The Office of the Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) has issued its fiscal year 2016 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 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.
New: Orthotic braces-reasonableness of Medicare payments compared to amounts paid by other payers. OIG will determine the reasonableness of Medicare fee schedule amounts for orthotic braces; compare Medicare payments made for orthotic braces to amounts paid by non-Medicare payers, such as private insurance companies, to identify potentially wasteful spending; and estimate the financial impact on Medicare and on beneficiaries of aligning the fee schedule for orthotic braces with those of non-Medicare payers.
New: Orthotic braces-supplier compliance with payment requirements. OIG will review Medicare Part B payments for orthotic braces to determine whether DMEPOS suppliers’ claims were medically necessary and were supported in accordance with Medicare requirements. Prior OIG work indicated that some DMEPOS suppliers were billing for services that were medically unnecessary (e.g., beneficiaries receiving multiple braces and referring physician did not see the beneficiary) or were not documented in accordance with Medicare requirements. Medicare requires that such items be “reasonable and necessary.” Further, local coverage determinations issued by the four Medicare contractors that process DMEPOS claims include utilization guidelines and documentation requirements for orthotic braces.
