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OIG Work Plan For HME Providers By: Jane Wilkinson-Bunch.

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Presentation on theme: "OIG Work Plan For HME Providers By: Jane Wilkinson-Bunch."— Presentation transcript:

1 OIG Work Plan For HME Providers By: Jane Wilkinson-Bunch

2 2008 OIG Work Plan  At the Beginning of each fiscal year, the OIG identifies vulnerabilities in DHHS programs and activities, and works to improve their efficiency and effectiveness  It is a year-round project that continually changes with new information, new issues and shifts in the priorities in the Congress, President and Secretary

3 2008 Areas Focused on for Home Medical Equipment  DME Payments for Beneficiaries Receiving Home Health Services  Therapeutic Shoes  KX and KS Modifiers  Medical Necessity of DME  Medicare Pricing of Equipment and Supplies

4 Beneficiaries Receiving Home Health Services  A review of medical records for DME items and supplies for beneficiaries receiving HHA services, to determine if the items and supplies were reasonable and necessary for the beneficiaries condition

5 Therapeutic Footwear  Determination will be made whether therapeutic footwear was reasonable and necessary for the beneficiaries whom it was provided.  Previous OIG report indicates that a significant percentage of beneficiaries did not have adequate documentation to support the medical necessity of the footwear

6 Therapeutic Shoes and Inserts for Diabetic Patients  Physician Order (coverage good for 1 calendar year) Must be signed by Dr. treating patient for diabetes  Must also be treated for diabetes  ICD-9 CM Codes AND Patient must meet medical policy guidelines  KX Modifier, RT – right, LT – left  Pair is reported as two units  Prescribing physician – writes order for shoe, modifications, and/or inserts (may be a pedorthist, M.D.,D.O., podiatrist or orthotist)

7 Therapeutic Shoes and Inserts for Diabetic Patients  Be sure you have documentation that the personnel fitting your shoes and inserts have appropriate training and you document how the patient was fitted  Check state licensure requirements for O & P

8 Some States Require Licensure for Therapeutic Shoes  These are some of the following states that require state Licensure to provide diabetic shoes:  Alabama, Arkansas, Florida, Illinois, Mississippi, New Jersey, Ohio, Oklahoma, Tennessee, Texas, Rhode Island and Washington  There are more requiring licensure constantly, so check your state requirements regularly!!

9 KX and KS Modifiers  When a claim is filed with the KX or KS modifier, the provider, upon request, must provide documentation to support the claim for payment  OIG has found that many suppliers had little or no documentation to support the claims, therefore many of these claims should not have been paid

10 Most Items Requiring “KX” Modifier – Diabetic Shoes and Inserts – Urological Supplies – Group I, II and III Support Surfaces (including wheelchair cushions) – Diabetes Monitor & Supplies (insulin dependent) – Dialysis Supplies (Epoetin Alpha-Epo) – Refractive Lenses – Bedside Commodes – Cervical Traction Equipment (E0849) – Conductive Garment (E0731) – Ankle Gauntlets – Orthopedic Footwear – Continuous Positive Airway Pressure Devices (CPAP) & Supplies – Respiratory Assist Devices & Supplies – All Walkers & Accessories – Negative Pressure Wound Therapy Pump – High Frequency Chest Wall Oscillation Devices – Hospital beds & Accessories – All Wheelchairs & Accessories – Trapeze Bars

11 Medical Necessity of DME  Determine the appropriateness of Medicare payments for items such as Power Wheelchairs, Wound Care equipment and supplies and orthotics  Assessment will include documentation to support claim, documentation to support medical necessity and whether the beneficiary actually received the item

12 Medicare Pricing of Equipment and Supplies  Comparison of Medicare payment rates for certain medical equipment and supplies with rates of other Federal and State Programs as well as wholesale and retail prices  Review will cover such items as Wheelchairs, Parental Nutrition, Wound Care equipment and supplies, and Oxygen equipment and supplies

13 Will You Be Audited? IS JANE BUNCH SOUTHERN?  Targeted Audits – Bill more than one million per year – Limited product mix – ***Beneficiary /other complaints*** – Frequent claims for abused items – Recurring errors on claims – Abnormal charge pattern – Dramatic changes in fees – Repeated billing for overutilization  Routine Audits

14 TARGETED TYPES – Program Integrity Reviews documentation and record content – Utilization Review Verifies need and frequency – ECS Authenticity/signature on file – Phone/Fax – Mail (Love Letter from CMS) – On-site – RAC Audits – CERT Audits Are you prepared to survive?

15 Your Internal Audit Should Include: – Review of Documentation Requiring Beneficiary Signature Assignment of Benefits Supplier Standards Release of Information Rental/Purchase Option Delivery Ticket/Pickup Slip HIPAA Notice of Uses/Privacy Practices ABN (Advanced Beneficiary Notice) – Review of Medical Necessity Documentation Physician Orders WOPDs CMNs

16 Patient’s Medical Records  The CMN is not enough if audited  Attempt to obtain the following: * Physician’s Office Records * Labs and X-Rays related to diagnosis * Hospital Records * Nursing Home records * Home Health Agency Records * Records from other Healthcare Professionals The medical records should contain objective data to support the physician statement, diagnosis or condition.

17 Auditing The Delivery Ticket  Patient’s Full Name & Address  Quantity of equipment and/or supplies delivered  Detailed description of the item being delivered  Brand name of equipment or supplies  Serial and/or lot numbers  Patient’s/Designee signature and date

18 Delivery Ticket Requirements  Signature date must be the date that the item was received by the beneficiary or designee – Designee is… “Any person who can sign and accept the delivery of durable medical equipment on behalf of the beneficiary.” Relationship must be noted on delivery slip  7 days to call...  5 days to bill...  48 hours following discharge after hospital / discharge...

19 Auditing the AOB Form  Assignment of Benefits – Equipment / supply itemized – New signed form required for each new product class – Must be itemized with each supply or piece of equipment the patient is authorizing you to bill. – Patient unable to sign – Requirements must be met

20 Auditing the ABN  Advanced Beneficiary Notice – Specific situation/reason noted – Must be obtained before delivery – Correct use of modifiers –“GZ” beneficiary did NOT sign ABN Upgrade with NO ABN –“GL” free upgrade provided –“GK” item physician actually ordered Item must be billed correctly –“GA” upgrade provided and supplier has obtained a signed ABN from beneficiary before item was delivered – Patient signature and date – Correct form used?

21 “ABN” cont… – “Routine" or “Blanket" ABNs to Medicare beneficiaries are not permitted – An ABN should not be given to a Medicare beneficiary unless the supplier has a genuine reason to expect that Medicare will deny payment for some or all of the services. – Assigned and non-assigned claims – ABN’s are only good for ONE YEAR!

22 NEW ABN FORM: (A) Notifier(s): (B) Patient Name: (C) Identification Number: ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN) NOTE: If Medicare doesn ’ t pay for (D)_____________ below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the (D)_____________ below. (D) (E) Reason Medicare May Not Pay: (F) Estimated Cost: W HAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the (D)_____________listed above.

23 NEW ABN FORM CONT’D:  Note: If you choose Option 1 or 2, we may help you to use any other  insurance that you might have, but Medicare cannot require us to do this.  (G) OPTIONS: Check only one box. We cannot choose a box for you.  ❏ OPTION 1. I want the (D)__________ listed above. You may ask to be paid now, but I  also want Medicare billed for an official decision on payment, which is sent to me on a Medicare  Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for  payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare  does pay, you will refund any payments I made to you, less co-pays or deductibles.  ❏ OPTION 2. I want the (D)__________ listed above, but do not bill Medicare. You may  ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.  ❏ OPTION 3. I don’t want the (D)__________listed above. I understand with this choice  I am not responsible for payment, and I cannot appeal to see if Medicare would pay.  (H) Additional Information:  This notice gives our opinion, not an official Medicare decision. If you have other questions  o n this notice or Medicare billing, call MEDICARE ( /TTY: ).  Signing below means that you have received and understand this notice. You also receive a copy.  (I) Signature:  (J) Date:  According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control  number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to  average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the  information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500  Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland  Form CMS-R-131 (03/08) Form Approved OMB No

24 Auditing Financial Hardship  Acceptable Form Utilized  Completed and signed  Patient meets hardship guidelines  Hardship Approval  Policy and Procedure developed  Poverty Guidelines – New one every Feb/March

25 2008 HHS Poverty Guidelines Persons in Family or Household 48 Contiguous States and D.C.AlaskaHawaii 1$10,210$12,770$11, ,69017,12015, ,17021,47019, ,65025,82023, ,13030,17027, ,61034,52031, ,09038,87035, ,57043,22039,750 For each additional person, add 3,480 4,350 4,000

26 Auditing HCPCS Codes  Correct code used  No upcoding  Verified by SADMERC – P.O. Box Columbia, SC – (toll-free) – 9:00 AM – 4:00 PM Mo, Tu, Th, & Fr. 9:00 AM – 6:00 PM We Eastern Standard Time

27 Summary  Audit now to be prepared later  Compliance plan adopted?  HIPAA Implementation  Test employees regularly

28 Jane Wilkinson-Bunch President/CEO Jane’s Healthcare Consulting, Inc. (770) cell (770) fax “An advocate for the Independent HME provider”


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