CMS has rejected a recommendation from the Office of Inspector General (OIG) to categorize all currently enrolled DME suppliers as high risk. Federal enrollment regulations currently require all suppliers to be classified into one of three fraud risk categories: low, moderate, or high. Under the new regulations, all newly enrolling suppliers are classified as high risk, while currently enrolled suppliers are considered to be a moderate risk. At the moderate risk level, suppliers revalidating their enrollment must pay a Medicare enrollment fee, pass licensure and database verification checks, and undergo an unannounced on-site visit. Had CMS accepted the OIG’s recommendation to deem all DME suppliers high risk, currently enrolled suppliers would also have had to undergo criminal background checks and fingerprinting (at a cost of $50 per individual) during revalidation.
The OIG issued the high risk recommendation, along with three others, in a report published on July 2011. According to the report, in 2007 Medicare inappropriately allowed $95-million in payments for power wheelchairs that were either medically unnecessary (i.e. the patient qualified for a lower level chair) or lacked sufficient documentation. However, supplier billing errors weren’t the only cause of improperly paid claims.
According to the OIG, 39% of the total claims reviewed had no direct billing errors in the supplier’s record. However, 78% of those otherwise clean claims were ultimately determined to be overpayments due to inadequate documentation in the physician’s record. As a result, the OIG provided the following three recommendations to which CMS concurred:
- Direct contractors to review records from prescribing physicians, in addition to those from suppliers,
- Continue to educate power wheelchair suppliers and prescribing physicians, and
- Review the suppliers for which claims were found to be in error.
These recommendations come on the heels of a new power mobility face-to-face exam checklist, released by CMS in May, and are indicative that both CMS and the OIG clearly recognize a need for greater physician education. What remains to be seen is whether concurrence with the recommendations means CMS and its contractors will play a more active role in educating physicians, and whether CMS may ultimately consider a revision to mobility documentation requirements as a solution.