Monthly Archives: December 2017

RAC AUDIT ALERT: Respiratory Assist Devices

On December 17, 2017, Performant Recovery, the National DMEPOS RAC, added Respiratory Assist Devices (RADs) to their approved issues list. According to their website, Performant Recovery will perform complex reviews of these claims to determine if coverage criteria and/or medical necessity requirements were met.

Codes included in the audit are: E0470, E0471

Performant will review coverage criteria outlined in the LCDs and Policy Articles. It is important to note that the RAC can review claims having a “claim paid date” as far as 3 years back. Be mindful of both current and retired LCDs based on the date of service being audited.

For more information on the coverage criteria being reviewed, please refer to our previous post regarding proposed RAC issues.

Want some help? Come to the experts! 

The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment.

Even more beneficial to you, is to allow our team to work for you proactively. Our clinical prescreen program provides reassurance that your documentation meets coverage criteria before you bill the claim. Our clinical team will review your claim prior to billing and work with you to obtain essential documentation from the ordering physician. Prescreens are charged on a per file fee.

Contact us for more information!

Same or Similar Denials: How to avoid it?

By Donna Youngblood, RN

Same or similar denials occur when claims information is checked against the patient’s CMN history. This will indicate when equipment is “same or similar” to that piece of equipment being billed on the claim. An example of same and similar items includes a K0800 (power operated vehicle) and a K0823 (Group 2 power mobility device) or an E0140 (walker with trunk support) and a K0003 (lightweight manual wheelchair).

These types of denials can be avoided early on when providing DME equipment to patients. The most important part in preventing this type of denial is by having a thorough intake process. Suppliers are encouraged to use an intake form to assure all necessary information is obtained prior to dispensing DME items. Such information may include:

  • Patient’s correct Health Insurance Claim Number (HICN);
  • Whether the patient has other insurance
  • If the patient currently has or had this type of equipment or similar equipment in the past;
  • When the item(s) were received and if the item(s) have been returned;

It is the suppliers’ responsibility to check the Supplier Interactive Voice Response (IVR) system or portal to determine if same or similar HCPCS are on file for a patient within the previous five years or specific reasonable useful lifetime (RUL) for the item. In the event that same or similar is suspected, a supplier must provide a proper Advance beneficiary Notice of Noncoverage (ABN) for each item likely to be denied as not medically necessary.

5 Ways to Start HIPAA Compliance off right in the New Year

As a new year quickly approaches, now is the time to take advantage of getting your practice or company set up for HIPAA compliance in 2018! Take a look at these five tips to help you get started.

1. Select or Hire a Compliance and Security Officer

If the budget allows, now is the perfect time to start looking to hire or train a compliance officer. Having someone on staff dedicated to ensuring compliance along with training and updating other employees, can help mitigate any non-compliance risks. Remember, if you don’t have someone designated to be leading compliance efforts, you’re not in compliance.

2. Develop a Risk Assessment

Designed to identify potential risks, vulnerabilities, availability and integrity of Patient Health Information that an organization creates, maintains, receives and transmits, having a risk assessment in place is critical to being compliant. Since entities can now be fined for not identifying potential risks, it’s highly encouraged this should be the first step after identifying your compliance officer. For more information on risk assessments, visit our blog here.

3. Create HIPAA Privacy and Security Policies

Creating Privacy and Security Policies are critical to becoming HIPAA compliant. These lay the groundwork when developing your compliance strategy. The goal of these policies is to develop a plan on how your organization will protect electronic PHI. These should be reviewed with staff on a regular basis and updated, at the minimum, on an annual basis.

4. Train your Employees

The Compliance Officer has been decided, the risk assessment developed and the Privacy and Security policies are in place, so what’s the next step? Training your employees. Employees should receive annual trainings on all the policies and procedures in place. You’ll need to accurately document the training of the employees for your records if you were to be audited.

5. Put it into Practice

Everything is in place, has been documented and everyone has been properly trained, now is the time to put your plan into action, with the help of  HIPAAwise, – The van Halem Group Solution, you can keep better track of your process, policies and documentation of required materials.


For more information about how HIPAAwise can help you become compliant through this easy-to-use program, contact us today.

Signatures from representatives still needed for H.R. 3730

Kay Koch, OTR/L,ATP

The holiday season is upon us and while this may not be on your holiday wish list many people who use complex rehab wheelchairs would like it to be. HR 3730 has still not gotten the signatures needed to exempt Complex Rehab Manual Wheelchair Accessories from Competitive Bidding. Introduced in the house in September 2017, this bill amends title XVIII (Medicare) of the Social Security Act to prohibit the application of Medicare competitive acquisition rates to complex, rehabilitative, manual wheelchairs and accessories. (A competitive bidding program has replaced the use of established fee schedule amounts to determine payments under Medicare for certain durable medical equipment such as wheelchairs.) Will you contact your representative to wish them a happy holiday season and ask them to sign on?

It is important to recognize the label “accessories” is a Medicare policy term that does not properly convey that Complex Rehab wheelchair accessories are “critical components” such as seat/back  pressure relieving cushions, positioning devices, recline/tilt systems, and specialty controls.  These critical components are what allows the Complex Rehab wheelchair to be individually configured to meet the unique medical and functional needs of the person with a disability.  The negative consequences of the current situation are not limited to just Medicare beneficiaries.  They extend to children and adults with disabilities covered by Medicaid and other health insurances plans, since most payers follow  Medicare  policies.

Congressional action is required to provide equal access.

CMS has elected to group heterogeneous products under a single HCPCS billing code and as a  result, the same code includes both Standard wheelchair accessories and Complex Rehab wheelchair accessories. Complex Rehab wheelchair accessories are different technologically, designed to meet a unique clinical  need, and are costlier to provide than Standard products. CMS is taking information obtained through  the competitive bidding of accessories used on standard wheelchairs and inappropriately applying that  pricing to Complex Rehab accessories that were not part of the CBP ( Competitive Bid Program).

Congressional action is needed. This is a lingering issue that was not addressed in CMS’  June 23, 2017 policy correction.  Accordingly, Congressional action is needed to stop CMS’ inappropriate  application of CBP pricing and ensure equal access for Medicare beneficiaries and others with significant  disabilities who rely on individually configured Complex Rehab manual wheelchairs.    Representatives Zeldin and Larson, along with 41 original cosponsors, introduced H.R. 3730 on  September 11, 2017 to replace the previous broader bill (H.R. 1361) and focus just on accessories used with Complex Rehab manual wheelchairs.  This legislation must be passed as soon as possible. As of Dec 1, 2017, there are 24 Republican and 29 Democrat co-sponsors.

Please write or call your representative to ask for their support for this new legislation and to emphasize the importance of protecting patient access, not just to accessories used with complex rehab power wheelchairs, but also access to those used on complex rehab manual wheelchairs. Regardless of injury, illness, disability, or chronic condition, all Medicare beneficiaries should be eligible for the same access to medically necessary mobility devices, services, and accessories. Anything less can have serious consequences for beneficiaries. Urge Congress to pass H.R. 3730 to ensure that accessories used with CRT manual wheelchairs are protected. With the links below it will take less than 5 minutes of your time.

Please check this link here and contact your representative to either thank them for their support or ask for their support of this important legislation.

Thank you to  www.  for the updates, new information and the following links:

Co-sponsors :

Access2CRT.ORG  for a link to email your representative :

Understanding the HIPAA Training Requirements

Do you understand the HIPAA training requirements? If you don’t, you’re not alone. HIPAA regulations concerning training can become a little vague and some people are unsure what they’re required to have training on or what it even entails. To help, we’re breaking down some of the confusion when it comes to HIPAA training requirements.

Who needs to be trained? Within the HIPAA Privacy Rule, it states training should be to “implement a security awareness and training program for all members of the workforce”. Meaning everyone on staff should receive regular, and adequate training.

What do they need training on? There are so many rules and regulations when it comes to HIPAA, so it’s important to remember that employees need a wide range of training, including but not limited to, the proper handling of Personal Health Information, seeing and reporting suspicious activity and/or any possible violations, what constitutes a violation and how to protect yourself and company from breaches, etc.

What’s the purpose of training? The overall goal of training is to provide a basis of the HIPAA Privacy and Security Rules. Since roles vary within a company, training should be tailored to their involvement with PHI or ePHI.

What do you do after training? After training has been provided, it’s critical that it’s documented. When you use HIPAAwise – The van Halem Group Solution, you can regularly document trainings for easy checks if you were to be audited. Within the documentation, the training material should be included, along with the frequency and who received the training.

To learn more about how HIPAAwise can help you with developing training modules or documenting the trainings, visit the website here. For more information about training, visit the U.S. Department of Health and Human Services website here.

OIG Hospice Report

Written by Lisa Eick RN

CMS recently re-published an article regarding the OIG report from September 2016 that found more than one third of Hospice election statements and certification of terminal illness documents were found to be non-compliant. The sample included only General Inpatient stays (GIP), however the article is a great reminder for all Hospice providers to monitor these documents to ensure they include all required elements. The takeaways from the OIG report include:

Election Statements      

Periodically review the election statements to ensure all required elements are included in the statement. This is of particular importance for agencies who have made changes to the election statement to meet compliance requirements. It is not uncommon, for old forms to find their way out of the filing cabinet (electronic or otherwise). As a reminder the following are the election statement requirements.

Election Statements must include the following:

  • The name of the Hospice providing care to the patient.
  • An acknowledgement that the patient (or authorized representative) has been provided a detailed explanation of hospice care. This must include a clear description of the nature of hospice care and treatment as palliative and not curative in nature.
  • An acknowledgement that certain other Medicare services are waived (not covered) while on hospice care.
  • Election date: Must not be prior to the date of election. May be the first day of hospice care or later.
  • Designated attending physician must be clearly identified by full name, office address or the National Provided Identifier (NPI).
  • An acknowledgement the attending physician was their choice.
  • The signature of the patient (or authorized representative.

An election statement missing any one of the required criteria is incomplete and may result in a Medicare denial.


Physician Certifications

Develop a system of routine audits of physician certification forms to ensure all required elements are completed and meet Medicare requirements for a compliant certification. By developing systems and processes for auditing the physician certification forms, agencies may identify areas of weakness and opportunities for educating providers on the Medicare requirements. As a reminder the following are the requirements for the physician certification form.

  • Written certification must include
    • A statement that the patient has a life expectancy of 6 months or less if the terminal illness
    • A narrative from the certifying physician which includes clinical documentation that supports the patient has a terminal diagnosis.
      • The narrative can be part of the certification form or an addendum.
      • If part of the form it must be located above the physician signature.
      • If an addendum the physician must sign following the narrative.
      • Must include an attestation statement above the physician signature and date stating he/she completed the narrative based on review of the clinical findings in the patient medical record or upon examination of the patient.
      • Benefit period dates.
      • Recertification for the third benefit period must include a narrative explaining the findings of a face to face visit that continues to support a life expectancy of less than six months. The narrative must include the date of the visit and an attestation that he/she performed the visit. If the visit was done by a nurse practitioner the must be an attestation the results of the visit were provided to the physician.
    • Signature requirements
      • Handwritten signature, must have a hand written date
      • Electronic signatures and date
      • Stamped signature are not acceptable.
      • The initial benefit period – the certification must be signed by the hospice medical director and the patient’s primary care provider if there is one.
      • Subsequent benefit periods may be signed by the hospice medical director


Source: Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1628.pdf accessed 10/30/17