Home Health & Hospice Week

Why are they picking on you? It may seem random, but there's usually a reason.

If your durable medical equipment regional carrier appears to have singled you out for intensive review of all your claims, then chances are you were billing for something in a way that attracted the DMERC's attention. Figuring out what triggered the radar can be the first step to extricating yourself.

Focused medical review can take a few different forms, say billing experts. It can involve prepayment or postpayment review of claims. It also can involve a random sampling of your claims, or claims focused on a few hot-button codes. And the proportion of your claims run through the wringer can vary as well.

What doesn't vary is that focused medical review is a nuisance and a drain on resources, says Catherine Brink, president of HealthCare Resource Management Inc. in Spring Lake, NJ. A prepayment review may slow your cash flow to a trickle, while a postpayment review will force you to chase documentation and compile massive dossiers for the DMERC.

A review may be random, but the fact that you're targeted probably isn't, says consultant Dwayne Thomas with Healthcare Management Solutions Inc. in Monsey, NY. The first thing you must figure out is, "what did Medicare find in their audit of your files that caused them to want to take a second look at your claims?" Thomas notes.

Usually, Thomas says, DMERCs will give you "a couple of chances" before putting you on FMR. These may take the form of regular audits of your certificates of medical necessity or requests for additional documentation on a few claims. If these audits turn up a sample that doesn't meet their standards, they may proceed to the next step.

Figuring out what the DMERCs saw in your claims that made them decide to put you on review means looking back at earlier audits and examining the claims you sent in previously, says Thomas.

You may not realize you're on review at first, until the carrier requests details on 10 claims, then another 10 claims, until it becomes obvious you're being targeted, Brink says. It's definitely important to look into ways you can clean up your act before you do anything else, she adds.

"After you see a pattern developing and it's becoming frequent, you obviously don't want to just sit back" and do nothing, says Brink. She advocates becoming proactive and contacting someone at the DMERC. Hopefully, your billing staff has established a good working rapport with at least one DMERC rep, and that person may be able to guide you to the right office.

There's no set protocol for getting off review, says Thomas. Usually, the DMERCs decide when to take you off review based on statistical analysis, so if your claims reach a certain percentage threshold of accuracy, you'll be home free.

"If you can put through 100 percent clean [claims], there would be no reason for Medicare to utilize the manpower," says Thomas. "The objective of a focused medical review is to educate the suppliers as much as possible."