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Hello Colleagues and Guests,

Here we go. Following is one of the responses we have received from a
congressman's office in DC. If this doesn't make your blood boil, then I
suppose nothing will. Here's the text from DC:

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/............ after hounding a few folks, I'm not sure I can tell you much
more than you already know. I want to say up front that my efforts were
focused on understanding the policy changes captured in the MLN Matters
article you sent to me. I did not raise your specific case with the
Medicare reps; that is what Teri is working on through our district
office. Once she has heard back from them she will get back in touch
with you.

Here is what I can tell you. In 2009 Health and Human Services' Office of
Inspector General (OIG) conducted a review specifically focused on lower
limb prosthetic claims submitted to Medicare. Their research indicated
that there was a high error rate associated with these type of claims, so
they made recommendations to CMS on ways to reduce the errors. These
recommendations are captured in the MLN article, along with CMS'
concurrence and proposed actions.

One of the actions CMS is taking is a pre-pay medical claims review for
high-dollar submissions. From my understanding this medical review is not
being conducted by the DME MAC (National Government Services), but it
happening at a higher level. Because of this increased scrutiny,
additional documentation may be required from suppliers. Suppliers have
45 days to provide this information, and then Medicare has 60 days to
review and process the claim. It sounds like this is in keeping with your
experience. I was also told CMS is conducting post-reviews for about 20
suppliers with an abnormally high volume of claims.

(highlighted in red for the impact)
I understand this change puts your business in a very difficult position.
Unfortunately this action has been taken because there appears to be a
number of bad actors in your industry. While I can't speak to your
situation and why they're specifically reviewing your claims, this policy
will be in effect moving forward. If you have questions about the policy
change, feel free to email or call me. Again, once Teri hears back on her
specific inquiry, she will be in touch./

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We need all the folks we can muster to help write and complain about
what is happening with the pre-payment audits. Get on board with your
letter writing and let's hold them accountable for their actions. If we
are the crooks they claim we are, then that will show up soon enough.
Even so, we need to hold them accountable for their actions, just as
they are holding us accountable for ours.

As a side note, we are told by one congressman's office that the
Regulatory Flexibility Act does not appear to have been violated by
these actions.

We believe that getting your claims reviewed by an administrative law
judge will take 6 months, or more, due to the required appeal process.
If you can sustain that kind of cash flow problem, then I guess there
really isn't a problem, provided you win all of your A L J cases.

Wil Haines, CPO
MaxCare Bionics
Avon, IN