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Adventures in Sleep

Reasons PAP Devices Denied as ‘Not Medically Necessary'

Published December 5, 2013 11:23 AM by Penny Mehaffey

I want to comment on the following that I read online in SleepReview:

"The top two reasons for a positive airway pressure (PAP) device being denied as not medically necessary are as follows: 1) no face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea (OSA) or to document that the beneficiary continues to use the PAP device, and 2) no documentation that the beneficiary and/or caregiver has received instruction from the supplier of the proper use and care of the equipment. This is according to a complex review of 313 claims from July 1, 2013 to September 30, 2013 by the National Government Services' Medical Review Department. National Government Services is the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC). Of the 313 claims, 159 were denied, resulting in a claim error rate of 51%. A large portion of claims (51) were denied for failure of the supplier to respond in a timely manner to the request for additional documentation.Suppliers are reminded that failure to respond to requests for additional documentation is in violation of supplier standard #28, which states the following: ‘Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.')"

Whew that was a mouthful. I almost got bogged down reading it. Can you imagine trying to operate within these types of guidelines on a daily basis? Not only are they cumbersome but they seem to behave much like a virus ... we barely get caught up with new rules and standards than the guideline changes or mutates and we're caught scrambling to comply again.

And isn't that word "sanctions" terrifying? Or is that just me? I hear these laments from DMEs frequently and it's worrisome. After all, they are a link in the chain that patients, aka beneficiaries, must deal with.

For my part, I try to help the vendors obtain needed documentation as much as I can in a timely manner, but this has become more and more difficult. For instance much of what they need is not mine to give, and we've had to adjust our methods just as everyone else has in this changing scape. I imagine that in much of the country everything is done electronically.  That is not the case everywhere, though. I must refer all requests for information through the medical records department.  If a vendor does not follow the guidelines set forth by medical records, then delays will be inevitable. 

I am sure there are some really savvy people out there who have great success obtaining documentation. I would love to hear your methods or at least a tip or two on how to get what you need for billing. Any comments?

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    Adventures in Sleep
    Occupation: Sleep technicians
    Setting: Various sleep facilities
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