Getting Paid: Building Your Case and Defending Your Claims

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By Judith Philipps Otto

"We're caught in a trap; I can't walk out...." —Elvis Presley, "Suspicious Minds"

Today's reimbursement problems sound a lot like this Elvis Presley song. Over the last two years, the Centers for Medicare & Medicaid Services (CMS) has developed an increasing number of more stringent processes, procedures, and requirements to address and prevent fraud and abuse of its reimbursement system, and as a result, life has gotten harder, more confusing, and more expensive for O&P providers.

When The O&P EDGE asked O&P industry leaders for their perspectives, we found that the primary problems include issues with Medicare and private insurance claims reimbursement, getting paid for high-tech and expensive devices, and dealing with the delay and avoidance strategies that some payers employ. Fortunately, our experts also had some solutions to share.


The Only Constant Is Change

A variety of auditing bodies originally created to monitor irregularities and recoup CMS overpayments and incorrect payments are now creating more problems than they are solving, according to Aaron Sorensen, CPO, O&P Billing Solutions, Murfreesboro, Tennessee.

Within a recent eight-month period, Sorensen attended three Medicare-sponsored seminars specifically geared toward O&P compliance and heard a different interpretation of newly changed policies at each one.

"Although policies themselves haven't changed much within the last three to five years, Medicare's interpretation seems to be changing from month to month, making it extremely difficult to keep up with what Medicare is expecting for compliance," he notes.

"Complicating matters further, CERT [Comprehensive Error Rate Testing] contractors are interpreting policy differently than the medical directors within the region. So even if you follow current policy, the CERT auditor is likely to find you noncompliant and require that you refund [what it has found to be an] overpayment," Sorensen says. "Then you must appeal the CERT ruling, and many times...Medicare redetermination overrules the CERT audit and finds that the provider was in the right."

The result, Sorensen explains, is unnecessary delay and huge costs in terms of the man-hours invested to protect or recover the same reimbursement dollars initially paid to the provider.

CERT contractors and Recovery Audit Contractors (RACs) can research CMS claims as much as two years old, Sorensen says. "And because their commission is based on a percentage of whatever they recover for CMS, they have an incentive to dig deep on as many providers as they can [and] find as many mistakes as they can. As a result, you can probably count on one hand the number of O&P providers in the country that have not gotten a CERT letter—and sometimes multiple letters—over the last couple of years."

Sorensen says this situation is the driving force behind an increase in phone calls and e-mail messages that his billing company is receiving. "The O&P field is a generational industry where many businesses have been family-owned for three or four generations. They understand how to run a business and they understand patient care, but they can't keep up with the rapidly changing and evolving reimbursement game."


Elizabeth Carlstrom, O&P Business Solutions, Austin, Texas, agrees that it's virtually impossible to avoid an audit from the alphabet-soup collection of auditing bodies, but she also notes that keeping your reimbursement can be an even bigger challenge than getting paid. Because of this, she says, scrupulously reviewing and providing all relevant documentation associated with claims has never been more important.

"Medicare has had these policies for as long as I can remember, but they haven't enforced them. Now you've got people from CERT, RACs, ZPICs [Zone Program Integrity Contractors], and then the DME MACs [Durable Medical Equipment Medicare Administrative Contractors] themselves, all looking at claims. Realistically, each of them can look at a percentage of claims, and a provider could conceivably hear from any or all four of them."

And with so many interested auditors out there, the individual provider's risk of having his or her claims scrutinized naturally increases dramatically.

There appears to be a promising ray of hope, however—the result of CMS getting tangled in its own web and becoming mired along with O&P providers in the quicksand of a relentless audits and appeals process. Every one of those appeals must be re-evaluated by CMS—adding significant personnel costs to their bottom line as well, Sorensen says.

"CMS is now overworking the staff members that they have in the redetermination departments of their different regions because of the number of CERT audits that are coming through. And they're finding that a lot of those appealed audits were paid correctly," he says.

Consequently, a CMS source recently shared the rumor that many medical directors are rewriting their Local Coverage Determination (LCD) policies to be more stringent, Sorensen says, "leaving less room for interpretation on the part of the CERT." At the time this article was being written, these revised LCD policies were rumored to debut in August. (Author's note: Check the LCD section of the CMS website to find the LCD policies for your region.)

If the only constant regarding CMS policy is change, how important is it to understand those policies—revised or otherwise?

Sorensen asserts that not clearly understanding policy is the most common reason for rejected claims. "Many of my billing clients just don't understand policy. And if Medicare accidentally pays you for an improper claim, I assure you the CERT or the RAC is going to find it and you're going to wind up paying it back anyway, so you have to understand policy. Unfortunately, when billing clients hire us to fight these audits for them, there's a limit to what we can do. If the client hasn't followed policy regarding what you can and can't bill...we can't win an appeal for them.... It's right there in black and white."

Carlstrom also stresses the importance of policy awareness. "I encourage everyone to sign up [to receive] their local DME MAC jurisdiction news. They should join the listserv for their jurisdiction, then check those e-mails every day and alert all their employees. They also need to read future LCDs so they can anticipate medical-policy changes and be prepared for them."

It's possible, she points out, to start a custom orthosis or prosthesis one month and find that a policy change has gone into effect prior to your delivery date, so it's smart to keep abreast of such changes prior to filing your claim.

"LCD changes can be very tricky," Carlstrom cautions. "They're hard to read and they can be misinterpreted, so be sure to access the medical-policy articles that are attached to some LCDs. They provide more detailed information, breaking it down and simplifying the criteria."

Changes are occurring at an equally rapid pace with private payers, too, Sorensen adds.

"We're finding different state Blue Crosses carving out DME and O&P services to other different types of administrators, and they're not letting providers know until they call in or send a claim and it's rejected because the provider is no longer part of this particular subset of providers," he explains. "Providers need to make sure that they're keeping up with the status of their contractual relationships with their non-Medicare payers.

"For every patient that comes through a provider's door, we recommend that you call and verify that you are still covered to do the work and there are no special restrictions or carve-outs."


Contracting—Who's in Charge?

Cathie Pruitt, president of the PrimeCare Network for Orthotic, Prosthetic, Pedorthic & Complex Rehabilitation, Germantown, Tennessee, notes that member reimbursement issues have increased dramatically, particularly within the last two years.

Since times have changed, Pruitt says, "we're fighting a lot more reimbursement battles on behalf of our members, often dealing with bill review companies and aggregators rather than the managed care organization [MCO]. We're digging deeper and going further in order to get our contracts honored."

Not paying until they absolutely have to seems to be a deliberate strategy with many payers, she says. "Often they delay in order to wear you down, hoping that you'll just give up because you've spent so much time you'll just take what they're willing to give. And sometimes, they stick to their guns and find ways to justify the decreased reimbursement. A recent example is a reviewer determining that an OTS [off-the-shelf] brace fit the definition of a DME [durable medical equipment] item.

"In the early days," she continues, "reimbursement was a fairly smooth process because the MCOs would generally abide by the contracts, and they weren't actively searching for ways to avoid payment and making offers that were not based on your contract to see if you'd accept lower money like they do now. It's just gotten to an epidemic level.

"The best strategy is to be very careful on the front end about the language in contracts under consideration since seemingly innocuous phrases can be loaded with the potential for problems on the back end if not corrected. Also, we maintain strong and secure relationships with our contacts on the contracting side. That way they are more likely to work along with us in terms of going back to the reviewers and making sure that contract terms are actually enforced."

Documentation Above and Beyond

Although O&P industry prophets have been preaching the importance of documentation for years, today's efforts must go further than documenting outcomes and procedures.

"Documentation requirements have gone so much further than a prescription now that a prescription is almost useless," Sorensen says. "It's a necessary part of the process, but just because you have a prescription doesn't mean you have a medical need for what was prescribed.

"Payers care less about our documentation and more about what the physicians and physical therapists are documenting," he adds. "So it comes down to educating our doctors on how to write a note! Payers want to see credible notes from the physician or therapist describing what the patient could do before their amputation or stroke, and what are they doing now."


Efforts to streamline the reimbursement process have helped to make such documentation easier. Paul Prusakowski, CPO, LPO, FAAOP, owner of Gainesville Prosthetics, Florida; CEO of OPIE Software, Gainesville; and president of the National Association for the Advancement of Orthotics and Prosthetics (NAAOP), notes that a number of coding tools such as the American Orthotic & Prosthetic Association (AOPA) Coding Pro, are available to help individuals code according to PDAC and DME MAC requirements. "Historically, a number of billing software systems have provided tools to facilitate claims submission and payment tracking. The required evolution to electronic medical records (EMR) is what led to the development of the OPIE Software system," Prusakowski says.

"When you have better tools for creating more thorough documentation, the practice is better prepared to respond to audits," he points out. "There's more consistency in the thoroughness of their documentation, there's more consistency between clinicians on what and how they're documenting, and there's a standardized thought process that culminates in the establishment of justifications for the goals and treatment plans for the patient. So although it may take a little bit more time on the clinician's part up front, it ultimately establishes better protocols for more thorough and professional documentation standards."

He notes that the Affordable Care Act (ACA) is likely to create a greater demand for coordinated communication of documentation between all referral sources and specialists. "We need to receive such information from physicians, but they also need us. They're going to be required to receive more information from any specialists that they refer to, and that includes O&P specialists—in the form of feedback on whatever treatment was provided."

This mutual need may make it easier for O&P providers to get appropriate documentation information from their referral sources in the future.

His advice to O&P providers struggling with reimbursement difficulties is to incorporate some form of outcome measure whenever possible, whether it's a patient satisfaction survey or a validated test to assess patient function.

"Success depends on a combination of doing a good medical assessment, involving the appropriate surveys, and having collaboration with referral sources," he says.

The best way to stay on top of current concepts in appropriate outcome measures is to "keep up with news from the American Academy of Orthotists and Prosthetists (the Academy) and AOPA and attend their conferences," Prusakowski advises. "Outcome measurements are not difficult to implement and take from just five to ten minutes to perform, but such outcomes studies are a very important piece of our documentation.

"If the physician, the therapist, and the clinician are all evaluating and seeing and documenting that the patient has potential and is showing progress," he concludes, "that's key. We can't operate independently—we have to collaborate with other healthcare professionals that are working with our patients."

Getting High-Tech Devices Reimbursed

Manufacturers also have a vested interest in supporting efforts for O&P clinicians to gain reimbursement—especially for expensive, complex technology—and some are helping with the process. Prusakowski points to Össur's educational seminars on how to document and prepare for pre-payment audits and authorization processes for high-tech devices.


Doug McCormack, CEO of Orthocare Innovations, Oklahoma City, Oklahoma, acknowledges that manufacturers are in a key position to provide clinicians with the tools and resources necessary for documenting why a particular component or technology is appropriate for a given patient.

"Orthocare is focused on working with clinicians to provide that documentation in advance to determine if a patient actually can benefit from a given component or technology," he says.

Orthocare's Galileo web-based outcomes system, introduced a year and a half ago, can be used in clinical settings as an objective determination of individual patient function. The patient wears the StepWatch™ Activity Monitor for a prescribed period, and then the collected data is analyzed and reported to the practitioner, providing real-world documentation and insight into how that patient is functioning with his or her prosthesis.

"The Galileo system serves as a basis for a lot of what we're doing as a company in the evidence-based practice arena," notes McCormack, who announced that by the time this story appears in print, the Galileo System will also include a new patient portal that allows patients to access their own objective documentation and data and use it to advance their own cause with their third-party payer. "We believe that enabling patients to be more involved in this process is going to be very significant for the field, and we're excited about that."

The system is already paying off in clinical O&P practice. Michael Oros, CPO, FAAOP, president of Scheck & Siress, headquartered in Chicago, Illinois, says that his company has been using Galileo for some time now to document patients' walking experiences and their activity levels. "In situations where we need to go back with some documentation, it's been really helpful," he says.

Oros cites the example of a Scheck & Siress patient who was recently fitted with the StepWatch monitor and was tracked both with his initial prosthesis and then with an Ottobock Genium bionic knee. "We were able to track and record the patient's activity level over time, and because there was a significant improvement with the patient's activity level over that time period, the insurance company agreed to pay despite an initial denial," Oros says. "Because we had this technology that documented that he's not sitting around all day long, they authorized the high-tech componentry for him."

As a result of their successes with the system to date, Oros says, "One of our locations is trying to beta test how [our company] can integrate the Galileo system into our more routine clinical practice."

Billing and Coding Cautions
and Advice

Sorenson provides some additional pieces of helpful advice for billing staff:

  • Have your billing staff do an internal audit of every claim before it goes to Medicare to make sure everything is correct.
  • Understand which codes need approval from the Pricing, Data Analysis, and Coding (PDAC) contractor. If certain codes are billed, the manufacturer and model number must be on the PDAC list.or there's a good chance that you're either not going to get paid or will have to refund the money.

Carlstrom stresses the importance of sweating the details and being timely:

  • Three things should be linked together: the detailed prescription with all the L-Codes and quantities; the detailed delivery receipt confirming that the practice received all L-Code items listed on the claim (the components used to construct the device)—complete with quantities and descriptions—and the claim form. Details on all three should match.
  • Billing is easy. The challenge is the documentation and matching the details on all pieces. Check delivery receipts; practitioners will change a code and not tell the administrative staff. Pay close attention because big problems can be caused by simple mistakes.
  • Don't repeat the same problems; retrain your staff on the fundamentals. Read everything carefully and check details on your documentation. Don't jump the gun in your hurry to get your claim filed.
  • Follow the 24-hour rule: turn documentation in to your billing department within 24 hours of seeing a patient because if you don't, it delays everything.

Other providers report similar reimbursement victories, McCormack claims. "We're getting real-time feedback from clinicians who have been able to document improvement in their patients' function to payers and as a result have been successful in increasing the level of technology that payers will pay for—sometimes in a very short period of time."

Ian Stevens, CEO of Touch Bionics, Livingston, Scotland, also notes the need for increasing manufacturer involvement in pursuit of reimbursement. "As prosthetic devices become more advanced and complex, the manufacturer has an increasing responsibility to provide the training needed by O&P providers to deliver successful patient outcomes. The reimbursement system faces challenges in understanding the level of complexity of new prosthetic devices, the resulting effect that this has on the clinical time spent by O&P providers when fitting them, and therefore the final cost of the prosthesis."

In the interest of ensuring that their products deliver improved patient outcomes that are supported with validated data, Touch Bionics has developed an online tool, the Patient Care Pathway, which monitors a patient's experience with his or her prosthesis, starting prior to fitting and continuing at regular intervals. The Patient Care Pathway uses internationally recognized outcome measures to generate patient scores that can be used to provide payers with evidence of the effectiveness of the prosthesis in improving function and quality of life.

Stevens notes that the Patient Care Pathway will help its users to build a database that uses evidence-based medicine to show the impact their prosthetic devices have on each patient's life, specifically their ability to complete activities of daily living. "This evidence will be helpful when educating CMS and other insurance providers on the real value of this advanced technology," he concludes.

There's no doubt that the O&P billing process can be like a maze fraught with moving targets, traps, and pitfalls, but there are ways to navigate the system. As the saying goes, the devil is in the details, and O&P's challenge is stay on top of those details so clinicians get paid for the services and devices they provide to their patients.

Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.

Editor's note: The song "Suspicious Minds" was originally written and recorded by American songwriter Mark James. The song was re-recorded by Elvis Presley and became a number-one song in 1969.