The U.S. Department of Health and Human Services (HHS), Office of the Inspector General (OIG), has issued its fiscal year 2014 Work Plan, which includes OIG’s ongoing and forthcoming activities related to suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). It provides healthcare industry stakeholders with a summary of new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year and beyond. The OIG Work Plan priorities often result in additional enforcement action, significant change in Centers for Medicare & Medicaid Services (CMS) policy, or both.
The following is a summary of issues in the Work Plan that will directly impact O&P.
- Lower-limb prosthetics supplier compliance with payment requirements. OIG will review Medicare Part B payments for claims submitted by medical equipment suppliers for lower-limb prostheses to determine whether the requirements of CMS’s Benefits Policy Manual, Pub. No. 100-02, ch. 15, § 120, were met. Context: A national OIG review of suppliers of lower-limb prostheses identified 267 suppliers that had questionable billing. Earlier OIG work found that suppliers frequently submitted claims that did not meet certain Medicare requirements; were for beneficiaries with no claims from their referring physicians; and had other questionable billing characteristics (e.g., billing for lower-limb prostheses for a high percentage of beneficiaries with no history of amputations or missing limbs). Such claims are questionable and, if determined to be improper, should not be paid by Medicare. Payments to service providers are precluded unless the provider has and furnishes upon request the information necessary to determine the amounts due. Medicare does not pay for items or services that are not reasonable and necessary. (Work in progress.)
- Competitive bidding for medical equipment items and services, mandatory postaward audit. OIG will review the process CMS used to conduct competitive bidding and to make subsequent pricing determinations for certain medical equipment items and services in selected competitive bidding areas under rounds 1 and 2 of the competitive bidding program. Context: Federal law requires OIG to conduct post-award audits to assess this process. (Work in progress.)
- Questionable billing patterns for Part B services during nursing home stays. OIG will identify questionable billing patterns associated with nursing homes and Medicare providers for Part B services provided to nursing home residents during stays not paid under Part A (for example, stays during which benefits are exhausted or the three-day prior-inpatient-stay requirement is not met). A series of studies will examine several broad categories of services, such as foot care. Context: Congress explicitly directed OIG to monitor Part B billing for abuse during non-Part A stays. (Work in progress.)
- Physicians and suppliers noncompliance with assignment rules and excessive billing of beneficiaries. OIG will review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. OIG will also assess the effects of their participation and claim assignments on the Medicare program (such as noncompliance with assignment rules) and on beneficiaries (such as excessive billing of beneficiaries’ share of charges). Context: Physicians participating in Medicare agree to accept payment on “assignment” for all items and services furnished to individuals enrolled in Medicare. CMS defines “assignment” as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or other supplier. The physician or other supplier in return agrees to accept the Medicare-allowed amount indicated by the carrier as the full charge for the items or services provided. (Work in progress.)