03/02/2016    Paul Kesselman, DPM

NPs and PAs Providing Diabetic Foot Examinations (Joseph Borreggine DPM)

While I was not on this call due to a scheduling
conflict, I was told that the meeting w NGS went
very well. This meeting was arranged for by APMA
and open to all. The presenters of NGS were
members of the Provider Outreach and Education
(POE) team, not auditors or a Carrier Medical
Director (CMD).

Prior to this call, one week earlier, a conference
call took place with Dr. Hoover (Region C CMD) and
supervisory auditors from CGS along with some APMA
staff and a few others selected by APMA. This call
was initiated by the Georgia Carrier Advisory
Committee rep, Dr. Len La Russa who himself had
12/16 claims slated to go to the ALJ pulled and
ordered paid by the Supervisor of the auditing
staff at CGS. She had researched these claims and
found the original documentation sent for pre-
payment audit, was in accordance with the LCD and
ordered them paid.

He and I had discussed these issues for the last
several months and thought it would be a good idea
for a small select few to specifically address
issues with the auditing process with appropriate
personnel at CGS. Here is a summary of the
discussion:

Dr. Hoover and the auditing staff allowed me to
speak for several minutes, during which time I
took them to task over the issues which the CAC
rep and many other suppliers constantly
confronted.

These included responses to the audits which
clearly made no sense and which were provided
based on the CAC reps experience and about 48
other examples which I had reviewed for APMA.
Rejections for things such as a lack of a foot
exam, when was clearly conducted by the DPM and
which clearly documented 1/6 qualifying conditions
and which clearly was co signed and agreed to by
the managing MD/DO in a timely fashion; lack of a
medical note from the MD which clearly outlined
the patients DM care, etc, which clearly was
provided and performed within the time constraints
of the TSPD policy.

There were even several rejections for lack of a
response to the audit, when it was clearly
received by CGS (e.g. proof of mail delivery
provided). I even took some exception to the CERT
December webinar webinar and have had several
respectful conversations with them regarding their
findings. They have been very sympathetic and
urged CGS to participate in the discussions which
recently took place.

There were of course many of the 48 examples which
clearly should have (and were) rejected by CGS and
those illustrated to me how many DPMs still lack a
clear understanding of what is required or just
choose to ignore the regulations and take their
chances. I readily admitted that fact and
suggested that perhaps CGS still needed to do a
better job of educating those asepcts of the
supplier community, no matter what type of
provider they are.

Dr. Hoover was very gracious on the call and he
agreed with the issues I (and other APMA staff
presented). He readily admitted that CGS needed to
and was now doing a better job at educating the
auditing staff. He suggested that in the last few
months they have revved up the educating process
of the auditors and results for January 2016 (and
his prediction for the remainder of this first
quarter) would reflect a significant difference
from the last quarter of 2015.

They are basing those results on the % changes
during January and saw no reason that this was not
going to continue. I also suggested that any
conflicting findings between Educational Review
Program Auditors and those of the Pre Payment
audit level would only further confuse suppliers
and continue to be costly to the DME MAC's profit
margin.

I also asked Dr. Hoover why statistics for any one
supplier group (e.g., podiatry) could not be
obtainable with regards to audit results. While
BMAD data is available for different supplier
types, this data does not adequately describe the
rationale for claims rejections.

Furthermore, years ago, I was able to obtain that
data for podiatry from Region A on a quarterly
basis. Dr. Hoover thought that this data was
obtainable and I am going to follow up w/him on
this. This could the carriers tremendously (by
saving them $$$) if they knew which supplier group
needs more educating and audits targeting those
who continue to fail. This ultimately would save
both the carriers and the CMS $$ by selectively
targeting the appropriate supplier types for more
or less education and increased or less audit
scrutiny. Less audits, less personnel, less
expenses to draw down the carrier's net profit
etc. He agreed this was a good idea and I am going
to follow up w/him to see what statistics can be
obtainable (possibly under FOI).

I asked several questions regarding the issue of
an NP/PA signing the medical exam (not the Cert
statement) and the MD/DO managing the DM signing
off on the exam, with the signature of that MD/DO
being dated and stating,"I was present and
supervised the exam."

Dr. Hoover's response (echoed by the auditing
staff):

1) A PA or NP may not perform or be a co-signature
to the medical record establishing the patients
diagnosis of DM. The exam must be done by an MD or
DO and the MD/DO cannot simply state "I supervised
and was present during the exam." This is true
regardless of HSA status.

2) AN MD or DO is the only degree acceptable on
the cert statement, regardless of HSA.

While the carriers are sympathetic to the issue of
hardship for patients, CMD Hoover expressed what I
have heard before from CMDs and CMS. Since TSPD
coverage was provided through an act of Congress,
any substantive changes to requirements must be
accomplished by another act of Congress. A HSA
area would not provide any exemptions to the
rules. The only exemption that the TSPD allows for
with respect to medical degrees is when Certifying
physician may also be the supplier. This is only
in an HSA.

There certainly was no mention of shortage areas
being granted an exemption to allowing the DPM NP
or PA to be the Cert physician. If anything there
was significant emphasis to the contrary.

My suggestion again is if there are any
discrepancies noted between the opinions presented
during the webinar open to all from NGS and the
limited access call w/auditors and the CMD from
Region C, one should defer to that which took
place with Region C. The reason being is those who
participated for Region C vs. those who
participated for Region B.

In the past, when questions during POE calls
cannot be answered by POE reps, they always defer
to auditors, policy writers and the CMD.
Calls like this and open dialog as was made
possible by Dr. La Russa can only serve to help us
provide the proper care for our patients.

Dr. La Russa deserves congratulations on a job
well done!

Paul Kesselman, DPM, Woodside, NY

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