Heritage Medical Equipment, LLC

Medicare CERT Task Force - O&P Community Response

Several members from the O&P community urged me to write a series of blog posts about CERT Audits.  The consensus among the practitioners was that the subject of CERT Audits needs more attention, and that the requirements are unfair and unrealistic.

It looks to me like the O&P community is going to get crushed with these audits.  

If you are unfamiliar with blogging, scroll down until the January 30th post (you will have to click on the "next" tab at the bottom of the page).  Read that, and work your way up.  There was one post per day from January 30th until now, with questions and answers from the CERT Task Force regarding the audit requirements.

We hope you take the time to read and comment on any or all of the posts.  What do you think about CERT Audits?  The CERT requirements?  Is there anything the O&P community should do?

We look forward to reading about what you think. 

Heritage Medical Equipment

 

Medicare CERT Documentation Affects O&P

Question:  Are there any CERT documentation requirements specifically affecting orthotics and prosthetics?

Medicare CERT Task Force Answer:  Documentation requirements are the same regardless of what type of equipment is dispensed.

Suppliers Are Expected To Educate Physicians

Question:  What is Medicare's role in educating physicians about the detail of documentation Medicare expects to find in the patient's medical record to justify equipment or on-going use of supplies?

CERT Tak Force Answer:  The DME MACs are required to and funded to educate the supplier community.  Therefore we only provide limited education to the physician community.  However, the DME MACs are working with Part A and Part B Medicare contractors regarding physician education pertaining to documentation requirements affecting the supplier community.  The O&P Suppliers are expected to help educate the physician community on the documentation requirements.

Doctors Don't Have to be Concerned About DME Statutes

Question:  When a doctor writes a prescription knowing that a patient does not qualify for the item prescribed, wouldn't that be fraud?

CERT Task Force Answer:  This would not be considered fraudulent,  Physicians may prescribe an item they believe is necessary for the patient without regard to DME statutes.

Medicare CERT Denials and the CERT Selection Process

Doublespeak:  The art of persuasively articulating nothing.

 

Question:  Why do claims still deny for medical necessity even though the CERT audits are answered?  Why do the same patients get picked for CERT audits over and over?

Medicare CERT Task Force Answer:  Submitting medical records to CERT does not guarantee that they support the medical necessity for coverage criteria of the items billed.  For example, a progress note sent may not contain the information necessary to meet an item's coverage criteria needed for the item.  CERT selects claims randomly.  The more claims an O&P supplier submits, the higher the probability that a supplier's claim may get chosen.

 

Little Can Be Done To Get Doctors to Cooperate

Question:  What can be done to get more cooperation from doctors in providing DME companies with sufficient medical documentation so that we may better comply and feel confident that we have obtained enough in case of an audit?

CERT Task Force Answer:  A vigorous intake process is recommended.  Asking the appropriate questions once an order is received based on coverage criteria requirements, begins the documentation process.  Partnering with the physician on behalf of the beneficiary is a must.  If you are finding that difficult, please refer and utilize one of the many physician letters developed by the DME MAC Medical Directors which discusses the ordering physician's roles, and responsibilities required by Medicare Law.

 

The Doctors are Untouchable

Question:  What avenues of recourse are there when the physician or physician offices do not respond to the audit documents requests and in fact refuse to collaborate with suppliers?

CERT Task Force Answers:  Currently there is no recourse on the physicians if they do not respond to the request from CERT regarding a DME supply.  O&P suppliers should refer to the PIM citation Manual 100-8 Chapter 5 section 5.8 which states the following, "the supplier should also obtain as much documentation from the patient's medical record as they determine they need to assure themselves that coverage criteria for an item have been met.  If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed ABN of possible denial has been obtained."  

The Signature Must Be Legible

Question:  Are you going to start to adhere to legible doctor signatures when deciding to accept / not accept medical documentation?

CERT Task Force Answer:  Yes.

 

Question:  How can we get doctors to sign their names legibly?

CERT Task Force Answer:  We are encouraging suppliers to start sending in signature keys.  Some suggestions are having a log with the physicians name printed clearly and then their signature next to it.  Also, we have heard some suggestions about on the orders having the physician's name printed clearly underneath his signature.

 

Question:  What exactly does the orthotic and prosthetic supplier need to do to verify the signature of the treating physician in the case of a CERT audit.

CERT Task Force Answer:  CERT will accept an attestation letter or signature verification.  CERT will also use other records submitted to attempt to match the illegible signature.

 

Medicare CERT Documentation Is More Stringent

Question:  Why are CERT documentation requests seemingly more stringent than the corresponding Local Coverage Determination (LCD)?

CERT Task Force Answer:  CERT documentation requests may seem to be more stringent due to the fact that not only are the LCD's being taken into consideration but also ALL applicable CMS manuals and regulations are being considered.

 

Question:  How should we handle requests for documents that are not a requirement of the LCD?

Medicare CERT Task Force Answer:  CERT asks for documentation beyond what is listed in the LCD.  They also ask for information from CMS Manuals and regulations.

Medicare CERT Program - Dear Doctor....

 

Question:  We have a terrible time getting physicians to respond to our requests for documentation.  When they do respond, it is never with the documentation we have specifically asked for.

CERT Task Force Answer:  Since the provider receives payment for the item dispensed, it is up to the provider to be sure they have or have access to the required documentation.  There are "Dear Physician" letters available on each DME MAC website to help obtaining the required documentation.

 DME MAC CERT Dear Physician Letter

Or:  National Durable Medical Equipment Medicare Administrative Contractor Comprehensive Error Rate Testing Task Force "Dear Physician" Letter.