CMS: Make Sure Claims are Squeaky Clean

BALTIMIORE — If HME providers hadn’t yet realized their
Medicare claims are being closely scrutinized, they got the point
in no uncertain terms on a joint CMS-OIG “listening session” June
7. The overall message of the special teleconference: Make sure DME
beneficiaries meet coverage criteria, and make sure claims are
supported by whatever — and all — documentation
required.

CMS’ Bill Gould, deputy director of the Provider Compliance
Group, explained the agency was taking a new approach to provider
education in response to several Office of Inspector General
reports addressing improper payments and sky-high denial rates for
a variety of equipment.

“This is a very unique kind of approach for us in provider
compliance and medical review to conduct such an educational call,”
said Gould, noting that if the format is successful, there could be
more collaborative sessions in the future.

Other presenters on the two-hour call included representatives
from the OIG along with DME MAC Medical Directors Dr. Paul Hughes
(Region A) and Dr. Adrian Oleck (Region B), who pointed out common
errors in an effort to make sure claims are compliant with policy,
billing instructions and medical review guidance.

The outreach call covered OIG reports on pressure-reducing
support surfaces, power wheelchairs, negative pressure wound
therapy and place-of-service issues related to DME provided to
beneficiaries in nursing homes. A few highlights from the call
follow:

Place of Service

In a report titled “Part B Services During Non-Part A Nursing Home Stays:
DME,” the OIG found that $30 million was inappropriately
allowed for DME during non-Part A skilled nursing facility stays in
2006. On 98 percent of the disallowed claims, “suppliers indicated
that the place of service was the beneficiary’s home when in fact
the beneficiary was already residing in a nursing home,” according
to the OIG presenter. Rentals accounted for 75 percent of the total
in disallowed payments, and wheelchairs and oxygen accounted for 72
percent. “That leaves you the question whether or not in those
instances it was possible that the patient first entered the
nursing home from their home and the place of service might not
have ever changed,” the presenter said.

“What I usually tell folks when they ask me,” advised Hughes,
“… is ask yourself if the person is getting any care from any
medical personnel — nurses, therapists, nurses’ aids,
physicians, etc. — and if they are, then they are getting
some level of care that will exclude that facility from being
considered as home.” Of facilities that designate particular beds
as distinct “home” beds, Hughes noted, “in general when we’ve done
audits, that distinction doesn’t hold up.”

Pressure-Reducing Support Surfaces

Another OIG report found that 86 percent of Group 2 support surface claims for the first half of
2007 did not meet Medicare coverage criteria totaling $33 million
in inappropriate payments. Eighty percent of the claims failed to
meet clinical requirements, and 38 percent were undocumented, the
report showed. “Further,” the OIG presenter said, “we found that 22
percent of the claims were actually medically unnecessary.”

In addition, the OIG found that a third of the claims did not
meet supplier documentation requirements for various reasons:
“Suppliers delivered the support surface before obtaining the
physician order or did not have a physician order on record at all,
or were missing proof of delivery or the physician order was not
dated,” the presenter said.

“Group 2 support surfaces are really intended for relatively
short-term use,” explained Region B’s Oleck, adding that once the
pressure ulcer has healed, “it would be appropriate to switch the
patient to a Group 1 support surface to try to prevent a recurrence
of that.” For that reason, he continued, “it is important that
there be ongoing involvement of the clinician with the care of the
patient and good communication between the supplier and those
clinicians so that they can keep abreast of what is happening with
the wound healing.”

There needs to be documentation not only of the initial coverage
criteria “but also on an ongoing basis,” the DME MAC medical
director said. “Generally at least on a monthly basis, we would
expect there to be some documentation by the clinicians who are
following the patient to be able to show what progress was being
made, and suppliers also need to be aware that when healing has
occurred, then coverage for that will have stopped.”

About the OIG’s denial rate finding, Oleck commented, “I will
say that when the DME MACS have conducted their individual edits,
we have often found similar high error rates, and also the CERT
contractor in their random reviews of claims has found similar high
error rates.

“Another group that will be looking at these, we think, are the
recovery audit contractors, or RACs. They’re really in the fairly
early stages of their activities on DME claims,” Oleck said, “but I
think support surfaces are one of the areas that they will be
considering.”

Power Wheelchairs

In a review of claims for power wheelchairs (KO823 and
KO835-KO864), last year the OIG published a memo on miscoded claims
and another on supplier acquisition costs. The OIG is also working
on a forthcoming report on compliance with Medicare clinical
requirements that will be based on a medical records review, a
representative said.

For its previous reviews of PWC claims, the OIG looked at
compliance with six documents, five from the local coverage
determination for power mobility devices and one from the supplier
standards regarding proof of delivery.

“Three out of five claims for standard and complex
rehabilitation power wheelchairs did not meet Medicare
documentation requirements during the first half of 2007,”
accounting for $112 million in improper payments, the OIG presenter
reported, although she noted PWC claims were “more likely to meet
documentation requirements than some others.” Error rates, she
said, ranged from 1 percent of claims that did not include proof of
delivery to 40 percent for which supporting documentation and
detailed product descriptions were not submitted or were
incomplete.

“Fifty percent of claims had at least one documentation error,
however many of these, or 38 percent of all the claims, had more
than one documentation error, which means that more than one
required document was either missing or incomplete,” the presenter
said. (For industry response to the OIG report, see Industry Fires
Back at OIG Report on PWC Documentation, Jan. 11.)

“This analysis that shies away from discussion of medical
necessity and focuses on a variety of technical documentation
issues is particularly timely because it’s an angle on power
wheelchairs that I know from our audits causes quite a number of
denials,” confirmed Region A’s Hughes. “Remember that this high
error rate — 50 percent — of these claims were denied
not because of the content of the medical record, not because of
the content of the face-to-face exam, but were denied because some
required piece of documentation either wasn’t present or, if it was
present, it wasn’t done up to the required specification.”

Hughes counseled providers to pay attention to all seven
elements of the order to support their claims.

Because there continues to be “a very high error rate” related
to power mobility claims, added CMS’ Gould, “this kind of
educational effort is part of a broader approach that we [are]
putting in place to hopefully reduce that error rate.” With more
specific education, he said, “we hope we can drive that error rate
down.”

Labeling the lengthy call a “test run” and “an experiment in how
we educate you on what we find in terms of claims payment,” Gould
said, “Our goal, as we’ve always stated, is to make sure claims are
paid appropriately, accurately and timely. This is part of our
mission to achieve that goal.”

CMS has set up an emailbox for comments and questions at
[email protected].
“We’d really like to get your feedback,” Gould told listeners.

You can find the reports discussed on the call on the OIG
website at oig.hhs.gov/reports.asp:

• OEI-02-07-00420 – Inappropriate Medicare Payments for Pressure
  Reducing Support Surfaces
• OEI-02-07-00421 – Memorandum Report: Vulnerabilities in
  Medicare Payments for Pressure Reducing Support Surfaces
• OEI-04-07-00401 – Medicare Power Wheelchairs Claims Frequently
  Did Not Meet Documentation Requirements
• OEI-02-07-00660 – Comparison Prices for Negative Pressure Wound
  Therapy Pumps
• OEI-06-06-00100 – Part B services During a Non Part A Nursing
  Home Stays: DME