Saturday, May 28, 2022

Medicare Pre-Payment Audits

Jim DeWees

Hello all again, I had a great weekend to stew over the problems with the Medicare issues. I have to say, this is the most frustrating and dissapointing situation that i have ever personally been involved with. I pride myself in being a very honest person, in my own personal life as well as my professional life. I do the most honest work, using the most appropriate components that the physicians and I agree on for the patients. Having NGS (Anthem) now reviewing my claims and coming to the conclussion that I did not submit information that will support the level of service for my patient is a personal attack on my judgment and ethical treatment of the patient. But, I have to stop and keep this into a business perspective, and that we are dealing with a heartless situation from a company that is only worried or concerned about making MORE money. As I have stated, in my situation here, Anthem (under their sub-company NGS) has been paid by our tax dollars to administer the benefits for CMS, and now they are also being paid to collect the money that they are trying to find as being “overpayments” OR to stop payments on existing claims. Today I tried again to get ANY more information out of them as to what is missing. I DID get a little more information from this extra phone call that I figured could not hurt to at least ask again.
I was told that in the notes on the computer, that “the use of a walker or a cane does NOT meet the K3 level of service”. So, just a word of caution to EVERYONE, be careful about making any comments about using a cane of walker.
What I have in my chart notes, is that on the day this NEW amputee was fit with his leg, and on this date of service, I noted that he walked to his car with his new prosthetic leg, with the use of his walker. The next office visit, I noted that he had progressed to the use of a cane to get into my office, and was walking very well, after just one week of having a prosthetic leg. Since we have submitted this information, I have MORE chart notes about a more recent check up, where he is not using a cane or anything. She claimed that the use of a cane is NOT allowed for a K3 level amputee. Is that correct?? It does not say ANYTHING in the official definition about canes. But WITH a cane this patient can walk with a varied cadence. He is able to negotiate barriers, he feeds cows every morning, even in the frozen ground, frozen piles of cow manure, etc. I am also a BK amputee, and I have to admit that I have used a cane/walking stick…BUT it was on a 58 mile backpacking trip, in 5 days. So, I guess by that description or new standards that NGS seems to have, I would not be a K3 either. I am waiting on a call from the manager to know WHAT my next step is. I am planning on doing a re-determination, and explaining that the definition of the CMS K3 level is that the patient “has the ability OR potential” to do all the required descriptions. This patient definitely demonstrates that he HAD the “potential” when he used his walker to get to his vehicle (instead of a wheelchair). Then returning in just one week and now only using a cane is another HUGE step in progress. Now 4 weeks later, he is NOT using anything.
I HOPE they will review this again, and see that this advancement is a big step for a NEW amputee, who is getting used to pressure on his residual limb, and tolerance for that is being built up during the time. He now has the ABILITY to walk with varied cadence and all that other stuff. But at the time of delivery, he had the POTENTIAL. So, my word of caution: Using the words “walker or cane” in the documentation is what messed up my audit. I hope this is resolved in the re-determination process with them. Good luck, it’s a mean world these days. Jim DeWees, CP

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