OIG details spike in vent billing

For E0464, Medicare paid 215,379 claims in 2015 vs. 2,258 claims in 2009, according to new report
Tuesday, September 27, 2016

WASHINGTON – Medicare paid 85 times more claims for noninvasive ventilators in 2015 than it did in 2009, says a new report from the Office of Inspector General.

For E0464, Medicare paid 215,379 claims in 2015 vs. 2,258 claims in 2009, according to the report.

The OIG believes the increase in billing is being driven primarily by three providers who accounted for 54% of the nationwide growth in the number of Medicare beneficiaries with ventilator claims from 2012 to 2015.

The OIG didn’t name names, but Lincare (paid $53.2 million), Apria ($30.5 million) and Sleep Management ($19.3 million) were the top billers for E0464 in 2015, according to the HME Databank.

In all, Medicare paid $263.2 million for E0464 in 2015 compared to $140.8 million in 2014, according to the Databank.

The report found a dramatic shift in the use of ventilators to treat respiratory, rather than neuromuscular, conditions. It also found that Medicare inappropriately paid $25 million for ventilator claims by paying for multiple devices or paying to treat obstructive sleep apnea.

In response to a spike in utilization, Medicare has already overhauled the vents product category over the past year, reducing reimbursement by about 33%, and decreased the number of codes from five to two.

Industry stakeholders have sought improvements to the product category, through both legislative and regulatory means.

The BREATH Act was recently introduced in the House of Representatives and the Senate. It would create medical necessity standards for determining the appropriate use of vents and would provide a 20% increase in reimbursement on Jan. 1.

Several pulmonary groups, including the American Association of Respiratory Care, the American College of Chest Physicians and the National Association for Medical Direction of Respiratory Care, have asked CMS to reconsider its national coverage determination for vents.