Insights from the Medical Director
Recently, the team at Engage Health was excited to announce that Dr. Robert Glenn has now joined our team. Prior to joining Engage, Dr. Glenn served as the Contract Medical Director (CMD) for the Durable Medical Equipment (DME), Home Health and Hospice Recovery Audit Contractor (RAC) program at Performant Corp. His experience and insights into both the RAC program and the challenges faced by suppliers, practitioners and agencies is invaluable to our clients as we endeavor to promote payment accuracy. That said, we thought one way to introduce Dr. Glenn would be by means of a quick Q&A session. Many people have commented to me over the years that they would really like to understand the RACs better. We thought there is no better person to dispel rumors and provide insights than Dr. Glenn.
Q: To begin with our first question, we understand that CMD as the RAC you had numerous engagements with providers during the discussion periods. In addition, you provided oversight to the review teams and had a direct line of sight into the audit responses from suppliers. With that information in hand, what is one of the biggest challenges facing DME suppliers from your perspective?
A: Having looked at thousands of claims during my time with the Recovery Audit Contractor and here at Engage, I genuinely feel that the current reimbursement regulations that are in place with Centers for Medicare and Medicaid (CMS) and commercial payers place suppliers in a unique and often frustrating position. The reason I say it’s unique is that currently, as we are all too aware, DME suppliers provide equipment to a beneficiary, based on an order from a prescribing provider. Because the supplier is the one who originally pays to obtain/create that item in question, it is the supplier who submits the reimbursement claim to the payor, except for those specific instances where the supplier is also a healthcare provider. As a result, it’s the supplier who carries the financial stake in supplying the DME equipment, not the prescribing provider. Yet, for claims submitted to CMS in particular, the regulatory language found in places such as the Program Integrity Manual and various Local Coverage Determinations and Policy Articles makes it quite clear that establishing the reasonableness and necessity of a dispensed DME item can ONLY be determined by what is documented in the MEDICAL RECORDS. In fact, Policy Article A55426 states very specifically that “records from suppliers with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary.” If an auditing entity such as a RAC or a Medicare Administrative Contractor (MAC) determines that that documentation does not demonstrate that coverage criteria have been met, the SUPPLIER is the one who faces the denial of the claim and the potential recoupment of money. Thus, as I was referring in the beginning of my answer, this creates a unique and very interesting dynamic between suppliers and prescribing providers.
Q: Dr. Glenn you certainly hit on a topic that is front and center with the supplier community. In fact, we often hear the frustration from suppliers because they find it difficult at times to ensure the records do in fact meet coverage criteria. There are several reasons that this situation exists. With that said, given your experience in the Recovery Audit Program, what have you seen because of this dynamic?
A: Well unfortunately, the Centers for Medicaid and Medicare Services (CMS) has reported over the years since the RAC program has been in place that a significant number of denials occurred because the medical records failed to demonstrate the reasonableness and necessity of the item that was prescribed. And if we stop and think about it for a minute, it can be understandable as to why this may happen. As clinicians we are trained to document what we see and appreciate primarily so that we can demonstrate what drove our decision making and to communicate with other clinicians. However, it is precisely those details that are found, or in many cases, not found in the medical record that demonstrate why something like a custom fabricated knee orthosis or a sterile urinary catheter kit are required for a specific case. Proper Payment to suppliers is heavily dependent on this documentation from clinicians. In addition, with the wide variety of insurance plans that patients may have, the idiosyncrasies of each medical or payment policy may not be known by the providers. As you know policy can and does change frequently. Keeping up with these changes is a significant undertaking.
The DME industry, including software vendors, have gone to great lengths to try to address this issue by creating templates and using policy specific language to satisfy coverage criteria. Unfortunately, CMS regulations view supplier generated documents as not being part of the medical record for the purposes of determining proper payment. In addition, CMS requires that any information intended to justify payment is corroborated with the medical record. If this doesn’t occur, then these templates, and the like, do not provide the evidence that coverage criteria has been met.
Q: I am sure that this information comes as a surprise to many people and may help explain why they receive denials. Often people have an untested confidence that their records are in order due to the use of this type of templated information. It is compounded by the advances of software companies with offerings such as “ghost scripts” and the like, which further this type of unwarranted confidence. So, what can be done to remedy this and make the dynamic work better for all involved?
A: That is a great question. Before I respond, lets think about the implications when the process fails to deliver. First, the beneficiaries do not receive the equipment or services they need. As a result, their condition may worsen and increase utilization. Second, the supplier may have provided equipment which may not be reimbursed. Naturally this causes financial difficulty and could potentially lead to the demise of the business. Now the community is faced with one less supplier of medical goods and equipment. Lastly, with the move to value based and quality incentivized payment programs, the physician may be penalized when the patient utilization increases. Thus, it sets up to be a potentially terrible experience all around with no winners.
In my opinion, the first step to avoiding this situation is communication. Both providers and suppliers need to be willing to engage to a common end. Suppliers need to have a strong grasp on what the reasonable and necessary requirements are for each type of DME item that they dispense. But they also need to be willing and able to communicate those requirements to the prescribing provider. The Prescribers, in turn, need to understand that what they document in the chart has a DIRECT impact on whether their patient will receive that prescribed DME item now and potentially in the future. If providers believe that their patient needs a custom fabricated knee orthosis, meaning that it must be specially constructed for that person and that person alone, then they just document what they see that leads them to believe that in the medical record. For example, is there a joint deformity due to a congenital or pathologic process? Describe it. How bad is it? What is the process that caused it? Each case is different, so the documentation needs to reflect that specific situation.
This is certainly a long-standing problem not only for DME suppliers but for provides across the entire care continuum. Clinical documentation improvement programs, scribes and software advances are all being utilized, and quite honestly tested, to determine if any gains can be had. At Engage, as you know, we are very aware of this issue and are synergizing the supplier / provider relationship as a primary step in addressing the issue.
Q: You said what provider documents can potentially impact if a patient receives a prescribed DME item now and in the future. What did you mean?
A: I'm glad to clarify because this is important, and we see changes occurring in the industry. I have heard many times from suppliers that it is becoming increasingly difficult to operate, be it due to denials resulting from a cumbersome pre-authorization process, line denials, full claim denials, a long and difficult appeals process and/ or an ever-changing set of regulations. Many DME providers do not have the capacity or capital needed to survive. To protect themselves, the dispensing of equipment to patients may need to be delayed or halted when documentation is not sufficient. It is a difficult position as everyone wants to ensure the patient is front and center. In the past, many suppliers delivered first and then concentrated on the documentation. But with audits going back up to three years, the increased liability this creates is causing the tide to be change. Even simple aspects of an order, such as the information regarding refills, can have a material effect on payment denials.
That's a great point Dr. Glenn, I'm sure that everyone will agree that ensuring awareness to coverage criteria at every step in the patient’s longitudinal care is important to everyone involved.
Q: Last question, what made you decide to join Engage Health Solutions?
A: As I was saying earlier, I’ve reviewed thousands of cases during my time at the Recovery Audit Contractor. It was apparent that there are common themes for denials. A missing but required element was not sent in or an incorrectly completed but required item like a Certificate of Medical Necessity was submitted, or simply the lack of medical necessity was not sufficiently documented in medical records. CMS’ own reports and statistics show that systemic problems occur with suppliers and providers. Most of these issues could be easily rectified with proper diligence on the front end. I began to think to myself that if there was just increased education on policy and on proper, thorough documentation in medical records, as well as increased diligence hen reviewing required elements, then many of these errors could be mitigated or, even better, ELIMINATED going forward.
I know Bill O'Malley from my time at the RAC and I know he and the team at Engage share this perspective. They want to affect positive change by partnering with suppliers and providers to provide guidance and insight that helps them navigate these complex regulatory waters cleanly and accurately. Eliminate the errors preemptively and the process not only becomes more efficient, but more gains are realized for those involved. I hear the term disruptive change used quite a bit. I would say that this certainly applies to how Engage is approaching the situation. It just felt like a great fit. I’m just very excited to join the team and affect some positive change for our supplier and providers partners.
To see Dr. Glenn’s bio information or learn more about the disruptive change Engage Health is leading, please check out the About page on our website at: engagehealthsolutions.com/about.
