Got questions about audits? Tom Walters has some answers

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09/28/2010

Tom Walters is the president of Total Office Management in Columbia, S.C. And when he says Total Office Management, he means it. Walters consults on everything related to running an office. Lately, and probably this will come as no surprise, he's been spending a lot of time helping providers do self audits. That's one way to discover if a company has its bases covered before a ZPIC, MAC, RAC or some other audit agency walks through the front door looking for trouble. I talked to Tom recently about his work with providers, and here's some of what he had to say.

HME News: When you do an audit, how many claims do you look at?
Walters: I look at roughly half of 1%. If I see issues coming up within that, then we'll do a more focused audit.

HME: Are you seeing certain problems coming up over and over again?
Walters: Lack of documentation in the medical record. The justification for the equipment as outlined by the local carrier coverage determination.

HME: Don't most provider know what documentation is needed?
Walters: We've become complacent in the industry and CMS has adopted a very stringent attitude that if it is not documented it didn't exist. And in that regard, they are taking the LCDs and going through them step-by-step, looking for those items that document medical necessity. They are looking at coding. They are looking at medical record documentation. They are looking at duplicate services.

HME: What's your advice to providers?
Walters: No. 1. They have to become very familiar with the LCDs. No. 2. An ounce of prevention is worth a pound of cure. They need to do a mock self audit. And where you can, educate the ordering entities on Medicare rules and regulations. Tell them what is expected of them. Too often I hear from physicians, "I've never heard about this before. Where did this come from?" And it's been a part of the LCD forever.

Mike Moran

Comments

Isn't that what acreditation was supposed to help? Knowing the LCD's? It is so hard to keep up with at times.

LCD's are always recommended but they are so vague. Medicare needs to understand that many HME companies care about there patients and the patients do need the services we provide. Not giving us the adequate information needed to bill a claim hurts HME suppliers but hurts the patients not able to receive services because a provider is too freaked out to accept documentation that may or may not support medical necessity more.