OIG Work Plan Zeroes in on HME Claims

WASHINGTON–Medicare claims from home medical equipment
providers–including those related to power wheelchairs and those
from providers in South Florida–will come under increased scrutiny
from the Office of Inspector General next year, according to a work
plan released last week.

Each year, the OIG, which was created by Congress to help
maintain the integrity of services provided by the Department of
Health and Human Services, compiles a list of issues related to
health care on which to focus in the coming year. The portion of
the 2008 list addressing Medicare includes 12 sections, among them
HME and supplies. The list also includes sections directed at
Medicaid and other CMS-related issues and investigations.

“Through our previous work, we have identified management and
performance challenges facing the Medicare and Medicaid programs,
most significantly oversight of Medicare Part D, integrity of
Medicare payments, appropriateness of Medicaid payments, Medicaid
and SCHIP administration, and quality of care in institutional and
community-based settings,” the OIG said.

The work plan lays out several areas related to HME that the OIG
intends to focus on through audits, evaluations and inspections.
The following areas are slated for review:

• Medicare claims for DME, prosthetics, orthotics and supplies
  furnished to beneficiaries receiving home health agency services.
  “Based on OIG interviews with home health patients, there were
  indications of unnecessary DME being ordered for beneficiaries
  receiving home health services,” the OIG noted.
• Appropriateness of Medicare payments to DME suppliers that
  submitted claims with modifiers. On review, several regional
  carriers that processed the DME claims “found that suppliers had
  little or no documentation to support their claims,” the OIG
  reported. “This suggests that many of the claims submitted may have
  been invalid and should not have been paid by Medicare.”
• Appropriateness of Medicare Part B payments for home blood
  glucose test strips and lancet supplies.
• Comparison of prices for negative pressure wound therapy pumps.
  “We will assess the range of supplier purchase prices for the pump
  to determine how Medicare reimbursement compares to the median
  supplier purchase price,” the OIG said, noting that between 2001
  and 2006, Medicare payments for the pump rose 624 percent. A recent
  OIG study found that 24 percent of pump claims did not meet
  Medicare coverage criteria.
• Payment suspensions for medical equipment suppliers. The OIG
  will seek to determine if CMS has inappropriately made payments to
  suspended or excluded DME suppliers; it will also assess the
  agency’s safeguards to prevent such payments.
• Adequacy of medical records and other supporting documentation
  used by the Comprehensive Error Rate Testing program. The OIG will
  consider appropriateness of payments for such items as power
  wheelchairs, orthotics and other supplies; whether documentation
  supports the claims; whether the items were medically necessary
  and/or whether beneficiaries actually received them.
• Appropriateness of Medicare reimbursement for pressure-reducing
  support surfaces.
• Medicare payments for power wheelchairs. The OIG will review
  documentation supporting claims for power wheelchairs to determine
  if Medicare beneficiaries received the required face-to-face
  examinations prior to receipt of the wheelchairs.
• Supplier purchase prices for power wheelchairs. The OIG said it
  will “determine the difference between the Medicare fee schedule
  for power wheelchairs and suppliers’ invoice prices.”

In addition, the OIG said it will continue to review claims
submitted by South Florida DME providers. In a report released
earlier this year, a review of DME suppliers in three South Florida
counties found that 31 percent did not meet selected Medicare
supplier standards.

The 2008 work plan also includes reviews of nursing home DME and
enteral nutrition.

Results of the reviews will appear in its annual report to
Congress next year, although some could appear in its 2009 report,
the OIG said.

Read the work plan in full.