Start with the small stuff


I read a comment the other day that had nothing to do with the HME industry, except that it kind of did. It was "start with the small stuff and the big stuff will follow."

If you put that quote in the context of audits/denials, that's an apt statement. We frequently report on various audit issues: the workload, the inconsistencies, the occasional absurdities. Providers are quick to complain about audits, and rightly so. What many providers are not so quick to do is fight audits or denials, especially on the low dollar stuff.

But if you don't fight the small stuff, it adds up to bigger stuff. It creates high percentages of denials that CMS then uses to justify ongoing reviews. And who wants that?

And how many times do we see "did not respond to request for documentation" as a reason for denials.

I know this lack of response, where it happens, is a concern for many of the consultants, attorneys and Walt Gorskis we talk to each week.

I get it and they get it. It costs time and money to respond to requests, appeal denials. A comment that appeared on our website from one provider says he spends about 30 cents of every dollar he earns on billing and collections.

But, if you look at the bigger picture, I think the value of fighting back outweighs some of the cost and aggravation. In other words, sweat the small stuff.

I also know that there's nothing HME providers love more than a good story about CMS being wrong.

Theresa Flaherty


I could write volumes on this subject but I will only disclose that my Legal Team and me have received both personal phone calls and "E" Mails from Providers acknowledging they had believed to be victims of inappropriate actions by CMS Auditors.  All claimed to having a problem with either the PSC's, ZPIC's, and MAC's.  All also claimed to fight the battle would be too costly and too time consuming for their consideration.

While Theresa Flaherty has a valid point, the problem with the current system is it is NOT a mathematical equation of a function of mass to time.  By that I mean It doesn't matter if you have ONE claim or ONE hundred claims the length of the process is the same.  A Provider has to be prepared to spend somewhere between one and two years from reconsideration to ALJ.  If a Provider is successful it will automatically be reviewed by The Medicare Appeals Council which would take between another one to two years.

CMS is aware of this scenario and uses it to their advantage.  Remember ALL these Appeals now purposely take place on CMS's Home Court.  CMS is in total control and establishes ALL the rules and regulations of who will do what and when.  The ONLY thing a Provider can DO is ASK!! 

There are NO short cuts!!

As I have posted in a previous comment keep this in mind.

"CMS is The King and ALL Providers are servants to The King"!!