Check out attorney Knicole Emanuel’s recent blog post, written to wound care practitioners, “Medicare Auditors Are Not Wound Care Specialists: Why Providers Win Appeals When the Full Story Finally Gets Read”! Her post reinforces the reports I am hearing, that practitioners get what seem to be “rubber stamp denials” of CTP/skin substitute charges all the way to the Administrative Law Judge (ALJ), a process that can take years.
Remember, however, that you can only win on appeal if the necessary documentation is in the chart. Also remember that a very long progress note containing all sorts of statements about care rendered (e.g., “adequate compression was provided for 4 weeks…“) won’t help you if the rest of the chart does not support those assertions.
Also, keep in mind that auditors are “following the money,” since they have a financial reason to do so. While I have no way of proving it, auditors seem to have particularly targeted practitioners who used large pieces of high-priced amniotics. This makes sense from the standpoint of “return on investment” – from the auditor’s perspective. They only need to audit one or two cases to deny millions of dollars in claims. We will have to wait to find out if the audits will lessen now that the new pricing structure has dramatically decreased the monetary incentive for audits.
Caroline
Related posts:
- Here Comes the Judge! Part 2 of the Incredible Journey of a Skin Substitute Audit – Guest Blog by Michael Crouch – Caroline Fife M.D.
- The Incredible Journey: Lessons Learned from a Skin Substitute Graft Audit (Part Three) – Caroline Fife M.D.
- The Incredible Journey: Lessons Learned from a “Skin Substitute Graft” Audit – Part One – Caroline Fife M.D.
- If You Use “Skin Substitutes,” Read This and Pass It On – Caroline Fife M.D.
- One of Your Letters: UPIC Denies Everything Without Reading the Chart – Caroline Fife M.D.
- What Claims Can Cellular Tissue Product / Skin Substitute Sales Reps Make About Wound Healing? A Closer Look at the Proposed List of 15 in the LCDs – Caroline Fife M.D.
- If You Wonder Why CMS is Looking at Skin Subs, Check Out These Claims… – Caroline Fife M.D.
- Is There a Justifiable Price Limit on Cellular Tissue Products (CTPs) / Skin Substitutes? Check Out the Article Now Available – Caroline Fife M.D.
- Medicare Skin Substitute Audits: “Agencies Cannot Make Up the Rules” – Guest Blog by Michael Crouch – Caroline Fife M.D.
