July 22, 2015

Do Auditors Make Up their Own Rules?

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Last week RACmonitor published my article on the transmittal published by the Centers for Medicare and Medicaid Services (CMS) that clarified the documentation requirements for home care services.

A series of Open Door Forums created a great deal of confusion by providing contradictory information, and this change to the Medicare Program Integrity Manual has clarified CMS’ original intention to ease the burden on physicians and increase access to home care services by beneficiaries, by allowing the home health agency (HHA) to do the lion’s share of the documentation required to certify home care services.

In response to the article, I received a note from the director of a well-established (20-plus years in business), well-respected (patient satisfaction scores exceeding the national average in every category) HHA who was excited about this transmittal but also frustrated with her past experiences with audits of her agency’s compliance with the regulations by the Supplemental Medical Review Contractor (SMRC).

Rules of Engagement

In 2013, CMS contracted StrategicHealthSolutions, LLC, to provide audits of Part A, Part B, and durable medical equipment (DME) billing as directed by CMS. According to the CMS statement, “The SMRC will evaluate medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing practices.”

CMS asked the SMRC to review HHA claims with Project Y1P18/Y2P18 and they audited 52,223 claims with dates of service between July 1, 2011, and April 30, 2013 (denying an unbelievable 49 percent.) These claims were reviewed for qualifications for home care services and compliance with the face-to-face requirement in effect at that time.

The Signature Issue

This HHA had five claims audited and two of the five were denied because “the physician did not put their credentials on the signature line of the face-to-face form.” This denial is wrong on many fronts. First, the instructions from CMS to auditors in the Program Integrity

Manual state that “in situations where the guidelines indicate, ‘Contact billing provider and ask a non-standardized follow-up question,’ the SMRC will contact the person or organization that billed the claim to request an attestation statement or signature log within 20 calendar days.” Yet this director, who was managing all audits herself, was never contacted by the SMRC.

Second, there is no regulatory requirement for credentials to appear with the signature. The Medicare Program Integrity Manual “encourages” including the credentials on a signature log, but it is not required. A publication from CGS on home health and hospice documentation states “the signature must include the credentials of the individual and be dated,” yet a thorough search of all references provided in that article finds nothing to support that contention and CGS, a Medicare Administrative Contractor (MAC), and all other contractors, including the SMRC, are not permitted to make up their own requirements.

To add insult to injury, when the director received these two denials, she reviewed the three claims that were approved and found that two of those included signatures with no credentials! This is a recurring theme with audits: The audit success or failure often depends more on the person performing the audit than compliance with the rules themselves.

The director’s frustration is palpable as she relates that “patient care has been pushed to the sidelines entirely by an ever-growing CMS mega-rule that forces manpower in agencies to be focused on paperwork, regulations, chasing doctors down to add two letters to a signature line or beef up sketchy documentation about things they do not care about such as documenting homebound status, and pleasing some auditor somewhere as opposed to quality patient care and optimal outcomes.”

Good Faith Issue

The new transmittal from CMS makes it clear that the HHA can document and the physician review and sign, but this director said that she “cannot in good faith rely on any CMS representative or third-party contractor to correctly interpret the new transmittal guidance when no one has gotten it right consistently for the past four and a half years… we cannot risk significant losses by doing something that was explicitly prohibited in 2011. For any agency to simply send its own documentation to a doctor to sign, keep a copy, return a copy, and consider the requirement met, is simply not smart given CMS’ wishy-washy guidance.”

I am sure her sentiment is felt by many, if not all, HHA staff around the country.

Providers want to follow the regulations and want to provide quality care to patients, but when the auditors make up their own rules (requiring credentials) and do not follow clear CMS guidance (not requesting a signature log), it makes that goal difficult to attain.

These auditors are also harming the reputation of CMS because CMS’ goal of easing physician burden and increasing access to home care services cannot be met when providers cannot trust auditors to follow CMS instructions. It is also difficult for providers to accept that they follow the rules and, when denied, have to wait years for their day in court, yet the auditors are able to seemingly do whatever they want without any consequences. Although her agency is in a rural area, this director knows she is not alone feeling these frustrations and hopes sharing will eventually lead to change.

Addendum:

As I was preparing this article, the HHA director contacted me and informed me she received a redetermination decision letter from the MAC for one of these claims. The decision was unfavorable and stated, “Upon review of the submitted documentation it has been determined a comprehensive assessment and visit notes for the billed services were not submitted for review. Therefore, all services will remain denied as insufficient documentation was submitted to support services were reasonable and necessary and rendered as billed.”

The director looked at the original denial letter and it requested that she submit an appeal with additional information pertinent to the denial reason. She therefore submitted a signed attestation letter and a signature log for the physician in question. She was not asked to submit all the records again and therefore did not, yet her appeal of the denial for lack of credentials was denied due to a lack of documents that were not even requested.

Will her frustrations ever end?

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians. 

Contact the Author

RHirsch@accretivehealth.com

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