But for suppliers of durable medical equipment, Medicare’s recoupment audits can be a serious hardship. Many suppliers have assumed that if an item was prescribed, the referring physician’s notes detail the item’s medical necessity. But that’s not always the case, and if Medicare deems the documentation on file for any DME item to be insufficient, it’s not the patient who must pay for the item. Rather, the DME supplier must absorb the cost. In order for DME suppliers to stay afloat, cooperation between suppliers, referring physicians and primary care physicians is critical.
Before I came to Idaho Business Review, I worked a stint as a medical biller for a DME supplier. I’ve experienced firsthand the rending of hair and gnashing of teeth that accompany the gathering of documentation Medicare requires to prove items such as lower limb prostheses and diabetic footwear are medically necessary.
In fact, Medicare’s requirements for diabetic footwear are downright unbelievable. Medicare will not consider payment for diabetic footwear unless the patient meets several criteria. He must be diabetic, and have at least one of several specific foot conditions. Each of those conditions must be specifically and thoroughly documented in the patient’s chart notes, and those notes (along with a diabetic verification form indicating which conditions affect the patient) must be from the M.D. or D.O. who treats the patient’s diabetes.
If the patient’s primary care physician for his diabetes is a physician’s assistant or nurse practitioner, an M.D. or D.O. must fill out the diabetic verification form and sign off on the primary care physician’s notes. Every condition on the diabetic verification form must also be documented in the patient’s chart notes, even though the patient only needs to have one of the conditions to qualify for footwear.
On top of all that, the diabetic verification form is only valid for three months, and chart notes must document a face-to-face visit with the patient no more than six months prior to the day the medical supplier provides the shoes to the patient. This can be a serious problem when the patient’s podiatrist prescribes shoes. Podiatrists’ notes aren’t valid under Medicare’s requirements. So if a patient sees the doctor who treats his diabetes in January, and his podiatrist in May, that doesn’t leave much time for his DME supplier to provide shoes. Gathering the required documentation and ordering shoes can take several weeks, and if the supplier provides the shoes six months and a day after the patient last saw the doctor who treats his diabetes, Medicare will deny payment.
Medicare also requires detailed documentation about the patient’s ambulatory status for lower limb prosthetics. Medicare wants the patient’s doctor to provide a detailed account what the patient can do now – such as climb stairs, work in the garden, chase after young children or participate in athletic activities – and what the patient has the potential to do after physical therapy and prosthetic training.
A Catch-22 of the lower limb requirements is that physicians are not usually trained in prosthetic technologies. When a physician writes a prescription for a lower limb prosthesis, he assumes the prosthetist will provide the most suitable device. The prosthetist can detail all of the activities the patient engaged in prior to amputation and all the activities the patient hopes to engage in after prosthetic training, but Medicare relies on the physician’s record to determine eligibility, not the supplier’s.
If a patient wants to move forward with an item, but the supplier is unable to obtain the required documentation, there is a form that can help protect the supplier financially. DME suppliers can ask patients to sign an advance beneficiary notice of non-coverage, which tells the patient why Medicare is likely to deny the claim, but that document does not guarantee payment for an item will be the patient’s responsibility in the event Medicare denies coverage. If Medicare denies for a different reason than the one the supplier put on the ABN, the supplier still has to eat the cost of the item.
And while Idaho Medicaid may not yet be requesting the same documentation Medicare is requesting, Medicaid does generally follow Medicare guidelines when it comes to DME. I predict that in the near future, Medicaid will also be requesting this documentation, so suppliers need to prepare. A little preventive care in the form of gathering extra documentation now will prevent hemorrhaging when Medicaid starts looking for more ways to cut costs.
This leaves DME suppliers with two choices: Require documentation upfront, which can delay delivery of a device and mean a patient must visit the doctor again to establish sufficient documentation, or provide DME supplies as prescribed and hope the referring or primary care physician has the proper documentation on file (or that Medicare never audits the claim).
The latter choice simply is no longer viable. Medicare may recoup tens of thousands of dollars for a prosthesis if the documentation is not on file, and the time restraints on diabetic footwear paperwork are too strict for suppliers to chase the documentation after the fact.
While slogging through the paperwork requirements and the financial difficulties of recouping costs, suppliers and physicians must keep in mind that DME is meant to improve patients’ quality of life. When physicians and suppliers work together, patients are able to maximize their insurance benefits to get the best possible equipment in a timely manner. When that cooperation fails, patients experience delays or unexpected costs, and suppliers can take a serious financial hit.
Both suppliers and physicians must work toward a common goal. Not only do suppliers need to maintain relationships with their referral sources to educate physicians about what Medicare requires, but physicians also need to be thorough and detailed in their chart notes. If a DME supplier is able to get detailed, valid documentation quickly, patients don’t have to wait as long for medically necessary equipment.
Ideally, as more practices adopt electronic medical records and use databases such as the Idaho Health Data Exchange, the process can be further streamlined. Suppliers need direct access to a patient’s medical record to see if the necessary documentation exists before the patient comes in to be evaluated, saving everyone time, paper and frustration.
But until then, doctors and medical suppliers must join forces to ensure optimum care for their patients. Both sides must recognize the requirements are a headache for everyone. But by working together, no one has to tear their hair out, and suppliers can rest easy knowing they’ll get paid.
Cady McGovern is Focus editor at Idaho Business Review.