Who's at fault: Doc or supplier?
I would like to respond to the brief article in the rehab section of the December 2005 issue of HME News, in which Dr. Paul Hughes, Region A medical director, makes several comments about the responsibilities of suppliers in obtaining adequate documentation for coverage of HME. His point that "a single piece of paper" is not adequate to document need for equipment is well taken. I also would agree that an ethical and up-to-date supplier would obtain additional documentation like hospital discharge records, PT and OT consults, oximetry and arterial blood gas tests, etc., to supplement the "single piece of paper" he refers to.
It is problematic, however, that in almost every instance in which a physician comments on the problems of fraud in the HME community, he gets a pass on his responsibilities. Why would a physician order a power chair without adequate supportive documentation in his records? Why would a physician order oxygen for a home patient without adequate testing? Is it not intriguing that a supplier must collect and review a variety of medical records to make a decision whether the medical record would support coverage of the item ordered, when in any court in the land, the supplier would not be considered the expert to make such a decision--particularly in a disagreement with the referring physician. But the physician, under present law, does not have to collect the medical information, or make the case for medical coverage of the item ordered. The supplier is required to do this.
In the past year we have turned down two referrals for BiPAP therapy in the home due to non-availability of required testing per Medicare coverage requirements. In both instances, the physician/referral source promptly called another supplier and the BiPAP was provided almost immediately. Also, in both instances, the physician complained that we were "difficult to work with"; thus, the change to another provider. In both instances, however, required testing was not obtained. So who is at fault here: the supplier or the physician?
I agree with Dr. Hughes that "...in Medicare . . . if it isn't written down, it didn't happen." Unfortunately, what he leaves out of this position is that it is not usually written down in the physician medical record. The "doctor's progress notes," which Dr. Hughes refers to, should have some relationship to other medical records available on the patient, and should, hopefully, refer to supplemental consults and testing used in making on-going treatment decisions, including ordering particular HME. This would be more appropriate than pressuring the supplier to collect the supportive data for the item ordered by the physician.
Improvement in preventing fraud in the HME industry will require that physicians be held accountable for ordering HME for which they have inadequate medical documentation. Even in instances where the physician is "only a piece of the puzzle" in providing complex care, the physician must have enough medical information in his records to support the equipment he's requesting, or be very open in cooperating with other providers to obtain the documentation needed.
--Tim Good, President, GoodCare by CPCO, Logan, Ohio.