Reporter's notebook: Audits: Denials, duplicates, delays

Friday, February 21, 2014

These days, we are hard-pressed to find a provider who doesn’t want to vent about audits. From massive recoupments to a two-year wait for an appeals hearing, the system, say providers, is broken.

Right hand, meet left hand

No sooner does provider Glenn Steinke respond to an audit, then he gets hit again—for the same claim.

“Five days after we send the responses, we get a request for the same audit again,” said Steinke, owner of Airway Medical in Bishop, Calif. “We’ve also had duplicate audits in the same envelope with a different audit number, but with the same date of service, same piece of equipment and same patient. It’s a waste of money and time.”

To that end, providers say it’s ridiculous that, with the technology available today, auditors can’t stop barraging providers on the same claims.

“I refuse to believe they can’t put an identifier on a claim to let other auditors know that it’s already been audited,” said John Daniel, president of Superior Medical Supply in Clarksville, Tenn., which has about $100,000 tied up in various stages of appeals.

Oh, we changed the rules

The staff at Okeechobee Discount Drugs makes sure to check and recheck its documentation before submitting a claim, but it’s frustrating when auditors deny a claim based on changes to the requirements that went into effect years later, says provider Steve Nelson.

“We are fighting them for electric wheelchairs we dispensed four or five years ago,” said Nelson, president/CEO of the Okeechobee, Fla.-based company. “We get all the documentation, and we check and verify. They pay the bill and then they come back five years later and say we don’t think she qualified, or we changed the formula in 2011 and now you owe us all this money back to 2006.”

Thank you for holding

These days, providers need to build a plan for dealing with audits into their business models, but with auditors denying on simple technicalities, they can find their hands tied, says provider Carter Fuller.

“We’ve got a compliance department to make sure we meet the standards and work the appeals,” said Fuller, vice president of business development for Chattanooga, Tenn.-based Professional Respiratory and Medical. “We’ve appealed about $150,000 worth of claims that we’ve sent on to the ALJ. We’re in a holding pattern waiting on that hearing.”



Below is a comment I wrote 12/08/2012

It may be worth reading why the industry is in the current state of affairs!!

Submitted by dominic on Sat, 12/08/2012 - 9:20am

After reading the well written article above by Leif Kothe it is most important that you allow me to further explain some of the most gory details of this case and what it means to the industry. Pleae read below.

I fully understand and am sympathetic with everyone's exhausted effort in the battle waged by the industry to counter Competitive Bidding and even more so I understand the exhausted pensiveness from the rampage of erroneous audit requests from the CMS Contractors. If you, however, give me the coutesy of continued reading below it may prove these are the least of the industry's problems.

Let's look at the facts of Nichole Medical vs. Tri-Centurion & NHIC. More than ten years ago Tri-Centurion conducted an unannounced audit on the company. The timeline was published by Leif in a previous article. After campaigning through every appeal step outlined by CMS's instructions the final appeal process, The Medicare Appeals Council concluded the following. First, the audit provided "lack of evidence". Second, the audit process used violated the statute and the rules & regulations established by The Secretary Of Health to conduct an audit. Finally, this is the biggest error, an audit such as this, CAN NOT be done on the basis someone might (and the word might is in bold letters in their Decision) be billing inappropriately.

This indisputable Decision by The MAC is probably the most compelling case of NEGLIGENT ineptness the industry will ever see in any case associated with any audit issue or a CMS contractor's actions. ALL these issues and facts were presented to both The Third District and Third Circuit Courts. The following is the result of their examination of this evidence.

The Third District ackowledged these infractions, however, cast upon the CMS Contractor an imaginary veil of "Outer Perimeter Discretion" dismissing them from any wrongful action campaign against them. The Third Circuit in it's review of The Third District's ruling affirmed this "Outer Perimeter Discretion" veil. To compound the application and influence of this Decision The Third Circuit has a Supreme Court Justice, Sandra Day O'Connor's signature on it. This signature would probably rank this Circuit Court Decision as one of the most influential Circuit Court Decisions for ALL other Federal Courts to Follow ever written. I did write previously, CMS was taking this case very seriously!!

This is the industry's biggest problem currently! Why, because any/all legislation passed or any/all CMS concession of rules & regulations alleged infractions would have to fall ouside this Outer Perimeter Discretion" to have any impact or application. This Decision says when a government contractor is on the government's clock whatever actions they do or whatever infractions they may commit this imaginary "Outer Perimeter Discretion" protects them from any adversity a Provider may claim against them. Legislature DOES NOT and CAN NOT legislate The Judges!

In a sporting event you would be synonymous with a program having rules but WITHOUT referees to enforce the rules because it won't matter what legislation could, would or may be passed it would take the application of The Federal Courts to enforce them.

The industry for NOW is in CHECKMATE game over unles a Supreme Court Decision can either overturn this imaginary "Outer Perimeter Discretion" or at minimum define it with some tangible parameters! It is most unlikely that any legislation would undermine this Decision with a Supreme Court Justice's name on it. Even though she is retired the rank of Supreme Court Justice is a liftime appointment and as such she remains as a Supreme Court Justice forever.

The industry needs to galvonize and face this issue head-on because if it doesn't it won't matter what legislation is passed. The Federal Court would have to be convinced that whatever alleged violation would ocurr by a contractor it would have benn committed outside this imaginary "Outer Perimeter Discretion"! January 19th is important because with NO further action on this case this Decision will be entered into the law books and ALL Medicare Providers will then be operating at your own risk. The Federal Courts will NOT protect you. Please, keep in mind that Competitive Bidding is administered by Contractors and this Decisions reads Contractors!

My Lawyers and me have taken this campaign as far as we could possibly go. I do not have the financial resources to properly attempt taking this campaign to The Supreme Court and my Lawyers can not afford to absorb the costs of the many man hours of research and lobbying efforts needed to properly attempt this undertaking either. I am NOT admitting defeat because I have been able to get this issue to some resolution and elevation of review further than anyone else has ever done or attempted to do. Defeat is reserved and would ONLY come at the hands of an industry that ignores the graveness of this Decision and allows it to go on the lawbooks uncontested January 19, 2013 with NO further Appeal or action taken thereby accepting this Decision as everlasting.

I personally owe a great deal of thanks to Marcus Suess, his dad, Frank, for their recognition as to the severe gravity of this case and the issues it presents for the industry from over a year ago. When I first informed the industry through HME News of it's events they jumped right in without any hesitation. I am most thankful for their support and the support of those that followed as a result of the Suess' family efforts.

In the grand scheme of this campaign as the military would view it we are only a Platoon on a mission that requires the support of an army to continue moving the campaign forward!!

Anyone wanting to reach me can do so "E" Mailing me.


A comment regarding Theresa Flaherty's Blog. 2/24/14

I am Operations Manager for a small Mobility Company and I want to add my 2 cents (Of which MC will probably Recoup 5 yrs from now) We have been haunted by Medicare recoupments since September of 2014. Although that seems like a minor time frame for a company but when you are a less than 5 million a year it is a big deal. We are experiencing a 100% recoupment from Medicare dating back to September 2014. We have not received a dime from them at all. When we attempt to get answers from them its like they speak a totally different language.... One of a person who has no tongue.

The bottm line is.. We are being recouped 100% of every dollar that is approved by Medicare. The hard part to that is, they say they can't tell us over the phone and they will mail the info and GUESS WHAT it never arrives. I know I sound like I am venting but really I am YELLING with frustration. We are small and they might as well have forced us out of business.

Our last call to them they informed us there were only two recoupments on file for about $20,000. Well then why are they still taking money. They got everything from 9/2014 until today and yesterday they recouped a power chair payment of $13,000. The numbers don't add up. We have 2 other chairs approved and billed for around $30,000. That was 45 days ago. Who wants to bet the suck that right out of us 100%

When will anyone be able to stop this obvious abuse of power. We as a small can not afford to hire a high priced attorney to dig into this andin the area of the country no attorney is going to take it on Pro-Bono.

I even read that long time guy Dominic Rotella ( I have bee seing his name for years in blogs etc..) had a attorney and although he got some results he had to back off. As long as we pay taxes the Medicare Thieves can fight till the end. Of course all this i my own (Freedom of Speach) opinion but I am sure there are many out there that agree with me. Medicare Audtis and recoupments are a total abuse of power.

Before you know it, the copycats out there are going to follow suit.Third Party Insurance companies are going to jump on the medicare band wagon and start asking for their money back and I dont just mean on complex rehab claims. Pretty soon the will be saying... We decided that we should not have paid for that car accident you were in 4 years ago. We are going to have to take that money back.

So the biggest scam of all time is... The commercial will read.... Medicare Audit and Recoupment Services. Gaurenteed to recover every dollar you ever received. Oh and you can feel comfortable knowing we will do everything in our power to never worry you about getting paid what is fair. Here at Medicare we strive to keep our money and take your money back from you.

Total first ammendment conversation expressed in this comment.