New Perspectives

Creating Solutions to Help Smaller Providers Soar

Creating Solutions to Help Smaller Providers SoarI’m a former director of rehab for The MED Group and former VP of contracting for CMS contractor Delmarva Foundation for Healthcare (pharma and ZPIC fraud, waste and abuse). Now I’m the national director for PMDRX, a physician power and manual mobility documentation system.

Thanks to that background, I see the supplier community from two sides. On one side, I see suppliers fighting to stay alive. On the other, I see government and private contractors trying to ensure the Medicare trust fund remains solvent in light of the explosive graying of America.

I see an unbelievable, unconscionable, deplorable supplier environment filled with futility. Likewise, I see a supplier environment filled with opportunity, prospective hope and a chance to reinvent yourself and your company to create a renaissance in health care.

Whether we are speaking about Medicare, Medicaid or private insurance, there is nothing predictable about the market today.

So who will succeed? Will it be the supplier who sticks his/her head in the sand and essentially says, “I have no control”? Will it be the supplier who turns his/her head away from the blaring lights and horn of the oncoming train?

Perhaps it will be the supplier who hears the train coming before seeing it. This supplier decides what moves to make, what alterations and modifications to make, who to call, what assistance to receive and give, all in a magnanimous effort to morph the precarious situation into something positive.

Obviously, the last scenario will take the most effort. It says, “I agree to be something tomorrow that I am not today.” It says, “I will find a way to not only stay alive, but to live better.” It says, “I am not ready to throw in the towel.”

As long as you agree to find a way to “live better,” this column and those to come are for you! While large, medium and small suppliers suffer many of the same trials and tribulations, and businesses of all sizes can benefit from what’s discussed here, it is the small supplier who will be the main focus of this editorial series.

The Challenges You’re Facing

So how will you begin to live a better day? I suggest we examine the handling of a seeming preponderance of denials, pre- and postpayment audits, Administrative Law Judge (ALJ) incapacitation, Recovery Audit Contractor (RAC) attacks and Zone Program Integrity Contractors (ZPIC) assertions.

Today and in the past, Medicare contractors report mobility errors in the 55- to 80-percent range.

There are many reasons for this; however, we will focus on two:

  1. The confounding requirements for documentation and compliance by the supplier keep moving like a ship on the high seas.
  2. In spite of CMS physician education relating to proper documentation of mobility devices, the education is not taking hold. Physicians are overwhelmed and confused as Electronic Health Records (EHR) systems do little to address proper mobility documentation.

By and large, it is the second issue related to physician documentation that is leading to the very high denial rates. Ultimately, the supplier suffers if he/she doesn’t have the correct documentation. This forces the supplier to seek and acquire improved physician documentation — an item seemingly out of their control.

If there is little or no improvement in physician documentation, the high denial rates will continue. This will inevitably force you to follow the long and arduous ALJ path — one currently on hold for the next two years or so. In the meantime, the dark cloud of the ZPIC and RAC audits continue.

So how can the small supplier, whose staff size has dwindled, cover the bases when seeking appropriate physician documentation?

What Are Your Choices?

Solutions used by suppliers run the gamut: Submit what can be submitted through the Advance Determination of Medicare Coverage (ADMC) process. Have the physician send all evaluations to a consulting physical therapist (PT). Call the physician’s office again (and sometimes again) to seek amended documentation because of initial insufficiency. Employ technology that supports physicians in properly documenting the need for mobility devices.

Let’s examine each of these solutions.

ADMC — It’s a wonderful process; however, we know it is not a guarantee of payment. And without proper physician documentation the first time, the supplier will need to go back to the physician for more documentation to submit the ADMC once again. This at best results in a delay.

PT evaluation — This is a solution commonly employed by complex rehab technology providers. Yet timing, dating and physician congruency of the PT documentation are all critical to avoiding denials. And the supplier still needs thorough physician documentation. This approach ultimately results in a delay.

Ask again — Asking the physician for amended dating, more clarity and to address more topics takes time from the supplier, the staff , the physician and physician’s staff . This puts pressure on the physician and results in further delays.

So what are the solutions?

Your staff could take more time to educate the physician’s office and hope that this will yield improved results. I know many suppliers who have attempted to improve the documentation through this process. Inevitably they find it costly with minor improvements in the documentation they receive from the physician.

Rather, I suggest you examine solutions that create an interactive approach while building a solid solution-based alternative that will serve both you and the physician. I would suggest you take a prompt and evaluative approach to examining physician/supplier electronic cloud-based solutions that will ultimately give you, the supplier, a nearly fool-proof approach to securing complete, compliant physician documentation, thereby vastly diminishing denials, successfully submitting first-pass ADMCs, keeping the RAC and ZPIC wolves away from your door, and telling the ALJ, “I don’t need you anymore.”

Over time, these “New Perspectives” columns will also discuss other ways to use technology to streamline your processes, create efficiencies, increase accuracy and just plain “do more with less.” We’ll talk about other strategies to help small suppliers, or any provider, to improve their reach via, for instance, supplies and equipment that can be profitable under any scenario. We’ll talk about which retail items are worthy of display in your business, and the best ways to maximize your floor space to capture greater cash sales.

Do you think that because you’re a complex rehab provider, you don’t have retail opportunities and don’t need ideas for storefront windows or sales floors? We’ll talk about how retail fits into the CRT business plan as well!

We’ll look at increasing your commercial payor markets, and at compliance and accreditation, specifically at examining the agencies and your strengths and weakness.

And we’ll look at forming partnerships with others, such as under what circumstances you should subcontract, and how to hire consultants and outsourcing services.

Undoubtedly, you will find the healthcare landscape continuing to become more challenging. However, armed with the correct knowledge, attitude and solutions, you will not only prevail, but will thrive. After all, from ashes come spring flowers.

And as the people in your neighborhood continue to age, who better to serve their needs than you, the community supplier?

This article originally appeared in the April 2014 issue of Mobility Management.

About the Author

Reid Bellis is national director of contracting & media relations for PMDRX. He can be reached by calling (916) 548-2525 or by e-mailing

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