Extrapolation still plagues HMEs, say attorneys

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Wednesday, August 31, 2005

WASHINGTON -- It doesn't appear that legislation intended to make DMERC extrapolations less onerous for providers has had much of an impact, say industry attorneys.
According to language contained in 2003's MMA, the DMERCs are not supposed to extrapolate provider billing errors from a small body of claims to a large body unless there has been a sustained or high level of payment error or a documented educational intervention that has failed to correct the payment error.
While the language appears to offer relief, the phrased "sustained or high level" is so broadly defined that it does little to rein in DMERC extrapolation, attorneys say.
"It can be determined through a variety of means, even allegations of wrongdoing by a current or former employee," said Lisa Smith, a healthcare attorney with Brown & Fortunato in Amarillo, Texas.
Attorney Neil Caesar, president of the Health Law Center in Greenville, S.C., said he's seen no drop off in extrapolations since the MMA passed. In part, that could be because, while the MMA implemented the change, DMERC officials have yet to experience the "change in mind set" required to carry out the new reg, he said.
Another possible reason: The MMA set December 2004 as the effective date for the change. That means many of the extrapolation cases now being handled by industry attorneys could have been initiated by the DMERCs prior to December 2004, said another industry attorney.
Additionally, while Congress passed the new reg in 2003, it has yet to tell the DMERCs how to apply it. Those instructions are expected by the end of this year but may not make it out until 2006," said attorney Asela Cuervo.
Region B Medical Director Dr. Adrian Oleck declined to comment on whether his region was performing fewer extrapolations this year than last. He did say, however, "it isn't a tool we use very often." HME

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