WASHINGTON — HHS' Office of Inspector General has released its 2011 work plan and, as in 2010, various investigations and audits of Medicare payments to HME providers are on the hit list.
The OIG said it will look at:
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Payments for power mobility devices, hospital beds, oxygen concentrators and enteral/parenteral nutrition. According to the OIG, prior reviews "have identified issues such as Medicare payments for DME that was not ordered by physicians, not delivered to the beneficiaries, or not needed by beneficiaries."
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Replacement supplies. The OIG notes preliminary work showed "suppliers automatically shipped continuous positive airway pressure system and respiratory-assist device supplies when no physician order for refills was in effect."
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Documentation for standard and complex rehab wheelchairs "to determine whether the claims were medically necessary."
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Claims with modifiers. Reviews by the DME MACs have shown "that suppliers had little or no documentation to support their claims," the OIG said, "suggesting that many of the claims submitted may have been invalid and should not have been paid by Medicare."
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The fee schedule for parenteral nutrition. The OIG previously found that Medicare allowances for major parenteral nutrition codes "averaged 45 percent higher than Medicaid prices, 78 percent higher than prices available to Medicare risk-contract health maintenance organizations and 11 times higher than some manufacturers' contract prices."
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Payments for home blood glucose test strips and lancet supplies.
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Qualifications of orthotists and prosthetists, and payments for lower-limb prostheses.
The new targets follow a slew of reports related to HME that have poured out of the OIG in recent weeks — evidence that the agency honored its 2010 work plan, which also focused on the sector.
In September, the OIG reported that CMS shelled out an estimated $8.2 million worth of Part B payments for equipment and services for dead Medicare beneficiaries. In a wry note, the report stated: "Because medically necessary services cannot be provided after a beneficiary dies, payments for claims with dates of service after a beneficiary's death are overpayments."
In separate reports on three of the four Medicare jurisdictions — A, B and D — the OIG said that in 2007 the DME MAC contractors had inappropriately paid about $179 million to providers who did not have proper documentation on file but who had used the KX modifier on claims indicating that they did. Another report found that NHIC might have reimbursed inappropriate claims for blood glucose test strips to the tune of $39 million in 2007.
The OIG's latest reports and its new list of targets come just as competitive bidding is on track to be implemented Jan. 1 and, at the same time, just as the agency itself seems more in the limelight.
Inspector General Daniel R. Levinson was a frequent face on Capitol Hill last month as he testified before various committees. Speaking Sept. 22 at a House hearing on Medicare fraud, Levinson said that the need to strengthen the program's enrollment standards could hardly be overstated.
"We need to lock the front door, and the Patient Protection and Affordable Care Act provides tougher screening methods for Medicare enrollment that can help with that," Levinson told the House Energy and Commerce Subcommittee on Health. "Put simply, criminals who commit health care fraud are going to be cut off from the Medicare Trust Fund faster, face longer prison terms and be subject to larger criminal fines."
To support his comments, Levinson pulled data from 2006 and 2007 but did not mention new enrollment requirements for HME providers that include mandatory accreditation and surety bonds (as of October 2009).
According to the American Association for Homecare's Michael Reinemer, "Data from before 2009 is out of date, and citing data from 2006 or 2007, without any reference to what has happened since then, is extremely misleading. To muddy the discussion further, OIG discusses reimbursement rates in the same breath as fraud, conflating those entirely separate issues. And when OIG's PR machine spins this information for the media, the news media inevitably confuse criminal fraud with reimbursement issues."
The result, said Reinemer, AAHomecare vice president, communications and policy, is that "the public and policymakers end up knowing less than they did before because the information is so mangled."
HME advocates are hoping, however, that a couple more subjects on the OIG's new work list could clear the waters somewhat. In addition to claims payments, the OIG will scrutinize exactly how the National Supplier Clearinghouse has been screening and monitoring enrollees "to identify applicants that pose fraud risks to Medicare." Closing the door on the front end is where the focus should have been all along, AAHomecare and others point out.
Neither does the 2011 work plan skip over the industry's most hotly contested topic. As required by law, the OIG will conduct post-award audits "to assess the process used by CMS for competitive bidding and subsequent pricing determinations under Rounds 1 and 2 of the competitive bidding program."
See the OIG's entire 2011 work plan at http://www.oig.hhs.gov/publications/workplan/2011/.