Prepayment audits are particularly burdensome for DME claims and all too often result in denials. These claims must be escalated through the formal appeals process via redeterminations at the MAC and then to reconsiderations at the DME QIC (if the MAC appeal is unfavorable). Per the CMS directive, if a claim is audited (and the supplier responds in good faith but is subsequently cited with errors), the MAC and QIC must limit their review to the errors cited by the auditor. This removes a lot of uncertainty in the appeals process for many suppliers dealing with larger volumes of audited claims.
CMS did release a clarification on cases that have been cited for non-response: when a supplier does not send a document, or does not reply to the initial audit request, the appeals contractors can examine new evidence independently and cite errors when newly introduced documents are insufficient.
You do not have be resigned to the status quo. Make sure your company is getting traction on your appeals and audits. If you are struggling with unsatisfactory audit results, please read our post from March 23, 2016 on Four Key Steps to Audit Exemption. And ventilator suppliers struggling with these processes shouldn’t miss our event on Wednesday, June 8 at 2 Eastern: Change Is Afoot – Is Your Ventilator Program Up to Speed?.