Monthly Archives: March 2015

Advice from The van Halem Group: Requesting a Reopening

The word “reopening” has different meanings, depending on what side of the fence you may fall. If you are speaking to your local DMEMAC customer service representative, they may suggest that a reopening is in order for claim submissions that contained a mistake or minor error. And yes, this is true. There are times that you may have transposed a number or letter, resubmitted a claim that resulted in a duplicate denial or made some other mistake that can fall into the human error category. But what happens when the human error falls on the side of the contractor?

In various speaking engagements, I often receive the same question: “What can I do when the Redetermination decision is wrong?” Now before I go any further, let me clarify this question. Of course, the natural inclination is to think the decision is wrong when it comes back unfavorable isn’t it?! I mean, you provided the necessary equipment to the beneficiary so, naturally, it should be covered! To consider the Redetermination decision to be wrong would be when referring to the “Explanation of the Decision” section of the decision letter. For example, the section contains inaccurate information, such as an item being detailed as missing or invalid, when it is not.

So how do you handle this when it happens to you? First and foremost, be sure that you are correct. What I mean is, do you have the necessary proof to indicate that the decision was wrong? If you submitted the appeal request via fax, you need to be sure that you have the fax confirmation to include all the pages that were submitted. If your appeal request was submitted in the mail, you need to be able to detail the number of pages submitted and which page number(s) included in the document are in question. In the most general of terms, can you prove that the documentation was received at the contractor in its entirety? If so, then let’s proceed to step two.

Upon discovering that the Redetermination decision contained an error, you need to bring that to the attention of the contractor. First and foremost, do this in writing. In the past, you were able to contact a customer service representative who could pull up your scanned appeal submission, verify the inaccuracy and then request the reopening on your behalf. Gone are those days! In speaking with various contacts at the DMEMACs, customer service representatives are no longer able to assist on this level. But do not fret! This does not stop the reopening from happening, it just adds another level for you to move through.

You have the right, by law, to request that the appeal decision be reopened. The CMS Internet Only Manual 100-04, Chapter 34, Section 10.1 states that “Reopenings can be conducted by a contractor to revise an initial determination, revised initial determination or redetermination; a Qualified Independent Contractor (QIC) to revise a reconsideration; an Administrative Law Judge (ALJ) to revise a hearing decision, and the Appeals Council (AC) to revise an ALJ decision or their own review decision.” And further, the IOM goes on to say that good cause exists when the evidence that was considered in making the determination or decision clearly shows on its face that an obvious error was made at the time of the determination or decision.

Upon discovering the contractor error and verifying that you have the necessary proof to be proceed, the third step in the Reopening process is to include all the necessary details in your request. When bringing an error to the attention of the contractor, be sure that you do the following:

  1. Make your request in writing
  2. Include the following elements:
    1. Clearly state that it is a “Request for a Reopening of a Redetermination/Reconsideration Decision”
    2. Redetermination DCN/QIC Appeal #
    3. Reason for Reopening
    4. Documentation to support reopening
  3. Submit the request to the Appeals address

Lastly, know that the contractor’s decision to reopen is based on the existence of good cause. They also have the right to refuse to reopen after determining that good cause does not exist. Understand that the timeline to request the next level of appeal does not stop for a reopening. This is very important. Please pay attention to timelines and do not assume that your request for a reopening stops the deadline to the next level of appeals. Should the contractor refuse to reopen the appeal remember that you still have appeal rights to the next level, however, the clock begins from the date of your initial decision letter.

Remember, a reopening is a valid request, no matter what step in the claims process you fall. And when your appeal request is not handled appropriately, you are entitled to a reopening. Be sure that you have the appropriate evidence to support the need for the request and that it is submitted accordingly and to the appropriate department. We all make mistakes, both supplier and contractor. The reality is that we appreciate the human attention taken to our reviews, but with human attention comes the probability for human error. Should you find that an error has occurred in your appeal, you do have the right to have it corrected. Take care of details and pay attention to timeliness deadlines to be successful.

The importance of physician documentation to the DME Supplier

In the month of February I traveled to four different cities for various association meetings, conferences or on-site client visits. During my travels I encountered suppliers that are all have or are currently being audited by one of many CMS contractors. Some suppliers indicated that the DME MACs’ prepayment review letters (ADRs) come to their office on a weekly basis. Others are experiencing postpay reviews from the ZPIC. These audits are considerably daunting and, when not handled appropriately, could result in 100% prepayment review of your claims or even revocation of your supplier number.

No matter the type of audit, one thing is certain. Preparing your files to be audited is your best defense. Although you, the supplier, has control over your own records, the documentation that is provided by the physician is heavily scrutinized by auditors to ensure medical necessity and coverage by Medicare is justified. Below I have provided answers to the common questions you encounter when requesting medical records from the beneficiary’s physician. Within the answers you will also see references from the IOM, Social Security Act and the Code of Federal Regulations for you to use when educating your physicians on the importance of their role in the documentation process.

Why do you need me to document?

For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable)…neither a physician’s order nor a CMN…nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN…or information on a supplier prepared statement or physician attestation (if applicable). [PIM Chapter 5, Section 5.7]

Says who?

Title XVIII Section 1842(p)(4): In the case of an item or service defined in paragraph (3), (6), (8), or (9) of subsection 1861(s) ordered by a physician or a practitioner specified in subsection (b)(18)(C), but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.

What are the consequences to me if I don’t?

42 Code of Federal Regulations (CFR) § 424.535:

A referring/ordering physician’s failure to provide the above required documentation may result in the revocation of enrollment and billing privileges in the Medicare program:

  1. Reasons for revocation. CMS may revoke a currently enrolled provider or supplier’s Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons:
  • Failure to document or provide CMS access to documentation. (i) The provider or supplier (as described in section 1866(j) of the Act) did not comply with the documentation or CMS access requirements specified in §424.516(f) of this subpart.

The other guys don’t make me do this, why are you?

It is ours, and your, legal obligation to comply with Medicare rules and regulations. In an environment of strict regulatory oversight we work hard to be compliant in our business practices. The other suppliers that are not collecting documentation from you may not be in compliance.

On March 15, 2013, Chapter 3, Section 3.3.2.1.1(C) of the Program Integrity Manual was amended to state that “physicians/LCMPs [licensed/certified medical professionals] who fail to submit documentation upon a supplier’s request may trigger increased MAC or RAC review of the physician/LCMP’s evaluation and management services”.

Can you make it easier on me?

CMS also amended Chapter 3, Section 3.3.2.1.1(B), probably in an effort to prepare for the use of eMR. The amended section states “CMS does not prohibit the use of templates to facilitate record-keeping.” The PIM goes on to define a template as a “tool/instrument that assists in documenting a progress note.”

Based on the above, a physician may use a template or form when documenting the need for the durable medical equipment. To be clear, templates cannot merely contain check boxes, predefined answers, or have limited space to enter information. These types of templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met. There must be sufficient space for free form information specific to the patient. A supplier generated form is not considered to be part of the medical record and is only used to gather information. However, a physician may create a form that is used when ordering prosthetics/orthotics. Physicians who use templates must make them the default method of documentation for prosthetics/orthotics. This means that the form must be completed for use on all patients in which the physician prescribes prosthetics/orthotics, not just when prescribing for one supplier.

What does my documentation need me to say?

Many of the prosthetics/orthotics that you prescribe have local coverage determinations (LCDs) that contain the criteria for coverage. The criteria listed in the Coverage Indications, Limitations, and/or Medical Necessity section of the LCD is what must be supported in your notes. You can access the LCDs from the respective DME MAC Jurisdiction’s website.

The bottom line is that if you are waiting for the audit letter to arrive, you are already too late and may not avoid paying money back to Medicare. Obtaining the appropriate documentation prior to billing, or as quickly as possible, is your only defense. Neither the DME MAC, nor the Part B MAC, is contracted to educate physicians on DMEPOS documentation requirements. This means that the burden to educate physicians on the documentation you need for your patients to meet Medicare guidelines is on you – the supplier. Work with your referral sources to understand the significance of their documentation in relation to the equipment they refer for you to provide and convey to them their role in the audit process.