:
Before submitting paperwork to a payer source, have two different people review it and then check it again. Denials for forgetting to date stamp the paperwork, not completing the detailed product order or forgetting to send the seven-element order can be easily eliminated.
Create and print a checklist: (a) seven-element order completed by practitioner, signed and dated; (b) face-to-face evaluation completed, signed and dated; (c) detailed product order completed, signed and dated (after the date of the seven-element order); (d) all documents are dated and all date stamps are within 45 days of the face-to-face evaluation.
Create and print a checklist for face-to-face evaluations received from physicians: (a) physician’s face-to-face notes contain enough information to clearly paint a picture of the patient’s mobility limitations; (b) face-to-face notes rule out the use of a cane, walker and the ability to self-propel an optimally configured manual wheelchair (upper and lower extremity strength and function is addressed in detail and not vague terms, i.e., “Bilateral shoulders MMT 3/5 ROM below functional levels” versus “upper extremities are weak”); (c) face-to-face notes clearly define how the mobility limitation impacts the patient’s mobility related activities of daily living (notes provide written information about what the patient was able to do prior to the mobility limitation, what they do now, and what the usage goals of the PMD will be); (d) physician’s notes state that the patient can safely operate a POV (scooter) or the POV has been ruled out and a power wheelchair ordered; (e) physician’s notes state that the patient is willing and capable of using the POV or power wheelchair.
It is true that PMD face-to-face evaluations and medical necessity are not always cut and dry. What if the patient’s physical strength is 5 out of 5? Ask yourself, what has led the practitioner to write the PMD order? Does the patient have a lung disease or heart condition? If so, the physician must list the reason the patient cannot propel the manual wheelchair, i.e., “Patient experienced heart palpitations and chest pain with exertion and required a 15-minute recovery.”
If you are overwhelmed with paperwork and do not want to create additional work and checklists, subscribe to an electronic template that incorporates the above questions, compares the physician’s answers to Medicare’s coverage criteria and helps DME providers accurately determine whether or not PMD requests will be approved or denied for payment. Electronic templates also help rule out requests for mobility equipment that are not considered a medical necessity. For example, if it is determined that the PMD request is for a patient to more easily go to the mall, the only way to handle this situation is to say, “Check, cash or charge?” In these cases, don’t waste your time, the physician’s, the patient’s or CMS’s by submitting a request for medical reimbursement. It drives up the denial rate, providing CMS further justification to implement prior authorization for other DME services.
Come on DME providers, we’re better than this. We can no longer successfully operate on a 50/50 gamble. If you are unsure whether Medicare will approve or reject the face-to-face notes, don’t roll the dice. A simple set of checklists can assist you in obtaining accurate and complete PMD documentation you don’t have to wager. Neither aviation nor CMS is forgiving of mistakes. Without checklists, DME companies will be grounded.
Jamie Loper, ATP, is the co-founder of DMEevalumate.com.