BALTIMORE — HME providers often express frustration with physicians in the ongoing battle to obtain proper documentation for Medicare claims. Cajoling, begging and even educating doctors has its limitations, callers complained during a Jan. 13 CERT teleconference hosted by the four DME MACS.
But representatives of the CERT (Comprehensive Error Rate Testing) Education Task Force formed by the MACs confirmed on the call that responsibility ultimately rests with providers.
As part of CMS' efforts to reduce Medicare fraud, providers have seen increased claims reviews and requests for additional documentation to support payments. The call covered topics including medical records requests, responding to those requests and CERT appeals. According to officials on the call, the top six claims garnering the most frequent errors are for oxygen, diabetic supplies, power mobility devices/wheelchairs, nebulizers and drugs, enteral nutrition and PAP devices.
In prepared comments designed to address these documentation concerns, one CERT official said:
It is the supplier's responsibility to obtain the documentation needed to support the medical necessity of the equipment being supplied. If the physician does not supply you with the documentation that you request, you can explain to them that it is stated in the Program Integrity Manual that for any DMEPOS item to be covered by Medicare the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement if applicable. The information should include the patient's diagnosis and other pertinent information, including but not limited to duration of the patient's condition, clinical course as to whether it is improving or worsening, the prognosis, nature and extent of functional limitation, other therapeutic interventions, past experience with related items.
It also states that there must be information in the patient's medical record that supports the medical necessity and substantiates the answers on the CMN if applicable, or information on a supplier prepared statement or physician form if applicable. If the physician continues to refuse to cooperate with your request for documentation, you can always inform them that your company will not be able to supply the equipment as ordered until the information has been provided.
In a question-and-answer session during the call, one provider lamented, "We do not have control over what physicians document or do not document in their medical records. CERT is holding us accountable for the lack of physician documentation ... If the CERT is asking for medical record documentation that would go back longer than seven years, how can we as a supplier control the fact that a physician no longer has that documentation?"
Amy Capece, outreach/education manager for the Jurisdiction A DME MAC (NHIC), responded, "This is probably not what you are going to want to hear, and you are not going to like what I am going to say, but it truly is the responsibility of the supplier to have the information in your file and readily accessible and available to support the medical need and the criteria for the equipment you are providing …We highly recommend that when you take on a patient, you make sure that you have the documentation and the information for the medical support of the equipment you are providing to that beneficiary."
Noting that physicians are receiving audits as well, added Capece's counterpart James Herren from Jurisdiction C (Cigna), "Doctors do need to document, document, document."
Yet another questioner took up the issue, saying, "The CERT program is placing all the responsibility on the provider to talk with physicians and to train physicians, but who are we to question what the physician is putting in the chart?"
The lengthy response boiled down to the importance of a proper intake, and continuing to educate physicians. "Have a conversation with your physicians," said one official, "and act like a partner with that physician."
Providers can contact the CERT customer service line at 888/779-7477 and via the Internet at www.certprovider.org.
For the PowerPoint presentation from the teleconference, which includes recommendations for reducing claims errors, see the NHIC Web site under "What's New."
