First you get a request for documentation on one or two patients. No big deal. Then another request is received for 15 or 20 patients. This is starting to look like a targeted audit. Now a request for 50 patient records and you are in a full audit and in a position of justifying the services you have provided. Avoiding being in this position is the goal of every home care supplier.

The majority of providers do a fine job providing patients with a qualified service and are fully compliant with Medicare documentation requirements. The problem is more likely to occur when incomplete documentation is provided or by not providing any response at all. Know what is coming when Medicare makes its audit requests. If handled properly, it is not a problem.

First, it is helpful to know the different kinds of audits going on and why they occur.

•Comprehensive Error Rate Testing Program or CERT. AdvanceMed is a third-party independent auditing firm hired by CMS. It is the CMS method to monitor the performance of the carriers. AdvanceMed randomly selects claims as part of this effort to provide CMS and the carriers with a “report card.” They are looking to be sure a claim was paid properly, that it qualified, and that the supplier has the appropriate documentation. AdvanceMed will send a request on a patient up to four times, every 30 days prior to finally requesting a refund if there is no response. The most common CERT errors are related to incomplete documentation or failure to provide documentation.

• Benefit Integrity Requests for documentation on a postpay basis. When the requests are for a single patient, they are generally coming as a result of a complaint the carrier received from the beneficiary stating that services were not provided as billed. Continually receiving these can point Medicare to a targeted review at a later time.

• Records requests for multiple Medicare beneficiaries. Sometimes this may contain a list with as few as five patients on it, but beware when you get a request for 50 patients. Something you have billed or previously provided in an audit may have triggered a larger audit.

• Random review for a specific piece of equipment. From time to time, Medicare will look at reviewing a specific HCPCS that they believe could have been over-used or underdocumented. If you receive a letter stating they are doing a random review, they will generally request documentation on random patients that received this equipment. The letter normally states how many dollars they have paid out during a specific period for the piece of equipment and what percent of the claims they are auditing. The information obtained during these types of reviews is usually published in a general format to all suppliers.

Any of these audits must be responded to in a timely manner. Medicare will always tell you the deadline in the letter. Waiting until the final hour to respond could find you scrambling to produce the documentation you know you had on file.

Steps to Avoid Additional Audits
1) Make sure your staff knows how DMERC requests are to be handled. Have them forwarded to one person in your organization who is your compliance expert. This person should understand and recognize the importance of the response and what should be included in the response.

2) Be sure to review the documentation completely and thoroughly prior to submitting to Medicare. Review the paperwork as if you were doing an internal compliance audit. If additional documentation is required to support the medical necessity, obtain it prior to responding whenever possible.

There is detailed information in your supplier manual to further support each section. Medicare will be reviewing a few key elements such as:

• Dispensing Order: The order must have documentation of when the service request was received, who requested it, and what was requested.

• Written Order: Must review for completeness with patient name, address, health insurance claim number (HICN), date of order, quantity and frequency of item, length of need if rental item, diagnosis, type of equipment, physician signature, and date.

• Beneficiary Authorization: Authorization must be signed either by the beneficiary or financially responsible party. If signed by other than beneficiary, authorization must state why the beneficiary could not sign, and the relationship to beneficiary.

• Proof of Delivery: Is there signed proof an item was delivered? Can you see what type of item was delivered with serial numbers and date on the ticket? If a delivery service was used, is there a tracking number on your delivery document? I suggest you attach the proof of the delivery via the tracking number provided by your delivery service—to remove any doubt it was delivered.

• Purchase Option Letter: copies of the letters being sent out to beneficiaries should be kept in the chart with the dates they were sent. One provider I worked with put a postmark on his letters when sending as proof they went out. Most often, the beneficiary never returns the letter and that is all you have for proof it was sent.

• Certificate of Medical Necessity (CMN): Provide a copy of the front and back of the qualified CMN. If you find there was an error that was never corrected, get the documentation corrected per the guidelines. Be sure to provide the qualified documentation with your audit response. And don’t forget to stop your billing if it is an active patient until the qualified documentation has been obtained.

• Progress notes: These are helpful if you have a diagnosis that does not fully support the medical necessity in your paperwork. Obtain more information to support why the patient needed the service, such as a letter from the physician, progress notes, etc. Medicare may request documentation from the physician office during audit also.

• Advanced Beneficiary Notice (ABN): Be sure that if you billed with a GA modifier, you have a signed ABN prior to the delivery date of the equipment.

3) Provide the documentation specific to the piece of equipment being audited. There is no benefit to providing information on equipment they are not auditing. However, there are times that you will not know which piece of equipment is being audited and will have to look at what was billed by a date of service to find out.

4) If you are receiving a request for documentation on a large number of patients, consult with an expert prior to submitting. I am not just telling you this to promote the hiring of consultants, but you gain the experience of someone who has seen how other audits have been handled. You can avoid unnecessary problems and unnecessary refunds.

5) If it is a Benefit Integrity request on a single patient, contact the beneficiary and work with them to be sure that any service issues are resolved. Many times there is a complaint as a result of miscommunication. Also, you can respond better to Medicare by finding out exactly what the issue is. By working with the beneficiary, you can avoid further issues and show them that you are interested in providing a quality service. Don’t forget also that your patients are your best advertising and you certainly do not want them left with a bad impression of your company.

6) Keep a log of the requests you are receiving. Indicate on your log what type of request you have received (CERT or Benefit Integrity), what HCPCS they are auditing if known, date of request, and date of response. The purpose is to be able to identify any trends of concern.

7) Organize the information and be sure it is logically presented. Make it easy for the reviewer to see the progression of information by date and why the patient qualified for the service provided. Make sure copies are readable. You do not want anyone to guess as to what your documentation says.

8) Be sure to prepare a cover letter stating what specific pieces of documentation you are providing. If there is a need to explain what services were provided with dates, do it in the cover letter.

9) If you identify a patient that you should not have been paid on, immediately do a voluntary refund—even prior to submitting the audit response. With the response, provide a cover letter stating that you identified a refund due and have previously refunded that amount.

10) If you identify an area of compliance that is lacking in your organization, immediately rectify that situation for all new orders. You also may need to go back on existing rental patients and correct the situation, depending on how large an issue it is.

Concerns and Consequences
Know that if you provide equipment for highly reviewed items, it is likely you will be audited. A few of the items today that are frequently audited are power wheelchairs (of course), ventilators, nebulizer medications, or any item that requires a written order prior to delivery. This is not a secret, and the DMERCs publish information on what they are seeing as a result of targeted reviews and CERT responses. Check out the Medical Review section of your appropriate DMERC. Most of them call it “documentation reminders.” This information is also published in the “What’s New” or “DMERC Dialogues.”

What happens if the Medicare reviewer finds you did not have the appropriate documentation to bill the service provided? You will have to repay the money paid by Medicare to you for the patients who had incomplete documentation. You will then have the opportunity to go to appeals with additional documentation. And hopefully you never have to deal with extrapolation, where Medicare takes the percent of the claims that were shown during this audit to have noncompliant documentation and applies it to all claims paid for a specific period of time. Regardless of whether that happens or not, it is likely you will have a much higher expense involved and will need to obtain expert legal assistance as well as consulting experience to assist you in being successful through the appeal process.

Save yourself some money and time. If you are not confident with the audit response you have prepared, or are not sure even how to prepare it, it is wise to have an outside review and experienced assistance prior to responding and avoid unnecessary repayments and future audits.

Gemma Perry English is president and owner of HealthCare Solutions Plus (www.hcsplus. net), a Phoenix-based consulting company focused on reimbursement. She can be reached via phone: (480) 704-5502; or email: info@hcsplus.net.