Task force aims to reign in 'out of control' audits

Thursday, June 17, 2010

ALEXANDRIA, Va. - In response to an incoming "tidal wave" of audits, AAHomecare has formed a task force to develop guidelines for Medicare auditing policies.

"We will be advocating for a set of clear rules so that providers know what is expected of them," said Walt Gorski, vice president of government affairs for AAHomecare. "Providers want to know what is expected of them. The goal post should not be moving all the time."

The taskforce plans to develop a strategy that includes legislative and regulatory remedies, education, outreach to increase awareness of the impact of audits and public relations efforts to highlight the burdens that audits create.

Of particular concern for stakeholders are the onerous requirements that HME providers must adhere to for payment. One example: oximetry testing.

"We can't think of a similar situation where we are asked to not only show the medical necessity but at the same time show the patient is using oxygen," said Gorski. "Do pharmacies have to get documentation to show a medical need for amoxicillin and also that the patient took it? That's what we are asked to do."

With audits being conducted by an alphabet soup of auditors--DME MACs, ZPIC, OIG, CERT and RAC--stakeholders fear the industry could be crushed under the onslaught. Last week, CIGNA, the Jurisdiction C DME MAC, announced that it would conduct a prepayment review of claims for E1390. A similar audit in Jurisdiction A found a 78% claim denial rate for oxygen.

Such a high denial rate points to a systemic problem, says provider Kim Brummett, a task force member.

"If you have a 78% failure rate, is the failure in the need of the patient or is the failure a technicality, such as an illegible signature?" said Brummett, vice president of contracting and reimbursement for Greensboro, N.C.-based Advanced Home Care. "A technicality doesn't negate the patient's need for oxygen."

Ensuring that CMS's guidelines are realistic as well as clearly defined would go a long way toward stemming high denial rates, stakeholders say. CMS's approach of constant audits solves nothing, they say.

"We are all about fighting fraud," said Brummett, "but there's got to be a break-even point. The audits are out of control."