Requests for documents are no joke

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Friday, September 30, 2005

Q: What change to the appeals process will most affect how a supplier responds to a DMERC audit?
A: Changes to the appeals process are in the works. Of these changes the one that will require the most work by suppliers is the requirement that all additional evidence be presented no later than the Qualified Independent Contractor level unless good cause can be found. This means that progress notes and other documentation in support of medical necessity must be presented much earlier in the process. In the past, suppliers often presented these items for the first time at the ALJ hearing. This will no longer be allowed.
An overpayment often starts out as a request for documents from the DMERC. In the past, suppliers have failed to take these request serious and sent only the documents in their file. When receiving such a request, a supplier should take immediate efforts to begin gathering physician progress notes. A supplier might even decide to implement a company policy that requires these documents to be obtained prior to the delivery of equipment. These documents should be forwarded to the DMERC, even if not specifically requested
Once the documents are sent, a supplier thinks nothing more of the request until it is hit with a large overpayment. A supplier should assume that the claim will be denied and continue to gather as much medical necessity documentation as possible. The clock has begun ticking and failure to gather documentation early will result in a delay in getting to the QIC appeal level. This delay may allow the DMERC to begin its recoupment efforts immediately. A request for documentation from the DMERC should never be taken lightly. A thorough response and continued diligence will prevent many sleepless nights in the future.

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Denise M. Fletcher is an attorney with the Health Care Group of Brown & Fortunato, an Amarillo, Texas-based law firm. She can be reached at dfletcher@bf-law.com.

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