Author Archives: Kelly Grahovac

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.

Correct Coding – Leg Rest and Foot Plates/Foot Platforms bundled into HCPCS E1012

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

This DME MAC Joint Publication was posted on June 22, 2017. It is a good reminder to those who are billing the E1012 center mount elevating leg rest on power wheelchairs.

Recently it has come to the attention of the DME MACs that suppliers are billing separately for footplates (K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH) or foot platforms (K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED) used with a center mount elevating leg rest (E1012 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH) for power wheelchairs when the leg rest is initially billed to Medicare.  This practice is incorrect billing.

HCPCS code E1012 describes a complete leg rest system.  It is an all-inclusive HCPCS code, meaning that all components of the leg rest, including footplates and foot platforms, are included in HCPCS code E1012.  Medicare claims for codes K0040 or K0108 (when used for foot platforms) billed in conjunction with code E1012 will be denied as unbundling.

Refer to the Power Mobility Devices and the Wheelchair Options and Accessories LCDs and related Policy Articles for additional information about coverage, coding, and documentation.

For questions about correct coding, contact the Pricing, Data Analysis, and Coding (PDAC) contractor at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form at .

RAC AUDIT ALERT: Power Mobility Devices

Performant Recovery, National RAC for DME, Home Health and Hospice has released another issue to the approved issues log. Power Mobility Devices not subject to the PA demonstration are under complex review, effective June 6, 2017. Claims will be reviewed for Medical Necessity and Documentation Review.

Visit Performant Recovery’s website to review this and all other approved issues.

The Cost of Compliance – An impassioned plea to be proactive

By: Wayne H. van Halem

To start, when I say compliance I am speaking directly to being compliant with government laws and regulations when treating patients receiving services from government or private payors. This isn’t licensure or accreditation, but a reimbursement compliance program – where your greatest risk is. I know this is not a topic many folks like to talk about. We hear from clients all the time that, “We hope we never need you, but glad to know you’re there!”  The problem is most of our clients don’t know they need us until it’s too late!

To illustrate this point, we’ve done a cost-benefit analysis on three clients in unique sectors that we work with:  Home Medical Equipment; Home Health and Hospice; and Physical Therapy.  As you will see, the results are astounding. In each of these examples, these clients came to us after compliance issues had been identified by CMS or one of its’ contractors. In each of these examples, despite the absence of intention or malice, our client’s compliance issues resulted in one or more of the following actions being taken as a result:

  • Large extrapolated overpayment
  • Payment suspension
  • 100% prepayment review
  • Corporate Integrity Agreement with the Office of Inspector General

These are all very serious actions that can be debilitating to your business. Imagine if this happened to you?  Luckily, our staff is very good at managing these issues and we have successfully navigated the process for each of these clients, in some cases saving them millions of dollars. However, as you can imagine, dealing with these issues requires an expert’s detailed analysis. It takes hours of time and effort in developing responses and strategies to correct the issues identified and/or to counter the overpayments or denials. This costs money. While our services are not as expensive as what you would pay if you hired a law firm, our hourly rates can add up depending on how serious the issues are. In the chart below, you will see the costs associated with helping our clients. These fees range from just over $15,000 over a 1-year period for a sole physical therapy practitioner who had to enter into a Corporate Integrity Agreement, to over $180,000 over a 1½-year period for a large home health agency with hundreds of employees who experienced a large extrapolated overpayment as the result of the ZPIC audit. It is also important to note that these do not include other financial hits these companies had to take with claim denials, refunds, workload, or hiring legal counsel in addition to our services.

All of this got us thinking, what if these clients had signed up for our monthly proactive compliance packages and were paying that amount, instead of our hourly rates, over the same period of time we were working to fix their issues? Not surprisingly, it turns out the cost of our proactive compliance services are just 10% – 34% of what they actually paid. For example, as illustrated below, our HME client paid us fees totaling over $55,000 over a period of almost two years to manage their issues. During that same time, our monthly compliance package for a company their size would have been just $5,600! This company was pushed to the brink of bankruptcy by CMS and its contractors and is still on a repayment plan today. They have also lost significant revenue and had to lay off half of their workforce.

In three examples from different sectors, we looked at what our clients would have paid for one of our monthly compliance packages over the same period of time as what they actually paid for us to resolve the issues. Below is a chart that illustrates the difference:

Now, of course, there is no guarantee that a comprehensive compliance program is going to catch and resolve every issue; however, leaving a lot of the work up to compliance “experts” who are innately familiar with the requirements and can provide affordable expert advice is a lot better than waiting to see if something bad happens. The van Halem Group offers a range of options for our clients, such as:

  • Customized Monthly Compliance Package, which includes:
    • Online compliance training and education with management reporting and tracking
    • Compliance policies and procedures
    • Quarterly Audits with Corrective Action Plans by clinical and audit consultants
    • Compliance Web-based and Hotline reporting
    • Quarterly compliance newsletters
  • HIPAA Risk Assessment and Monthly Package, which includes:
    • Quarterly HIPAA compliance training with management reporting and tracking
    • HIPAA policies and procedures
    • On-going Security and Risk Assessments with Mitigation Plan by HIPAA consultants
    • Electronic Business Associate management
    • HIPAA Documentation management
    • Breach Reporting
    • Comprehensive and easily accessible HIPAA library

If you’re not sure you want to dive into a long-term agreement, we have one time audits and assessments similar to what is described above as a quick analysis of where you stand or a test of the services we offer. All of our proactive compliance services are reasonable, customizable, and comprehensive. Not to mention, these are all things the government expects that you are already doing. Have you seen the news reports lately of the fines being assessed by the government for HIPAA violations? Some of our monthly compliance packages cost as little as $165 per month per location.  You can’t hire compliance support staff on your own for that.

These services are not designed to replace your compliance officer or your compliance staff, but to augment the work they may be doing. We provide key expertise and assistance while they focus on the many other duties and tasks they are also responsible for.  We make sure that compliance is engrained within your organization and the program is an evolving one that protects your business. We understand that reduced reimbursement has impacted many providers, but even our clients with the most comprehensive internal compliance program are only spending 2-4% of their overall budget on compliance. Considering the risks in today’s environment, that is not an unreasonable spend. A good compliance program will mitigate the cost of itself and you’ll see a return on your investment through better processes, efficiencies, and quality of care. We invest in insurance for our business, why don’t we invest in compliance?

As Roy Snell, CEO of the Health Care Compliance Association – a national association of healthcare compliance experts, says “Organizations that have effective compliance and ethics programs attract and retain good staff and are more trusted by their communities and potential customers. Good compliance and ethics programs have an impact on revenue that must be considered when you calculate cost. Trusted companies get more revenue than companies that can’t be trusted.”

The van Halem Group is here for you when you need us…but you should understand that you may need us now. Since founding The van Halem Group in 2006, we have helped countless providers save over $75 million in overpayment and denials. I am so proud of that, but we could have avoided much of that from ever happening. That is our goal with our proactive services. We have fought and will continue to fight for fairness and reasonableness in the audit and appeal process, but wouldn’t it be nice to avoid it altogether?

It saddens me greatly to see family-owned companies that have been in business for over 20 years be brought to their knees due to avoidable compliance risks. While reactive work may be more lucrative, it also weighs heavily on our clients, and on us. It adds unnecessary stress and tension for everyone involved in the process. We have relieved that stress for a number of clients, but we have a lot more work to do.

Be proactive. Be prepared. Let us help you.

Potential ventilator overpayments identified by the OIG

In September 2016, the OIG released a report titled “Escalating Medicare Billing for Ventilators Raises Concerns“. The report findings were a result of the 2016 OIG Work Plan that identified ventilators as a target for review. The OIG investigation looked to identify (1) billing trends and factors associated in the increase in billing of ventilators (E0464), (2) the frequency of ventilators billed inappropriately for beneficiaries with non life-threatening conditions, (3) instances in which ventilators would not be considered reasonable and necessary to treat conditions described in the CPAP or RAD LCDs, and (4) the impact competitive bidding had on ventilator billing trends.

To conduct the investigation the OIG conducted data analysis of claims billed with code E0464, against other variables. These variables included a diagnosis of Obstructive Sleep Apnea (OSA), a CPAP or RAD billed in concurrent months, and ventilator accessories. Some of the highlights from the published report include the following:

  • Medicare inappropriately paid $25 million ventilator claims
  • 85% increase in ventilator billing from 2009 to 2015
  • Increase is driven by 3 national suppliers (54% growth)
  • Shift from treatment of neuromuscular conditions, as indicated in the NCD, to respiratory conditions
  • Inappropriate billing due to diagnoses of obstructive sleep apnea, billing for multiple devices for the same beneficiary, and billing separately for accessories (unbundling)

At the time this report was published, the ramifications were not quite known. The OIG indicated that they would make recommendations to the CMS for appropriate followup. The result? The CMS has required the DME MACs to identify suppliers of potential overpayments for ventilator claims made to them. In the past two weeks, suppliers nationally have received letters from Noridian and CGS, advising them to investigate and self-report claims identified by the OIG that were potentially overpaid.

If you receive one of these letters here is what you need to do:

  • Review the reason the claims were identified by the OIG. Your letter will identify one of three reasons you may have been overpaid. The identified reasons are:
    1. Multiple devices concurrently
    2. OSA diagnosis, or
    3. Separately billed accessories.
  • Carefully review the claims indicated on the letter. More specifically, check the claims history to determine if a CPAP or RAD was billed prior to or during the billing cycle a ventilator claim was filed if the reason given is “Multiple devices concurrently”. If an OSA diagnosis was the reason given, review your claims history for diagnoses billed. Lastly, check the claims indicated for separately billed accessories if that reason was given.
  • Respond accordingly. Your letter will indicate your option to either attest that you reviewed the claims and no overpayments exist or that you identified an overpayment and you will be taking the appropriate steps to reconcile the overpaid claims with the DME MAC.

Please note that your response to the DME MAC requires your printed name and signature, thus attesting that you have conducted your own investigation of the claims indicated and acted appropriately, in accordance with 42 CFR 401.305, if required.

At this time there is no indication that the DME MACs will conduct further audits on the identified claims. However, as is all things with Medicare, anything is possible. For that reason I strongly encourage you to conduct a thorough investigation of the claims to determine they are medically necessary, and more importantly, that you have the documentation to prove as much. Self-reporting an overpayment does not imply guilt or fraud, and will not leave you open to a barrage of future audits. Should those claims be audited in the future, you will be afforded appeal rights, as you are with any overpayment claim.

If you received one of these letters, take a deep breath and begin your due diligence. For now, the opportunity to self-report versus the DME MAC automatically auditing the claims is a welcome change!

The full report can be viewed by clicking here, “Escalating Medicare Billing for Ventilators Raises Concerns“.

If you would like further assistance, let our Clinical team help! The van Halem Group can conduct reviews of your claims to determine risk or prescreen any future ventilator claims prior to billing. Should your claims be audited later, our Audits and Appeals team will work hard to get your claims overturned. We also offer a variety of compliance solutions to protect your business. Give us a call today!

Schedule a consultation at Heartland

The van Halem Group (vHG) has announced something new for Heartland attendees this year. Multiple vHG representatives will be on-site and available for personal consultations throughout the day Tuesday through Thursday. Whether you have questions about a specific situation you are experiencing or want to learn how to protect and safeguard your business from compliance issues, now is the time to take advantage of a free consultation!

Scheduling is easy! Just visit the Heartland Scheduling page on our website, and select a day and time that works for you. The Heartland conference is the industry’s premiere education and networking event! Let us help make this year the best one yet! For more details on what you can expect at Heartland this year, visit the VGM Heartland page.

New CMS ABN form available

Effective June 21, 2017, providers must use the most recent version of the Advance Beneficiary Notice (ABN) Form CMS-R-131 with the March 2020 expiration date to deliver a valid ABN. If the new form is not used on/after this date, any new ABN executed on the old form will be considered invalid and would result in provider liability if Medicare denies the claim. Providers may begin using the new ABN Form CMS-R-131 immediately.

For more information and to download the new ABN form, visit the CMS’ Advance Beneficiary Notice of Noncoverage webpage.

RAC Announces it will review Underpayments made on Group 3 Wheelchair options

On May 17, 2017, Performant Recovery, the National DMEPOS RAC announced that it will begin to recover underpayments, or incorrect reductions owed to suppliers, for wheelchair accessories and cushions for Group 3 complex power rehab wheelchairs.

Section 2 of the Patient Access and Medicare Protection Act (PAMPA) mandates that adjustments to the 2016 Medicare fee schedule amounts for certain DME based on information from competitive bidding programs not be applied to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with Group 3 complex rehabilitative power wheelchairs (codes K0848 – K0864). The change was effective January 1, 2016, however, Medicare was unable to implement changes to the claim processing systems until July 1, 2016. During that time frame, payments were based on adjusted fee schedule amounts. The underpayment recovery will apply to claims for accessories for dates of service 1/1/2016 – 6/30/2016.

DME suppliers rarely experience RAC underpayments, so this is a welcome change. Even better? This review was suggested by The van Halem Group’s own Wayne van Halem! “Many folks don’t know this, but the RACs are funded to find underpayments, in addition to overpayments,” expressed van Halem. “And in this environment, every little bit helps!”