CEO Esther Apter Cited as Audit Appeal Expert in HME Business
January 21, 2016
Category: News
HME Business's January cover story explored the best way to navigate Audit Appeals. Medforce CEO Esther Apter was quoted extensively as an expert. Below, we pulled some of her top quotations and advice for providers when dealing with Audit Appeals.
Click here to read the full article on the HME Business website.
.jpg)
Esther Apter, CEO, Medforce Technologies, said that in general, she recommends appealing because the subsequent claims will be docked if you don’t take any action. But, like any business decision, you need to weigh the cost of the effort with the potential value. Time is money and there is effort associated with an appeal.
“We coach our clients to sort appeals by strategic priority — usually by dollar value, but it can also be by deadline or complexity,” she said. “That is when a business process management tool is especially helpful in helping to organize and prioritize appeals. If you are following traditional paper methods, appeals are often handled by the order they come in, or alphabetically, or just randomly.
“Plus, the piles of paper that need to be sorted can be especially time consuming,” she adds. “When you use technology, you can first tackle the appeals that will reap the most reward. Also, you can gain access to all the needed documentation and can track the status of compiling the appeals package and make sure to stay on track and on time.”
According to Apter, 86 percent of audits are based on inaccurate or incomplete documentation, such as date not stamped or the detailed written order is missing, and 22 percent is for missing documentation completely, such as delivery tickets and proof of a Face-to-Face with a physician.
“The top criteria for building a case to appeal are all about documentation,” she said. “Do you have the right documentation to meet requirements? DWO, signature, date stamp? Do the medical records meet requirements? Do you need to prove medical necessity? And if so, did the physician hand-sign the CMN?”
Apter suggested:
- The first step is having a strong internal process for handling an appeal. This includes establishing procedures and protocol, assigning responsibilities and having appropriate training.
- Once you are faced with a denial that you’d like to appeal, refer to the guidelines and checklists that Medicare provides. They are created by type of equipment (oxygen, power device, etc.) and can be incredibly helpful in ensuring you can defend that you provided the service or product in a way that justifies reimbursement.
- Now that you know the lay of the land and what the auditors will be looking for, start by gathering all of the information and organizing all of your documentation into one place.
- Review all of your documents to make sure they are clear and legible. If the auditors can’t tell what it is or read the document, they won’t give you the benefit of the doubt.
- A clear and concise cover letter is a must. Indicate what was denied on what date, what you are sending, what is attached, and why it meets the guidelines. Clearly state what your request is at the end. Don’t leave anything up to guessing on the auditors’ part because they will not give you the benefit of the doubt. End with a direct statement, such as “Please reconsider…”
Finally, Apter recommended leveraging technology to help win an appeal:
- At a minimum, a robust document management tool will enable you to gather all of the needed documentation with a few clicks, especially when you can leverage full-text-search in the case that something has been misfiled.
- Business Process Management (BPM) tools are incredibly powerful when it comes to planning appeals. The BPM technology sets out a workflow that determines who needs to take what action, with which documentation at what time. The who, what and when are laid out to guide you, and the timeline and use of alerts and escalations keeps everything on track.
- If a provider is not able to purchase a full BPM system, look for something that is geared specifically toward appeals. We have an Appeals Management App that is focused specifically on workflows that manage incoming ERNs, gathering pertinent documentation and creating professional cover letters. Not only does technology help keep things from falling through the cracks, but it dramatically reduces the effort associated with planning and tracking an appeal, which improves your effort-to-value ratio.
- esMD is another technology that can help with the transmission of these requested documents to auditors. When you send by email or fax, it can feel like your submission went into a black hole. That is why we had Medforce certified as a one of the first HIH providers, so we can assist our clients in electronic submission of medical documentation (esMD).
Click here to read the full article on the HME Business website.
SHARE THIS POST
