What's good for the goose is good for the gander

Friday, January 25, 2013

I read the article titled “New OIG report: Is it good or bad?” (January 2013). While I would agree that current CMS policy is too ambiguous to allow for consistent determination of claim reimbursement, I do not agree that CMS’s proposal of requiring providers to pay for appeals is appropriate unless the following is allowed: If CMS requires providers to pay a fee to appeal a denied or recouped claim, we can accept that only if, when the provider wins the appeal at any level, the fee is not only refunded back to the provider, but also the provider receives interest on the payment that was due in the same way providers have to pay interest on overpayments.

The issue here is that, at least in the majority of my appeal cases, it is the contractor who misinterprets the guidelines and therefore incorrectly denies payment. A few recent brief examples are the reviewer who denied a claim because he stated he could not read a physician signature, even though the name was typed under each signature, and the signature and name were consistent on all documents. Another is a denial because the contractor stated he did not receive our additional documentation that was requested even though we sent it UPS and had tracking to prove it was received within the required time frame. Another was the reviewer who did not understand that the completion of the face-to-face date is the date the physician signs, in this case, the therapist order. Therefore, the reviewer denied the claim stating the written order was not in compliance with the required time frames. In each case we were required to appeal to the next level and not given the opportunity to address the issue at the level it had stalled at due to incompetence on the part of the contractor.

These examples happen in all areas of contractor review, not just in my business of complex rehab. Charging providers for the incompetence of the hired contractors, while not forcing the contractors to have accountability, is just plain ludicrous. Providers are contractors for CMS. Auditors are contractors for CMS. We should be held to the same standards of accountability for the services we are contracted to provide CMS.

—TJ McEnany, Florida manager, United Seating and Mobility, formerly Wheelchairs Plus