Audit Headaches? Then Get Documentation Up Front

For 10 years, I worked in various roles at various Medicare contractors, but I spent much of that time in the area of program integrity working as a fraud analyst, Medicare fraud information specialist and fraud investigator. In my many years in that role, it was ingrained in me that durable medical equipment suppliers were inherently bad. It was my job, as an investigator, to protect the Medicare Trust Fund.

I remember the moment that things started to change for me. I had conducted an audit on a small family-owned HME in the Midwest, a company that had been in business for a very long time. The audit resulted in a significant overpayment that would have a devastating impact on the company's ability to remain in business. The overpayment was identified because, perhaps, the company had become lax over the years in keeping up with Medicare policies and guidelines and was not getting supporting documentation up front.

I remember the owner of the business, who had inherited it from her father, called me up and cried over the phone, begging me for a different outcome. My hands were tied, and all I could offer her were her appeal rights.

I mention this because with the proliferation of audits, the issue that has, by far, caused the biggest problem for providers is insufficient physician documentation. The burden of being placed on prepayment review or appealing large overpayments is costly and overwhelming for most HME businesses.

After I hung up the phone with the supplier I audited, I realized that I was quite possibly taking away this woman's livelihood because of careless mistakes in not following convoluted policies. The policies did not require that HME companies get documentation up front, and most companies didn't.

Years later, the industry still isn't getting documentation up front in most cases. The big difference, though, is the government's huge increase in funding for audits and increased oversight that requires suppliers to provide sufficient physician documentation to support their claims. In this specific case, as with countless others, the overwhelming majority of claims denied because the physician documentation was deemed to be insufficient.

Don't Take the Gamble

I assumed at the time that getting physicians to document things accordingly was easy. I realize now how very wrong I was. Unfortunately, most auditors that work for the government or its contractors haven't yet come to this same realization. I've tried relentlessly to portray the difficulty in this task, but I'm not certain the message gets through.