Monthly Archives: July 2017

The Four Fundamentals of HIPAA

In 2015, the Office of Civil Rights issued $6 million in fines related to HIPAA violations. In 2016, that number increased to $23 million, a 283 percent jump. So far in 2017, they have issued $17 million in fines with the projection of upward growth.

If you think those numbers seem like a good reason to get your business on track to be HIPAA compliant, you’re right! Most fines stem from not understanding and implementing the four fundamentals of HIPAA:

  1. Compliance Team: The first step is to assign someone within the office to oversee the HIPAA compliance. When this responsibility is assigned it must be documented so the Office of Civil Rights will be aware if they were to audit your business. The compliance officer will need to receive proper training and evidence will need to be provided this training occurred.
  2. HIPAA Policy and Procedures: Not having policy and procedures in place within your office is a top reason for fines. Your policies and procedures need to be created, shared with employees and documented. At a minimum, the policies will need to be reviewed on an annual basis. You must create the policies structured for your practice or business, and be active in updating, sharing them with employees and documenting this activity.
  3. Workforce Training and Awareness: Training will need to be provided to anyone on staff who handles or is in contact with patient records. Once training and updates are provided to staff, records of training should be tracked. There will need to be regular reviews and retesting to ensure understanding and compliance.
  4. Security and Risk Assessment: You’ll want to take the time to ask questions about security. Are cabinets that store patient information locked? Are computers password protected? Are doors locked so unauthorized personnel can’t get into medical records? The HIPAA compliance officer must make sure security and risk assessments are completed on a regular basis.

Get your business on the right track. The van Halem Group now has an easy to use solution to ensure HIPAA compliance called HIPAAwise.  With HIPAAwise, our goal is to simplify the compliance process with our web-based program. To see The van Halem Group Solution for yourself sign up for our free trial and discover how simple it can be to become HIPAA compliant! For any other questions, please contact us here.

New Brightree Tool Supports HME Industry Efforts to Collect Data on Medicare Audits

The next HME Audit Key data submission period, covering the time period through the 2nd Quarter of 2017, is set to open on July 17.  Even if you haven’t previously participated, you can still take part starting with this round.  HME suppliers of all sizes and specialties are encouraged to join this campaign to build a strong data-set of performance benchmarks and help the HME community make the case on Capitol Hill and at CMS for much-needed audit reform.

New Resources Streamline HME Audit Key Data Collection Process for Brightree Users

A new tool developed by Brightree streamlines the data collection process and makes it easier to participate.  Brightree customers now have the option of printing a report from their My Files folder to answer many of the operational questions on the quarterly survey.

To print the report simply retrieve the report names AAH_Output.csv from the Inbox for the My Files page within Brightree and open the report in a spreadsheet program like Microsoft Excel. Please see comprehensive guidance for using the Brightree report here: PDF versionMS Word version.  You can also see more about the new tool in this press release.

More About the Audit Key:

Suppliers can go to to complete the survey and find tips/guidance on entering your data.

Individual Audit Data is NOT Required: The Audit Key does not require you to submit data on individual claims, but instead seeks cumulative counts of pre- and post-payment audits and appeal claim outcomes under DME MAC, RAC, and SMRC reviews.

How does my company benefit by participating?  In addition to providing critical data for the campaign for audit reform, individual suppliers will have access to their own quarterly survey results, and will have access to aggregate survey results and key findings. Suppliers can use this information to see how they compare to others in terms of audit volumes and appeal overturn rates.

Data Security Assured:  Your company’s individual information will never be shared, but will be included in the aggregate data. See additional details on how your data is protected in the Audit Key.

Assistance is just a call or click away:

The HME Audit Key is sponsored by the American Association for Homecare.


Are you prepared for the new nationwide PAR?

By Kay Koch, OTR/L, ATP Rehab Clinical and Education Consultant

Beginning July 17, 2017, K0856, single power option and K0861 multiple power options, Group 3 Power Mobility Devices will be subject to Prior Authorization Review (PAR) nationwide. Prior to this date, the PAR program has been in place since September 1, 2012 and included all POV and standard PMDs, all Group 2 PMDs and all Group 3 non-power PMDs for certain states.

What does PAR provide?

PAR allows the supplier to provide medical record documentation prior to delivery and billing to verify eligibility for a Medicare claim payment.

The PAR request was not, and is not, considered a claim.

Claims process

Prior Authorization is a condition for payment.

Any claim eligible for this program after July 17, 2017 must go through the prior authorization process prior to delivery or it will be denied.

The 25% penalty reduction does not apply to this program.

How to prepare for PAR

The PAR cover sheet is optional but encouraged.

Submitters are encouraged to include the following information when submitting PAR requests to avoid potential processing delays:

  • Beneficiary information:
    • Beneficiary Name
    • HIC #
    • Beneficiary Date of Birth
    • Beneficiary address
    • Place of Service, and
    • Diagnosis code
  • Supplier information:
    • Supplier name
    • Supplier address
    • PTAN
    • NPI
    • Supplier phone number
    • HCPCS code
    • Submission date

Supplier must also indicate if this is an initial or subsequent request AND indicate if this is an expedited request, and if so, the reason it is expedited.

It is also important to indicate if the request contains an UPGRADE.

All documentation to support prior authorization must meet all applicable rules, policy, and LCD requirements.

Documentation required:

  • Face to face
  • LCMP/ Specialty Evaluation
  • Financial Attestation
  • 7 Element Order
  • Supplier ATP evaluation
  • Detailed Product Description
  • Home Assessment/Visit (if available, but not required. The Medicare reviewer may prefer to have the home assessment included in the review)

Documentation must meet the coverage criteria for the wheelchair base and certain accessories/power options that include tilt, recline, and tilt and recline and specialty seat/back cushions.

PAR review for applicable HCPCS codes does not apply to accessories, except those accessories noted above where coverage criteria must be met.


Initial Submission

For the 1st PAR request  DME MACs will conduct a medical review of the documentation and send a decision letter to the supplier and the beneficiary (if requested) within 10 days (postmark notification) of receiving the request.


Resubmissions are allowable to correct errors or omissions identified in the 1st review. DME MACs will review the medical documentation and send a decision letter to the supplier and beneficiary (if requested) within 20 days of receipt (postmark notification) of the request. Providers have unlimited options to submit subsequent PAR requests.

Expedited Requests 

An expedited request is considered when the usual review time-frames could jeopardize the beneficiary’s life or health. When applicable, DME MACs will render an affirmative or non-affirmative decision and provide the decision to the supplier or beneficiary (if requested) via phone, fax, or other “real-time” communication within 48 hours.

Unsupported expedited requests are downgraded to a standard request.

Keep in mind

This is a preliminary finding that the future claim submitted to the DME MAC will likely meet Medicare’s coverage, coding, and payment requirements. Even if the supplier has an affirmative PAR decision, the claim may still deny due to technical requirements or due to information later provided that was not available at the time of the PAR review.  It is highly encouraged to submit all paperwork in sequential order to avoid potential delays in processing.

Following the favorable PAR decision, the DMEPOS item is delivered to the beneficiary and the claim should be submitted with the Unique Tracking Number (UTN) that is provided on the PAR decision letter.



Noridian has a webinar scheduled July 19, 2017 at 10:00 CST/11:00 am EST. Follow this link to register:

Coversheets can be found on the CGS ( and Noridian ( DME MAC websites.


A Warning from Wayne

We received word from several VGM members of contact with them by a company out of the Philippines trying to engage companies in paying for referrals on back braces. The entity makes claims that their “surrogate agreement” is OK with CMS.  We’d like to take this opportunity to heed a very strong warning to any suppliers who consider engaging with this company, and any others that make similar claims.

They indicate that they will provide the lead, orders, medical records, etc.  All you have to do is submit the claim to the government for payment, which ironically, is where the potential for a false claim violation or improper payment occurs. They have no liability in the process and leave you holding the bag.

Often times, what they promise is too good to be true. I understand with the reimbursement cuts that many are looking for opportunities to generate more revenue. While nothing wrong with lead-generation services and direct-to-beneficiary marketing, some of these companies are engaging in suspect activity including cold-calling, misleading and confusing marketing, and even in some cases actually paying the physician to perform a telephone consultation with a patient and order orthotic bracing. I even recently received a call on my cell phone from someone indicating that they were returning my call following my request for a back brace from Medicare. This was absolutely a cold-call – which is prohibited for Medicare patients. How they got my number as being associated with a Medicare patient is another story.

The important thing to remember here is that you cannot contract with another entity to do what you are not allowed to do yourself. If you pay the lead generation service for the referral and they pay the physician for the evaluation, then you have unwittingly yourself paid for the referral. As you know, that is violation of the Anti-kickback Statute which carries criminal penalties of up to 5 years in prison and criminal fines up to $25,000 per violation and civil monetary penalties of up to $50,000 per violation. This is no joke. See the process outlined below.


Strip all of the steps away and you may have violated the Anti-Kickback Statute. Also, because the physicians do not have any established relationships with the patients and often times are located nowhere near the patient, it’s very easily detectable in your claim data.

Another thing to note is many of these companies will make claims that an attorney or consultant has reviewed and approved their process. If so, get the name of number of who they say has, contact that person, and ask for evidence of such in writing. You’ll likely find that such a review hasn’t occurred.

These codes are being heavily targeted, and rightfully so, by auditors and ZPIC investigators. Entering into an arrangement like this and dramatically increasing your billing in this product category will quickly put a target on your back that could lead to increased audits, denials, extrapolated overpayments, payment suspensions, or revocations. We have seen good suppliers get caught up in this mess and the entities they engaged with have no liability, as they have not submitted any claims to the government.

Don’t get caught up in this. Heed this warning. If you engage a lead generation service, conduct your due diligence on their processes, engage your own counsel to review all contracts and marketing materials, and perform regular evaluation of their telephone calls and procedures. Make sure you scrutinize the referrals and understand where they came from. A legitimate lead generation service should have no problem providing this information.

If you have questions or have more information on these companies calling you that you’d like to share, please call The van Halem Group at (404) 343-1815.