Friday, June 14, 2013

Palmetto GBA Releases Results of Second Quarter Review

Emergency and Non-Emergency
Palmetto GBA, the Medicare Administrative Contractor (MAC) for Railroad Medicare, nationwide, and Part A/B MAC for the States of West Virginia, Virginia, North and South Carolina has released the results of a widespread review of Advanced Life Support ambulance services which was conducted during the Second Quarter of Fiscal Year 2013.

Railroad Medicare claims were exclusively reviewed in this latest sampling.

Palmetto audited a total of 3,571 claims submitted between January and March 2013, specifically looking at the Emergency transport, Level ALS 1 and Non-emergency transport-BLS HCPCS codes.

Better Than Half Denied
Of the total reviewed, Palmetto GBA determined that 1,916 claims were denied, but they allowed 1,655 to stand. The overall error rate of the sampling came in at a dismal 56.9 percent.

A poor error rate such as this is concerning to the ambulance industry, to say the least. The current political climate points to CMS and the MAC’s continuing to ramp up further auditing and review efforts on a scale that the industry has never witnessed at any time in the past.

Palmetto cited future plans to continue this prepayment review cycle into the ensuing quarter and warned if billing error rates continued to be high that a review of individual providers may be initiated.

Signatures an Issue
If you’re a regular reader of our blog space, you know that we have been warning of the evolution of signature review. We have predicted that CMS and the MAC’s, by extension, will be reviewing patient signatures and provider signatures alike.

Palmetto GBA has now joined another MAC, WPS Medicare, by interpreting that patient signatures can no longer be accepted as “lifetime” signatures. During recent communication between our office and Palmetto GBA, on behalf of a client, Palmetto indicated to our staff that they interpret CMS directives to call for the capture of a patient Medicare beneficiary’s signature for each and every transport scenario, regardless if the patient is a repeat patient or has previously signed an authorization form.

No longer will collecting a signature as part of a past ambulance run be accepted as the required signature authorization for present and/or future transports, in Palmetto’s eyes. The use of “SOF” or Signature on File will no longer be recognized by Palmetto joining western States’ MAC, WPS Medicare.

How long until the other MAC’s follow? We don’t think it will be very long.

In addition, Palmetto denied 80 services in the sample because crew signatures on Patient Care Reports were either missing, illegible and/or undated. Likewise, they found missing, illegible and/or undated patient or patient representative signatures (while noting some persons signing on behalf of beneficiaries were not properly documented). In tandem, illegible signatures or missing appropriate person’s signatures were discovered on Physician Certification Statements (PCS’s) that accompanied non-emergency claims negating their use and thus causing the affected claims to be denied.

Two Parts

Now there’s a lot of information to glean from this report. So much, we’re going to break our recap into two parts. The bulk of the denials came from Palmetto’s determination that services were not reasonable and necessary coupled with findings of insufficient documentation to support the billed services.

We’ll recap that in our next blog post, so we can spend some time on that topic alone.

Our Recommendation- Take Action Now!
Don’t wait for Palmetto GBA or any other MAC to come knocking on your door before you attempt to tackle the issues if you know that there are areas of concern within your department.

The ramifications of such bleak findings will certainly be widespread as CMS is applying unprecedented pressure on the MAC’s to remedy what they feel is an epidemic of inappropriate claim payments.

Since we keyed on the signature issue, this time around, our recommendations for corrective action including the following.

We strongly recommend that you start today to put policies in place, educate your administrative, street and office staff of these findings and the accompanying rule changes. Once you have provided the proper communication internally, then test and measure the effectiveness of your initiatives immediately.

Set Goals and Share
Be sure to share the specific results of your internal auditing process with the entire staff. Provide specific goals that you wish for them to reach by providing correctly documented and captured information.

Require Crew Signatures
While most MAC’s only “require” that the author of a PCR sign the PCR, date his/her signature and properly identify himself/herself by printed name and certification level; we are finding that documentation is being denied on appeal when additional providers (minimum of primary crew members) are not all signing off on PCR’s.

For some time we have recommended that our clients capture full crew member signatures on all PCR’s, if possible. Legible signatures are best, complete with an accompanying date when the signature was affixed to the PCR along with an accompanying typed or printed name and certification level of the person signing in proximity to the actual signature.

A Signature for EVERY Run
If your department’s ambulance claims are being billed to either Palmetto GBA or WPS then it is now very important that you obtain a patient or patient representative signature for every ambulance incident, regardless if the patient is a repeat patient or not.

Remember, it is important that the patient sign a properly prepared authorization signature form (hard copy or computer generated), identifying himself or herself by printing when the signature is illegible. The signature must also be dated to show the date the signature was affixed to the authorization form.

Also, remember to properly identify those scenarios when the patient is “physically or mentally unable to sign” by listing a valid reason the patient cannot sign on the actual signature form and then obtain a signature from a patient representative in those instances. The aforementioned rules apply for the actual physical signature capture.

Monitor Who’s Signing PCS’s

We’ve provided a lot of education concerning PCS’s in the past.

Once again this report reminds us that the healthcare provider signatures on PCS’s are best when the signature is legible. Signatures must be dated with a printed name typed or printed in proximity of the signature itself.

Ahead of the Curve
Enhanced Management Services has been ahead of the curve in predicting these changes. We have blogged and issued direction to our clients for a few years on this very subject. We are satisfied that an overwhelming majority of our clients are properly capturing signature and maintaining compliance in all facets of the required documentation because of the advance education we have provided.

If your department isn’t receiving the guidance you need on this issue because it hasn’t yet transitioned your billing program to Enhanced, then today’s the day to begin the boarding process.

Contact Business Development Manager, Chuck Humphrey, today to learn more about how your department can to tap into Enhanced’s expertise and many years of combined experience. We’re compliance “fanatics” and we wouldn’t have it any other way.

You can reach Chuck by phone at (800) 369-7544, Extension 108 or by e-mail at

Don’t wait. Call Enhanced today!

The next letter you may open may be an audit request. Are you ready?
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