Moving the HME Industry Forward

Billing/Reimbursement

Audits on the Brain – van Halem Addresses Concerns at Medtrade Spring

March 17, 2014

LAS VEGAS – Onerous audits have plagued a huge percentage of HME providers in recent years, and unfortunately the audit tempo shows no sign of slowing.

According to Wayne van Halem (pictured), president of the van Halem Group LLC, the future holds, among other things:
• Supplemental Medical Review Contractors;
• Zone Program Integrity Contractors vs Unified Program Integrity Contractors;
• RAC Program expansion
• Managed Care risk;
• Extrapolated overpayments;
• Face-to-face requirements; and
• High dollar volume edits.

“All of it, unfortunately, means the audit situation is not going away anytime soon,” said van Halem. “DME MACs hired Associate Medical Directors for the sole purpose of attending ALJ Hearings and defending denials. DMDs or other clinicians may attend hearings as a ‘non-party participant.’”

Along with Kelly Grahovac, senior consultant, van Halem summarized several strategies to help ease the audit burden. For example, to avoid improper use of the KX modifier, van Halem and Grahovac said:

• suppliers must add a KX modifier to the [Procedure Code] only if all of the coverage criteria in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.

• Suppliers must add a KX modifier to [Procedure Code] only if all of the criteria in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy have been met.

• If the requirements for the KX modifier are not met, the KX modifier must not be used.

• Civil monetary penalties for improper use of KX modifiers are around the corner.

• Hold physicians accountable and request documentation as much as possible.

• Determine the liability you are willing to take on.

To listen to the entire van Halem/Grahovac presentation, you can purchase the Medtrade Spring 2014 Digital Conference by clicking here.