OIG Aims at DME in 2009 Work Plan

WASHINGTON–In its Work Plan for 2009, issued earlier this
month, HHS’ Office of Inspector General said it will take on a
number of DME investigations.

Among them, the OIG will focus on payments for CPAP; enteral
nutrition provided to patients in nursing homes; blood glucose test
strips and lancets; pressure-reducing support surfaces; negative
pressure wound therapy pumps; DME items and supplies provided to
patients in nursing homes; power wheelchairs; and repair and
service of capped rental DME.

Citing its reasons for choosing these particular targets, the
OIG said:

–CPAP: “Previous OIG work revealed cases in which
Medicare paid for CPAP devices that were not used by or delivered
to beneficiaries. We will determine whether Medicare payments for
CPAP devices were supported, billed, and paid in accordance with
Medicare requirements.”

–Enteral nutrition for nursing home patients: “We
will review Part B ENT, commonly called tube feeding, to determine
the appropriateness of payments for associated services. This
review will specifically assess the medical necessity, adequacy of
documentation, and coding accuracy of claims submitted for Medicare
beneficiaries during a nursing home stay that is not covered under
the Part A SNF benefit.”

–Diabetes supplies: “The Local Medical Review
Policies (LMRP) or local coverage determinations, whichever are
applicable, issued by the four DME MACs require that the
physician’s order for each item billed to Medicare include
certain elements and be retained by the supplier to support billing
for those services. Further, the LMRP require that suppliers add a
modifier to identify when the patient is insulin-treated or
noninsulin-treated. The amount of supplies allowable for Medicare
reimbursement differs depending on the applicable modifier. We will
determine the appropriateness of Medicare Part B payments to DME
suppliers for home blood glucose test strips and lancet
supplies.”

–Pressure-reducing support surfaces: “In 2006,
Medicare-allowed charges for support surfaces reached $164 million.
We will conduct a medical review of claims to determine the
appropriateness of payments for support surfaces.”

–Negative pressure wound therapy pumps: “A
previous OIG review found that 24 percent of pump claims did not
meet Medicare coverage criteria. Between 2001 and 2006, Medicare
payment for the pump rose 692 percent. We will assess the range of
supplier purchase prices for the pump to determine how Medicare
reimbursement compares to the median supplier purchase
price.”

–DME for nursing home patients: “A previous OIG
report found that $210 million was potentially inappropriately paid
for DME for beneficiaries residing in nursing homes. We will review
Medicare claims data to determine the extent of inappropriate
Medicare Part B DME payments made on behalf of Medicare
beneficiaries during nursing home stays not covered by Medicare
Part A.”

–Power wheelchairs: “In 2003, Medicare payments
for power wheelchairs peaked at $1.2 billion. In 2004, as a result
of expanded CMS program integrity initiatives, power wheelchair
spending decreased to $850 million. However, Medicare payments for
power wheelchairs increased again in 2005 to approximately $920
million. We will determine the appropriateness of Medicare payments
for power wheelchairs.”

–Service and repair of capped rental DME: “For
capped rental DME furnished on or after Jan. 1, 2006, Medicare
requires suppliers to transfer the title of DME to the beneficiary
after Medicare pays 13 months’ rent under a capped rental
arrangement. After that time, Medicare continues to pay for
reasonable and necessary repairs to the equipment. Previous OIG
work found that Medicare paid substantially more for maintenance on
rented equipment than repairs on purchased equipment. We will
examine servicing records from suppliers and interview
beneficiaries regarding their experiences with capped rental DME to
determine if Medicare made proper payments for maintenance and
repair services.”

For a PDF of the 115-page OIG work plan, which also includes
investigative projects involving hospitals, home health agencies,
hospice, physicians and other medical professionals, click here.