Page 16 - HME Business, October 2019

“The requirement in the letter is scary, because you either audit every claim for the last six years that takes that code, or you take a statistically valid sample that you can justify as being accurate and audit that. When you do a self-audit on the last six years that you’ve filed for that one number, there could be thousands.”
— Kim Brummett, American Association for Homecare
CPAP, wound care, catheters and other repeat products are getting scrutinized because they are more susceptible to documentation errors and fraud. While you may not intentionally send unneeded supplies, mistakes can happen. And there’s no guarantee that one-time products won’t be audited in the future.
“It’s a risk for everybody. They are looking at things like orthotics, because of all the issues they have had with the braces. The six-year look- back applies to any avenue of DME that CMS wants to go down,” says Kim Brummett, Vice President of Regulatory Affairs for the American Association for Homecare. “I don’t think there
is any way to avoid it. Smart suppliers probably already have compliance teams.”
If you don’t have a compliance officer or team, it might be time to get one. “We all seem to be on the same page that we think this is going to be the norm every time the Office of the Inspector General (OIG) issues one of their reports,” says Wayne van Halem, president and founder of audit consulting firm The van Halem Group, a division of VGM Group. “That’s some- thing we have to keep track of now and monitor because [a six-year lookback] is such a huge undertaking.”
One thing that seems sure based on conversa- tions with DME MACs, Brummett adds, is that “It will never come out of a DME MAC unless they are instructed to by CMS.”
HOW WE GOT HERE
Baird explains what led to the CPAP reviews under way now. The OIG released a report in June 2018. That traces back to 2014-15 when the OIG reviewed 110 claims nationwide and found 24 of them compliant and 86 noncom- pliant. Though the total overpayment for the 110 claims was $13,414, OIG’s next step was to do an extrapolation that estimated how much it was costing across the Medicare system
-- $631,272,181.
“The OIG said, man, we’ve got a big problem
out here,” Baird says. Since the 86 noncompliant claims came from 82 DME suppliers, CMS told the DME MACs to have the suppliers do internal
investigations. The MACs sent letters ordering the investigations, including the six-year look- backs, to those suppliers.
THE LETTER ARRIVES. NOW WHAT?
Step 1: Read letter.
Step 2: Mutter something that probably isn’t
printable here.
Step 3: Call a lawyer. You don’t know for sure
what you will find, and having an attorney can protect your related conversations and reviews under attorney-client privilege.
“If DME companies hire Brown Fortunato, we hire van Halem Group,” Baird says. “If they discover not only bad claims but our client is doing awful, terrible things that could even be criminal, that is protected by attorney-client privilege.”
Most businesses are doing their best to comply, but sloppy or incomplete paperwork can trip them up. If you got a letter, you now have two choices: “Either look at every CPAP resupply claim for the last six years; or, hire a statistician to do a statistically valid sample of claims over the six-year period and extrapolate,” Baird says.
Rooting around through six years’ worth of claims may be a complicated process, but it’s nothing compared to creating a statistically valid sample. Most DME firms, especially small ones, just don’t have ready access to the expertise — unless you have an exceedingly low volume of claims for that code.
If you started by hiring an attorney, the attorney can hire the other help you need and the attorney-client privilege extends to the information those contractors generate during the review. As Baird explains, “The attorney can, in turn, hire an outside consultant to assist with the lookback. The attorney will pay the fees to the consultant (the supplier will reimburse the attorney for the fees), the consultant will report to the attorney, and the attorney will report
to the supplier. By following these steps, and assuming that no intervening action occurs that compromises the attorney-client privilege, then the work performed by the consultant will be protected by the attorney-client privilege.”
While CMS allows DMEs to use RATS-STATS
to perform their own sampling, Brummett says, “That’s a tool, but nobody knows how to use it. Suppliers aren’t statisticians. The requirement
in the letter is scary, because you either audit every claim for the last six years that takes that code, or you take a statistically valid sample that you can justify as being accurate and audit that. When you do a self-audit on the last six years that you’ve filed for that one number, there could be thousands.”
“It’s not something that a lot of people can
do internally,” van Halem says. “Where it gets challenging is that you have to run a statisti-
cally valid random sample. Most DME suppliers don’t have anyone with that expertise. We have a statistician who is able to design a sample that is statistically valid.”
Unfortunately, you can expect to spend $10,000 or more just for the audit, which van Halem estimates takes about 40 hours to review about 100 claims — plus the time it takes to pull your records, perform your internal review and go through the process.
“That’s just for the audit component, not pulling the claims or identifying the sample and doing all that. It’s a significant amount of time, particularly the review element,” van Halem says. “Overall, in general it would probably be close to or over 100 hours of time dedicated on it — that’s if everything goes smoothly. What we find is that once we get through the first part of the review there are a lot of documents missing that they have to go back and try to locate. There’s
a lot of back-and-forth and communication with attorneys.”
In most cases, it’s probably not wise to try to do the review yourself. Most of your existing service providers can’t be much help. Likely the best your software and billing services providers can do is help you identify the universe of poten- tial claims.
WEIGHING THE COSTS
The help you need to do your internal audit right the first time isn’t cheap, but the cost is likely to be far lower than making a mistake. In addition to the looming threat of FCA claims, the results of your internal audit may be the path to getting claims rehabilitated, which would reduce any amount you would have to pay back.
In some cases, for example if your review was triggered by just one or two faulty claims, you may be able to dodge the six-year lookback bullet by rehabilitating those claims.
“Some clients have not had to pay, because we were able to get the claim overturned in the appeal process,” Van Halem says. “Once the claim was overturned there was no overpayment. There was only one payment to begin with that
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