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In the SMRC's (Supplemental Medical Review Contractor) most recent current project detail for Diabetic Test Strips, they include verbiage that not only impacts the DME supplier, but also the ordering practitioner.

Specifically the SMRC's current project explanation states, "It is the supplier’s responsibility to obtain from the ordering practitioner, as much documentation from the patient’s medical record as necessary, to be sure that coverage criteria for an item is met. If the practitioner does not send the requested documentation to the supplier, the supplier may not receive payment from Medicare for provided items. "

"Failure to supply medical records upon request may be indicative of a Medicare vulnerability. If a practitioner doesn’t respond to a supplier’s request for documentation to support the DTS billed, CMS is concerned that the practitioner may also have other services that are not supported by documentation. Therefore,we are now auditing those practioners’ claims for evaluation and management services."

This requirement for providers to comply with a supplier's request for documentation to avoid risk of audit on their own E & M services has been outlined in the Program Integrity Manual for some time. In fact, we even reference this excerpt from the PIM ourselves when working to obtain medical records on our clients' behalf. What is interesting, however, is that the SMRC is holding the ordering practitioner accountable and acknowledging that the DME supplier's payments are reliant upon the documentation of someone else.

For the DME industry, this is great news! Suppliers have long communicated to CMS and its contractors the imbalance in documentation requirements and audits when reliant on the ordering practioner. The A/B and DME MACs often work together to educate providers on the importance of documenting for DMEPOS orders. Unfortunately, the MACs have not shown any further collaboration besides education...until now.

When DMEPOS claims are audited, medical necessity denials most often prevail. Worse, these denials often stem from documentation that is not written by the supplier, but instead, the ordering practitioner. In effect, a provider can order the equipment and then have no further responsibility or financial stake. This acknowledgement by the SMRC that ordering providers will be held accountable for withholding documentation could have greater impact to DME suppliers and their relationships with their referral sources in the future.

If a supplier has a "difficult" referral source, sharing this notification may help them obtain the medical records they need to adhere to Medicare coverage and billing guidelines. CMS' concern with a practitioner's defiance to comply with documentation requests for services ordered, and how that relates to their own documentation for services performed shows their focus on program integrity across the board.

CMS has been clear in their message that they will continue to focus on new initatives to fight fraud, waste and abuse, as improper payment rates continue to decline. As TPE continues to be a CMS All-Star, other areas are becoming central to protecting the Medicare Trust Fund, including newly implemented Provider Enrollment initiatives. Accountability should extend across all those that provide care to the patient, and it seems that CMS agrees with this sentiment.