OIG targets orthotics payments, vents billing

Friday, November 6, 2015

WASHINGTON – Orthotics and vents are among the HME that the Office of Inspector General plans to focus on in fiscal year 2016, according to a work plan published this week.

The OIG plans to determine the reasonableness of Medicare fee schedule amounts for orthotic braces. The agency will compare Medicare payments made for braces to amounts paid by non-Medicare payers to identify potentially wasteful spending. It will also estimate the financial impact on Medicare and on beneficiaries of aligning the fee schedule for braces with those of non-Medicare payers.

Also for orthotics, the OIG plans to review Medicare Part B payments for braces to determine whether the claims of DME providers were medical necessary and were supported in accordance with Medicare requirements. Prior work by the OIG has indicated that some providers were billing for services that were medical unnecessary or were not documented in accordance with Medicare requirements.

The OIG also plans to describe billing trends for vents, RAD and CPAP devices from 2011-14, as well as examine factors associated with the increase in vent claims. From 2013-14, there has been a 127% increase in allowed amounts for E0464, and during that same period, the number of beneficiaries receiving the devices increased from 8,633 to19,085. The OIG says providers may be inappropriately billing for vents for beneficiaries with non-life threatening conditions, which would not meet the medical necessity criteria for vents and might instead be more appropriately billed to codes for RADs or CPAPs.

In addition to orthotic braces and vents, the OIG plans to examine provider compliance with payment requirements for power mobility devices, and nebulizer machines and related drugs.

The agency also plans to examine the effectiveness of system edits to prevent inappropriate payments for blood glucose test strips and lancets to multiple providers, and access to DME in competitive bidding areas.