Don't take this lying down and other words of wisdom


During the course of my work week, I often call up people I haven't talked to in awhile just to chat and see if there's anything going on that we ought to check in to. All kinds of press releases find there way into HME News' World Headquarters here in Yarmouth, Maine, but often the best news, information and advice comes from these cold calls. Cold calls are kind of like digging for gold. Anyone can find the nuggets laying on the surface, but only the folks willing to pick up a shovel and break a sweat are going to find the hidden treasure below.

This week during my calls I had a couple of interesting conversations with industry attorneys Neil Caesar and Asela Cuervo. I think most, if not all, providers can benefit from what Neil and Asela had to say, so here, in their own words, is what they said.

Neil Caesar on audits

"The various entities, the ZPIC and RAC contractors, even just the MACs on the regular audits, are taking their new empowerment and running with it to see what they  can get away with.

"I don't mean to imply that there is any kind of conscious venal motive. I don't know that we are going to find some memorandum out there, secretly, where they say, 'Don't worry about the rules, let's just see what we can get way with.'

"But I think their interpretation, for all the financial incentives, is to push hard on everything, be as aggressive as possible, until they are slapped down by an administrative law judge or CMS. I think that it is going to be a year and a half before there is enough push back that we'll see a lessening of that aggression."

Neil's Advice

"Make sure you are doing it as well as possible up front. There's more reason than ever before for investing in the front end and pre-submission audits and monitoring how you are doing things.

"Second. The instant you get any kind of request for documentation, do your own investigation and figure out truly what is going on .

"And third, fight unless you have have absolutely no argument to make. They  are counting on nine people being passive for every one who fights. More than perhaps regular audits, I think there is going to be some picking and choosing. People who make the most noise and give them the most grief are the people least likely to get hit repeatedly."

Asela Cuervo on surviving reimbursement cuts

"I tell my clients that home health agencies were creamed in BBA '97. And now they are making so much money that they are attracting attention again. Those who survived it and knew how to reposition themselves and restructure their businesses are doing great. It was a rough patch but they came out the other end and are doing great.

"The ones who adopted technology are doing very well, and that is what I tell my clients. If you can figure out how to make it through the next three, maybe five years, you can come out the other side. You are not going to be making as much per patient, but you certainly are going to be doing well because the demographics point in that direction.

"You don't have to give up Medicare, but you want to have other pieces to what you offer. There are opportunities and the creative suppliers will explore them."

Mike Moran


I disagree with Neil in that they are seeing how much their "new empowerment" can allow them to get away with. As I see it, Medicare reserves the right to review every claim we submit and, with 10 years in the compliance business, I'm used to getting overwhelming Additional Documentation Requests that most companies clearly could not respond to in the 30 day time period. Their is nothing new or rule breaking that the ZPICs are doing and as far as I'm concerned, its business as usual in the world of govt reimbursement.