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New administrative burdens possible for many durable medical equipment orders
Court decision is raising the bar; approvals likely to take more than a certificate of medical necessity.
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In light of a recent appeals court decision, medical suppliers are likely to increase their scrutiny of medical necessity documentation.
As a result, physicians who order durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) should revisit their documentation standards and coordinate with their medical suppliers to ensure that their processes are compliant.
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Many orthopedic practices have already seen — or soon will see — their suppliers taking steps to limit the risk that Medicare will recoup payments because of insufficient documentation of medical necessity. That is because suppliers know their ability to receive — and keep — Medicare reimbursement depends on the ordering physician’s ability to document medical necessity, and now those rules are changing.
In November, the 11th Circuit Court of Appeals reasoned that a certificate of medical necessity (CMN) — “an optional prepayment tool designed primarily to reduce paperwork” — could not be the “exclusive means for proving medical necessity.” The court found that the Secretary of Health and Human Services could demand that suppliers furnish documentation beyond a CMN to meet the requirement that Medicare-reimbursed DMEPOS be medically necessary.
Generally, durable medical equipment regional carriers (DMERCs) reimburse DMEPOS suppliers for covered items deemed medically necessary by obtaining CMNs from physicians and submitting them to the DMERCs. As physicians who order DMEPOS know, the CMN is a document in which they attest to the following language:
“I certify that I am the treating physician identified in … this form .… Any statement on my letterhead attached hereto has been reviewed and signed by me. I certify that the medical necessity information … is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability.”
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Now, orthopedic practices face a new bottom line: They must ensure that their ability to document medical necessity properly improves on the grim Medicare audit statistics that have emerged during some recent court cases. For example, in Gulfcoast Medical Supply Inc., the DMERCs determined that 29 of 30 sampled claims were deficient and calculated a $508,747 overpayment. The CMN alone did not justify the charge.
There is an adage among auditors: “If it’s not written down, it didn’t happen.” Based on the Gulfcoast Medical Supply decision, the DMERC corollary would be, “If the ordering physician does not document the medical necessity and reasonableness of a DMEPOS item someplace other than the CMN, the item is neither medically necessary nor reasonable.”
Last year, the Centers for Medicare & Medicaid Services (CMS) published medical necessity documentation requirements that may be a preview of things to come for physicians who order DMEPOS.
In April 2006, a rule eliminated the CMN requirement for powered wheelchairs. In doing so, CMS expected “physicians and treating practitioners will now prepare written prescriptions … and submit copies of relevant existing documentation from the beneficiary’s medical record, rather than having to transcribe medical record information onto a separate form such as a CMN.”
Because DMEPOS suppliers may implement similar procedures to verify the existence of medical necessity documentation, orthopedic practices should expect new administrative burdens on the horizon.
For more information:
- Anthony H. Choe, associate, Arent Fox LLP, 1050 Connecticut Ave. NW, Washington, DC 20036; 202-775-5751; choe.anthony@arentfox.com.