The work plan gives suppliers a glimpse into where Medicare may be making changes in the future. In 2016, the DME focus appears to be on lower volume products such as orthotic braces, osteogenesis stimulators and ventilators.
- In 2016 the OIG will evaluate the reasonableness of Medicare fee schedule amounts for orthotic braces. The agency will compare costs with non-Medicare payers to potentially identify wasteful spending on the part of Medicare and, based on the results, may consider reducing fee schedules for these items.
- Also for orthotic braces, the OIG will be assessing DME supplier compliance with the medical necessity requirements for these products.
- The agency will consider imposing capped rental guidelines and eliminating the lump sum purchase for osteogenesis stimulators.
- Due to a spike in ventilator utilization, the agency will be reviewing various trends in billing that are likely contributors. This review will include analysis of the utilization and billing for respiratory assist devices (RAD) and continuous positive airway pressure (CPAP) devices from 2011-2014. Additionally, the OIG will examine the impact of the competitive bidding program on ventilator billing trends.
As a part of the prescription drug section of the work plan, the OIG also plans to review payments made for immunosuppressive drugs billed with the KX modifier. This review will focus on documentation requirements to support the presence of the KX modifier which requires the supplier retain documentation of the beneficiary’s organ transplant date preceding the date of service for the immunosuppressive drug.
Two additional items were added to assess the effectiveness of CMS procedures to prevent and recoup payments made for items and services furnished to incarcerated beneficiaries and those unlawfully present in the United States.
A new issue was added to evaluate the efforts made by CMS to proactively manage the implementation of ICD-10. The OIG will review efforts made to educate and assist providers in the transition and also consider the impact on claims processing post transition.
Many other issues were carried over from the 2015 work plan including a review of lump sum purchase verses rental for power mobility; the impact of competitive bidding on patient access and DME suppliers; supplier compliance with payment requirements for power mobility and nebulizer equipment and supplies; and the effectiveness of system edits to prevent inappropriate payments for diabetes testing supplies.
Upon completion of a project, the OIG will make recommendations to CMS based on their findings. However, CMS has the final authority to implement or refrain from adopting the recommendations. The OIG is unlikely to tackle every item on the work plan, but MiraVista believes that additional scrutiny will take place in the ventilator category. This product is on the radar of a number of auditing contractors. There are a variety of complexities with the coverage of this product that remain to be satisfactorily resolved. MiraVista is acutely aware and actively involved in industry discussions to address the coverage gap that currently exists between RAD and ventilator coverage. MiraVista advises suppliers to adopt conservative procedures for ventilator qualification to insulate reimbursement from known exposure points. If you have questions or concerns regarding your ventilator program, contact our office.
To see the full OIG work plan visit: http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf