Faces Behind the Red Tape Chapter 1: Sandra’s Story

This 3-part series explores the impact of Medicare audits on homecare recipients and providers.

When it comes to providing care for her aging parents, Sandra De La Cruz is no stranger to it.

She joins 43.5 million Americans caring for parents over the age of 50. Once or twice a month, she travels to Austin, Texas, where her parents, Roberto and Nora De La Cruz, reside. She stays four days to a week each time. She has been doing this since 2012 and shares the role with her sisters.

“Caregiving for me began when my mother had her first major fall that required her to go to a rehab facility for an extended stay,” says Sandra.  “She has been in rehab six times since that first fall.  She has had two brain surgeries, a broken hip, a fractured pelvis, two separate subdural hematomas, all requiring assistance and support from a rehab facility.”

Since her mother’s fall, she has been coordinating the daily details of her parents’ lives and navigating the complex road of health care services for them.

“I help my parents by making phone calls for them, taking them to appointments and doing whatever they need.”

Caregiving for her parents has become complicated because of Medicare’s red tape.

Trouble started when she began coordinating a wheelchair for her mother. The $30 transport chair that her mother had been using from Goodwill had broken and a walker was deemed inappropriate for her mother’s needs.

Little did she know that getting a wheelchair for her mother would turn into months of phone calls, paperwork and frustration.

The long road to a wheelchair

The doctor prescribed a wheelchair for Nora, and paperwork was sent to Travis Medical Supply right away. After reviewing the documentation, staff at Travis Medical sent it back to the doctor, because it didn’t fulfill Medicare’s guidelines. After months of back and forth with no wheelchair, Sandra called Travis Medical one final time to see what the issue was.

Medicare audits.

“I finally asked to speak to a manager in March.  He told me they were undergoing an audit that was requiring them to get much more information from doctors. He then stated that I maybe should consider another vendor to work with.”

Backround on audits

This story isn’t unique. Providers of durable medical equipment like Travis Medical are facing a surge of claim reviews and audits by multiple Medicare contractors.  Often times, claims are flagged due to a simple clerical errors such as illegible doctors’ signatures or missing date stamps.

After an audit has been conducted, the provider can appeal, but the road to getting an appeal reviewed and reversed is lengthy and expensive.  The appeal process is broken down into three levels. The first two levels are overseen by Medicare. If the appeal is denied during these levels, and the provider would like to continue, the appeal is seen by an administrative law judge where it can be overturned.

Audit dysfunction

870,000 AUDITS IN LINE TO BE REVIEWED BY AN ADMINISTRATIVE LAW JUDGE

 According to the Office of Medicare Hearing and Appeals, there is a backlog of over 1 millions audit appeal cases (hospital-based and DME-related) waiting to be heard by an administrative law judge.

It will take on an average 935 days for a case to be heard, despite a 90-day statutory requirement. Until an audit is overturned, the money from the claim is tied up. It can be thousands of dollars.

At this level, over 60 percent of claims have been overturned, exposing the dysfunctional system.

Providers not taking chances

With audits in the pipeline and the imminent risk of getting audited, providers are refusing to submit paperwork until it has been properly reviewed by staff. This process is naturally increasing the wait time for beneficiaries like Nora to get the equipment they need.

Audit issue raises concern with legislators 

Members of Congress have expressed concern about the broken Medicare audit system.

“I just returned from my home state of Utah, where Medicare issues remain a serious concern for my constituents.  For the past two years, like many members here, I have heard about the terrible backlog of Medicare appeals,” Sen. Orrin Hatch (R-Utah) commented in a recent Senate Finance Hearing.

In 2014, Rep. Mark Meadows (R-N.C.) pointedly asked CMS about the audit backlog during a House Oversight and Government Reform Committee hearing.

“Here we are with a budget request that says the backlog is going to reach 1 million,” Meadows says during the hearing. “At what point does it become a crisis? At what point? When you start putting companies out of business?”

In theory, audits are supposed to protect the integrity of services provided and eliminate fraud and abuse.  However, Sandra’s story shows that the excessiveness of Medicare’s red tape is having a real and serious impact on Medicare beneficiaries.

“If audits stall my 85-year-old mother and 88-year-old father from getting medical equipment, there is something very wrong with the process,” concluded Sandra.

READ CHAPTER 2

Travis Medical shares their side of the story in chapter two of Faces Behind the Red Tape  — Read here —.