The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG), has issued its fiscal year 2015 Work Plan, which includes OIG’s ongoing and forthcoming activities related to suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), among other things. 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:
Quality of Care: Planned work will examine settings in which OIG has identified gaps in program safeguards intended to ensure medical necessity, patient safety, and quality of care. OIG will also continue its focus on access to care, including beneficiary access to DMEPOS in the context of new programs involving competitive bidding.
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 Benefit Policy Manual were met. 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.”
Competitive bidding for medical equipment items and services, mandatory post-award 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. Federal law requires OIG to conduct post-award audits to assess this process.
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. Congress directed OIG to monitor Part B billing for abuse during non-Part A stays to ensure that no excessive services are provided.