Commercial audits of DME, HIT and HCD claims taking place

SCIO Health Analytics^®, an independent company that provides auditing support for Blue Cross Blue Shield of Michigan, began audits for durable medical equipment, home infusion therapy and high-cost drug claims on July 1, 2019.

Blue Cross conducts audits to ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract according Blue Cross’ compliance and policy guidelines. Specifically, audits are conducted to:

• Confirm compliance with ICD-10 guidelines and diagnostic codes that are in effect on the date of service
• Confirm compliance with CPT^® guidelines and codes
• Confirm proper use of HCPCS codes
• Detect, prevent and correct waste and abuse
• Facilitate accurate claim payment

You’ll need to provide medical charts for review at the time of an audit.

Durable medical equipment and diabetic supplies
Documentation for DME and diabetic supplies must support all items billed on the claim form. It should include:

• Prescription or order form from the referring physician
• Certificate of Medical Necessity, if applicable
• Physician chart notes, if applicable
• Orthotist or prosthetist evaluation notes, if applicable
• Delivery ticket
• Pickup ticket, if applicable
• Blue Cross’ authorization for treatment, if applicable
• For diabetic supplies, proof of member contact must be documented for each refill.

SCIO will confirm you’ve properly documented requirements for:

• Duplicate therapies and inappropriate equipment for diagnosis
• Purchase versus rental
• Multiple providers billing for same services
• Multiple purchases of same items
• Capitation arrangement with additional fee-for-service item
• Capped rental items

Home infusion therapy and high cost drug claims
HIT and HCD claims will be audited to ensure injections and infusions were ordered by the physician, billed appropriately by the provider and paid accurately by the payer. Considerations include:

• Duplication of therapies by different providers
• Waste
• Correct dosages administered
• Various billing and processing errors
• Validation of drug pricing
• Medical record reviews to verify compliance of dosage, method of administration and other criteria

More information
After an audit, SCIO will send you a finding letter with instructions on how to request an appeal in case you decide to do so.

If you have questions, call your Blue Cross provider consultant. Or, to speak with a SCIO representative, call 1‑866‑628‑3488, ext. 7411.