Clayback: Many PMD Errors Due to Confusion, Not Fraud

• By Laurie Watanabe
• Feb 28, 2012

Among the stakeholders listening carefully to what was said during the Centers for Medicare & Medicaid Services' (CMS) Feb. 23 Open Door Forum was Don Clayback, NCART's executive director.

Clayback and the other participants on that conference call about Medicare's upcoming power mobility device (PMD) demonstration project repeatedly heard the CMS personnel running the Forum -- Barbara Cebuhar, Melanie Combs Dyer, Amanda Burd and Doris Jackson - refer to the sky-high incidence of provider fraud involving rejected PMD claims.

Dyer, quoting an Office of Inspector General (OIG) report, said the PMD denial rate is currently 80 percent - a statistic that was repeated later on in the call. Curbing fraud was repeatedly given as the reason behind the demonstration project.

Clayback, among others on the call, objected to universally characterizing errors on claims as attempts at fraud.

"I think we all agree that the PMD arena needs more attention and some improvements for a lot of reasons," Clayback said during the call's question-and-answer session. "I do feel compelled to make a statement on the constant mention of fraud. I think we all agree that fraud needs to be prevented, and we need to put some additional controls in to combat that, but I do think that many of the errors around the PMD claims stem from documentation questions or confusion."

That sentiment was echoed by a provider on the call who pointed out that there is no objective form for prescribing physicians to fill out, and that therefore, people reviewing claims for the DME MACs are using a certain amount of subjective interpretation to decide whether physicians have adequately described medical necessity.

"If that nurse (reviewing the claim) has a different opinion as to how that question should be answered, does it make it wrong if a doctor has answered the question in a different way, but he's answered the question?" the caller asked.

While using the term "fraud" may make for dramatic headlines, Clayback said "error rates" might be a more accurate term to describe what's happening with a lot of denied PMD claims.

"What is causing those errors?" Clayback asked in a Mobility Management interview following the Open Door Forum. "When you drill down, you find that this claim was considered not medically necessary because the doctor put the wrong date for the face-to-face examination. You kind of have to stop and take a step back and ask what that really tells you. It would tell me that if everything else was right, that person needed that piece of power mobility, but the doctor didn't understand the requirement. It could have been inattention or confusion. If you take those examples of what's causing those error rates... if (it's) a minor detail that is happening with some regularity, that indicates a need for better education with the physician or maybe taking a look at what's causing those errors."

As for the caller who said claims reviewers may be issuing rejections based on their personal preferences or interpretations - Clayback says the caller made a good point.

"If some of these things are because of interpretation, where the doctor is actually answering the question, but not in the form the reviewer would like - well, that's something that needs to be addressed," Clayback said. "But one, I don't think the claim should be denied, and two, it shouldn't be broadly listed as a fraudulent claim or equipment that's not necessary being provided.

"I certainly don't pretend there's no fraud out there, but when you look at the vast majority of suppliers who are accredited and have been in the business for a number of years - if there's a problem with their claim, it's not because they're trying to be fraudulent. It's very difficult to get the physicians to complete this information. It's confusing and it's very detailed."

Clayback suggested that more effective education could be a better solution than assuming providers who make errors are trying to defraud Medicare.

"I don't want to come across as saying we don't think there's need for change in this area," he said. "I think there is need for changes, and some of that involves closer scrutiny. But there's also a need for looking at what's causing the problem when you have legitimate suppliers and legitimate doctors who are doing their best to get their patients the right equipment, and it's being denied or it's being classified as fraud because one of 18 things was not in the medical record.

"I think the legitimate players in the industry are 110-percent behind any effort to combat fraud, and I think we've shown that historically."