HME industry group cites 15 audit problems, recommendations
WASHINGTON, July 16, 2012—Medicare’s audit system needs better oversight, clearer regulations, standard policies, transparency and accountability, according to a white paper produced by the VGM Group and several independent providers, with assistance from the law firm of Munsch Hardt Kopf & Harr, P.C.
Written at the request of the Senate Finance Committee—and prepared by Edward Vishnevetsky, Esq.—the 31-page whiteQ paper lists 15 problem areas and recommendations for the ZPIC (zoned program integrity contractor), RAC (recovery audit contractor), MAC (Medicare administrative contractor) and CERT (comprehensive error rate testing) audit system. Summaries and recommendations for each of the 15 problems cited are:
1. The initial determination process imposes unilateral deadlines against DMEPOS suppliers.
RECOMMENDATION: Require that ZPICs/MACs also be held to deadlines and require them to issue an initial determination within 30 days of receiving an ADR response. If the deadline is not met, require automatic claim approval.
2. Existing redetermination and reconsideration deadlines are often not followed by MACs/QICs.
RECOMMENDATION: Enforce regulatory deadlines for MACs/QICs. If a MAC/QIC does not respond in a timely manner to an appeal request, require that the claim be automatically approved.
3. DMEPOS suppliers are penalized for problems with medical documentation submitted by professionals over whom suppliers have no control.
RECOMMENDATION: Relieve DMEPOS suppliers of penalties related to documentation issues beyond their control. Use lesser sanctions and provide opportunities for DMEPOS suppliers to correct documentation problems.
4. The Competitive Bidding Program and ZPIC audit processes are misaligned and create unnecessary conflict.
RECOMMENDATION: Integrate competitive bidding and the audit processes.