DME Makes OIG Work Plan Once Again

WASHINGTON — HHS’ Office of Inspector General released its 2010 work plan Oct. 1, and as far as DME is concerned, it sounds like it could be a busy year.

The annual OlG work plan is an outline of various projects to be addressed during the government’s new fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations and Office of Counsel to the Inspector General.

Involving DME, the OIG said, next year it plans to:

• Review physician self-referral for DME.
• Review “the appropriateness” of payments to providers of power mobility devices, hospital beds and accessories, oxygen concentrators and enteral/parenteral nutrition. The OIG said prior reports had identified issues such as payments for DME that was not ordered by physicians, not delivered to beneficiaries or not needed by beneficiaries. “We will identify DME suppliers in selected geographic areas with high-volume claims and reimbursements to determine whether payments were made in accordance with Medicare requirements,” the work plan said.
• Review payments involving claims with modifiers. On this subject, the OIG said, “Reviews of suppliers conducted by several of CMS’ DME regional carriers found that suppliers had little or no documentation to support their claims. This suggests that many of the claims submitted may have been invalid and should not have been paid by Medicare.”
• Verify CMS’ actions in implementing the OIG’s recommendations regarding medical review of claims for the CERT (Comprehensive Error Rate Testing) program. In an August 2008 report, the OIG recommended that CMS require the CERT contractor to “review all available supplier documentation, review all medical records necessary to determine medical necessity, and contact beneficiaries named on high-risk claims.”
• Review DME categorization in the Medicare fee schedule. Because the fee schedule was created more than 20 years ago, the OIG said, some DME items may be in categories that no longer reflect current costs, expected duration of beneficiary use or the extent of servicing involved to maintain the equipment.
• Review enteral nutrition therapy “to assess the medical necessity, adequacy of documentation and coding accuracy of claims submitted for beneficiaries during a nursing home stay that is not covered under the Part A SNF benefit.”
• Review Medicare’s fee schedule for parenteral nutrition compared to fees paid by other sources of reimbursement.
• Review payments for blood glucose test strips and lancet supplies.
• Review documentation supporting claims for PWCs “to determine whether Medicare beneficiaries received the required face-to-face examinations from the referring practitioners prior to receipt of power wheelchairs.” In 2003, the OIG said, payments for PWCs peaked at $1.2 billion. In 2004, as a result of expanded CMS program integrity initiatives, PWC spending decreased to $850 million; “however, problems may persist.” In 2007, approximately 173,300 beneficiaries received PWCs at a total cost of $686 million.
• Review documentation of payments for standard and complex PWCs “to determine whether suppliers meet Medicare’s coverage criteria and medical necessity documentation requirements.” The work plan said OIG will determine whether providers had the required documentation from beneficiaries’ medical records “that clearly supported the medical necessity of the power wheelchairs.”
• Review payments for repair and servicing of capped rental DME, including wheelchairs and hospital beds. Because previous OIG work found that Medicare paid “substantially” more for maintenance on rented equipment than repairs on purchased equipment, the OIG will examine servicing records and interview beneficiaries about their experiences with capped rental DME to determine whether Medicare made proper payments for maintenance and repair services.
• Review the Medicare contractors’ processes for enrolling and monitoring DMEPOS providers.

To view the work plan in full, go to oig.hhs.gov/08/Work_Plan_FY_2010.pdf.