Often clinicians groan about third party payers and their devious schemes to deny their claims. Are carriers out to get you or are they simply asking you to play by their rules?
Let’s make a comparison of DME audit and a football game.
Each has players and coaches, referees on the field and in the studio.
You and your back-office claims team are the players.
On the carrier side there are level 1 auditors (level 1) who are simply there to read through your chart and either pay/deny or recoup money. As in football you can score or you claim can be called back and you penalized to one degree or another. The auditors and claim representatives have the carrier’s playbook and they’ve been taught the rules.
However, sometimes the rules (as in an LCD) can be confusing, and you may use different language in your chart which really means the same thing as what’s in the playbook (LCD). Thus, sometimes your referee or claims representative simply doesn’t know all of them as well as a Level 2 supervisor.
So if your referee calls a penalty against your team (recoupment or failure to pay) you can always throw out your review flag and ask for a higher authority (level 2 supervisor or appeal representative) to review your chart (playbook) and see if the ruling on the field is affirmed (you are penalized by either having a claim denied or recouped) or if you win (are paid or your appeal is held up and the penalty (recoupment) is overturned.
Either way, clinicians need to know the rules and be able to translate medical findings they have worked so hard to understand, into terminology that either the claims representatives or auditors at any carrier level will understand.
It is far better to use documentation language right out of the playbook (LCD) and have it tell the story that the auditor (referee) will understand.
You will be paid far more often and hold onto your money more frequently during a post payment audit if you play by the rules and use language from the LCD which the auditor understands. Doing so in the way the LCD presents itself is also recommended.
Remember the referee of your claim (level 1 auditor) is also being monitored by a higher authority and too many wrongs on their part costs them money and may result in their MAC contract not being renewed. It may also guarantee the auditor a one way trip to the unemployment line!
