Page 18 - HME Business, October 2019

caused it.”
There are three possible steps in the process:
Redetermination, Reconsideration and admin- istrative law. With redetermination, the supplier submits paperwork correcting the problem and submits it to the DME MAC.
For example. blanket orders are out if they
fail to include the exact quantity the patient needs. To fix the problem, “the supplier goes back to the doctor, says ‘please issue me a new order, dated today (because we don’t want to be dishonest), that says this new order is correcting or rehabilitating the prior order you’ve filled until now, today.’ The doctor is stating the quantity ordered for the patient two years ago until today. The old order will have a new order, which is effective two years ago. That is a way to reha- bilitate the order.”
If the DME MAC declines the redetermination, the DME can seek reconsideration. At this stage the supplier can no longer add new material to the case. If that review fails, the DME may appeal to an administrative law judge for a hearing but, Baird warns, “Between the reconsideration and the ALJ, the DME MAC can and will offset” the disputed amount against the supplier’s account.
“Most people lose at redetermination or
reconsideration,” Baird says. “Out of 30 claims at issue, you might win three at redetermination. At reconsideration you might win on three claims. But you still lost on 24 claims.”
But for one or two faulty claims it’s prob-
ably worth a try, because as Brummett notes,
if the appeal on the triggering claim succeeds, “The MACs have told us they are not going to respond. They’re putting it in the file and closing it.” van Halem adds, “We’ve had clients with claims that were actually denied that we got overturned in the appeal process. The good thing is, CMS did indicate that if that was the case, they don’t think it was necessary to do a six-year lookback.”
PROACTIVE IS THE WATCHWORD
In most of the cases under review, “DMEs would put out the product and not have the documen- tation in the patient file that was sufficient to withstand an audit,” Baird says. The lookback rule is “motivating the DME not to put out the product until their documentation is complete... If you are running a tight ship, even though you will have to respond, you’ll be just fine.”
It may be small consolation, but Brummett says at least six-year lookbacks don’t require any
new day-to-day processes. “If you are following the rules you should not have to change any processes,” she says. “They are not looking to change anything, just make sure you are doing what you should have been anyway.”
Going a step further, van Halem advises that DMEs police themselves carefully and early to avoid problems. “We shouldn’t sit back and wait for this to happen again. We should be, on a quarterly basis, auditing our claims proactively to identify any issues. If you catch it within a quarter you can minimize the impact of it and get it taken care of, so that moving forward we don’t have this issue ongoing.”
He also advises DMEs not to get complacent once they pass a six-year lookback: “There is this six-year lookback. That means they are probably going to come back and do a review in another couple of years to make sure this issue is no longer an issue. I would just go back to being proactive and trying to put the effort in up front to identify issues before the government does that.” n
Holly Wagner is a freelance writer covering a variety of industries, including healthcare. She can be reached at documentarydvdiva@yahoo.com.
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