US Politics OIG report

Posted By: Jim DeWees on June 13, 2012

Hello everyone, Here is a link to a new OIG Report that I just got this afternoon from the listserve for our region (Indiana). It is quite interesting, and bothering at the same time. I will outline a few items that concern me, and should concern everyone. 1. The spending from 2005 to 2009 increased 27% for lower limb prosthetics....and the number of Medicare beneficiaries decreased by 2.5%. SO as you can see, that raised a big flag with CMS (OIG??) on the reason that there is a substantial increase. 2. There were 267 lower limb prosthetic providers who had "questionable billing practices" (they define what that means, and are listed in the article). There were approximately 136 suppliers who "frequently" did questionable billing, and did not have claims from the referring physicians. An additional 131 suppliers had other questionable billing practices. 3. Due to these kinds of billing issues, I agree that something should be done to make sure to tighten up how some people are billing or what is going on. Are there people in this field that bill for prosthetics and do not KNOW that they need a prescription from the physician? Or don't know that they must have a "right or left" modifier, OR a K level of function? If there are people in this field that do not know this, WHY do they not know? Maybe we need better training or mandatory updated training from ABC or some required continuing education that includes appropriate billing methods and rules. To be honest, I just learned about what CMS (or the local contracted administrator, in my case it is a company owned by Anthem Blue Cross, which is called "National Government Services, Inc." which few people know that Medicare is really being administered by Anthem in a lot of this nation) is requiring. I did not realize that the physicians MUST have the patient's functional level noted in THEIR chart notes, along with the patient's "abilities or potential" in their notes. This is a real pain to get the physician to write this in the notes. They are very cooperative in doing it when they know they have to do it. They have all worked very well with me to get them to chart and document the patient's level of function. I write an "example" of what Medicare is looking for, which will protect all of us and the patient. But I didn't learn this from any of our organizations, but I learned it from the manufacturers. I learned this at an Ossur training course, also from a Freedom course, and most recently from a PEL supply company/Otto Bock meeting in Cincinnati. I consider myself fairly active and up to date with rules and regulations, and I didn't know about this requirement or safe guard for upcoming audits from our local administrators and all the terms (PDACS, ZPics, and I have NO idea what all these mean, and who is what, etc.). 4. The list of 6 recommendations from the OIG to CMS. Out of the 6 recommendations, CMS agreed to 5 of them. You ALL need to read these recommendations, and then think about the consequences of these items and actions. 5. We are now ALL listed at "Moderate Risk" suppliers since we provide Lower Limb prosthetics. How nice!!! I feel so loved by them to automatically be labelled as a "Moderate Risk". BUT then CMS will monitor ALL of us, and if they see anything out of the ordinary, we will be elevated to "HIGH RISK" suppliers, and watched more closely. Here's a copy of the text: OIG Recommendation 5: Enhance screening for currently enrolled suppliers of lower limb prostheses. Federal regulations place new DMEPOS suppliers at the high-risk level and currently enrolled DMEPOS suppliers at the moderate-risk level. CMS should consider placing current suppliers of lower limb prostheses at the high-risk level, thus subjecting them to the more rigorous screening procedures.

CMS Response: CMS did not concur and stated that it has in place sufficient tools that allow for increased scrutiny of existing DMEPOS suppliers. CMS noted that if an existing supplier meets one of several triggering events, that supplier automatically is elevated to the high-risk level. 6. Here's another bothering issue, There will be "triggers" and thresholds that will bring on additional reviews and probes of suppliers. CMS agrees to set up supplemental criteria to determine "High Risk" suppliers.

OIG Recommendation 2: Strengthen monitoring of billing for lower limb prostheses. CMS should instruct the DME MACs, ZPICs, and DME PSCs to monitor billing for lower limb prostheses using the measures discussed in this report. CMS should develop thresholds for these measures and instruct its contractors to conduct additional reviews of suppliers that exceed the thresholds.

CMS Response: CMS concurred and stated it would issue guidance to the DME MACs and instruct them to consider the measures used in the OIG report as supplemental criteria for detecting high-risk suppliers. So what are these "thresholds"?? In an earlier section of the report, it listed a criteria for suppliers that were paid over $100,000 . It almost sounds like this is an attempt to restrict what they are paying for, or providing. Is this the new "Affordable Healthcare Act" and what we are going to be faced with, even worse than what we have been dealing with? We all need to read this information, keep up on what is going on, and take action before it is too late. What action? We are all supposed to be required to have "continuing education credits" to maintain our credentials. I think it might be a good idea to have some "required" courses. These need to include items like this, which appears to be killing this field, questioning all of us in this field, and automatically being placed as "Moderate Risk". If we are providing TOO many services, or making TOO many limbs, then we are placed in "High Risk" it seems. We really need to have some education in this area. I am not saying that we are all stupid or un-informed in this field, BUT there is a huge lack of education from our organizations and there are NO courses that I have seen where this is being discussed, or at least not available in some really accessible place or where I have seen it listed. As I said, I am up to date on most things in this field, and spend a lot of time following politics, rules, guidelines, classes, etc. OK, this basically sums up most of what I think is going on, and I am not that "hopeful" for the future of this field. It seems to be going downhill quite quickly, and there seems to be NO trust from CMS in our abilities or ethics to identify the patient's functional levels, or our abilities to recommend what the patient needs. This article clearly states that the Physical Therapists and Physicians should be now identifying and giving these functional levels, and documenting them. Don't our notes mean anything anymore?? Well, of course they do, and that is to find holes of issues in them that would place us in some "fraud" label. A missing "dotted I" or a crossed "T". We need to do more to improve our image in this area. We are losing this badly here. Thanks Jim DeWees, CP
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