The Department of Health and Human Services (HHS) Office of Inspector General (OIG) released a report on September 10 titled “Durable Medical Equipment Claims Paid by Noridian Healthcare Solutions, LLC, Did Not Always Meet the Requirements of the Local Coverage Determination for Lower Limb Prostheses.” Noridian is the Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor (DME MAC).
For the report, OIG reviewed lower-limb prosthetic claims Noridian paid between January 1, 2010, through December 31, 2011. The OIG’s findings for this two-year period follows.
- Noridian paid $96,509 for 48 lines of service for lower-limb prostheses that did not meet local coverage determination (LCD) requirements. Of this total, $89,762 was paid for 41 lines of service that had missing or incorrect functional level modifiers and $6,747 was paid for seven lines of service that had unallowable combinations of components.
- In response to a March 2012 Technical Direction Letter (TDL) from the Centers for Medicare & Medicaid Services (CMS), Noridian implemented and improved edits to address the LCD requirement, reprocessed claims from the prior period using the updated edits and found an additional 657 unallowable lines of service totaling $1,417,638, and then recovered the overpayments.
- Of the 48 lines of service OIG identified that did not meet LCD requirements, five lines of service occurred after Noridian implemented its improved edits. Noridian did not identify the other 43 lines of service during its reprocessing of previous claims.
OIG recommended that the Noridian recover the $96,508 in identified overpayments and continue to monitor the edits in response to the March 2012 TDL from CMS. Noridian said it had recouped all but $5,544 of the overpayments, was in the process of recouping the rest, and described corrective action it has taken to remedy these issues with its claims processing.