Regulatory news: CMS revamps audits, lawmakers question CPAP bundling

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Friday, August 18, 2017

WASHINGTON – Claims submitted by providers that have the highest claim error rates or billing practices that vary significantly from their peers will soon face increased scrutiny, CMS has announced.

As part of an expanding “Targeted Probe and Educate” program, the Medicare Administrative Contractors will identify these providers through data analysis.

“TPE claim selection is different from that of previous probe and educate programs,” the agency stated in an Aug. 14 announcement on its website. “Whereas previously the first round of reviews were of all providers for a specific service, the TPE claim selection is provider/supplier specific from the onset. This eliminates burden to providers who, based on data analysis, are already submitting claims that are compliant with Medicare policy.”

Per the program, the MACs will review 20 to 40 claims per provider, per item or service, per round, for a total of up to three rounds of review. After each round, providers will be offered individualized education based on the results of their reviews.

Providers with moderate and high error rates in the first round of reviews, will continue on to a second round of 20-40 reviews, followed by additional education. Providers with high error rates after the second round will continue to a third and final round of reviews and education.

Providers with continued high error rates after three rounds of review may be referred to CMS for additional action, which may include 100% pre-pay review, extrapolation, referral to a Recovery Auditor Contractor, or other action.

Providers may be removed from the review process after any of the three rounds of review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS.

The program began as a pilot project in one MAC jurisdiction in June 2016 and was expanded to three additional jurisdictions in July 2017. CMS will expand the program to all jurisdictions later this year.

Lawmakers question CPAP bundling program

WASHINGTON – A bipartisan group in the House of Representatives is circulating a congressional sign-on letter that asks CMS to delay a CPAP bundling pilot program from the next round of competitive bidding.

The letter states a number reasons for delaying the program, including the lack of evidence that it will save money or enhance care, and CMS’s lack of authorization to test alternative payment models as part of its competitive bidding program.

“Instead, we encourage the agency to work with Congress and stakeholders to prioritize efforts that bring stability to the program,” the letter states. “If the agency is interested in reforms to ensure better compliance with CPAP therapy and other home respiratory care, we stand ready to work with you on initiatives that have a greater potential to save money and improve health outcomes.”

AAHomecare encourages HME providers and other stakeholders to ask their representatives to add their names to the letter by Sept. 13.

The association has argued that bundling a CPAP device, consumable items, maintenance and service into a single monthly payment could cause disruption for providers, could provide an incentive to furnish inferior products, and could result in lower quality of care.

CMS announced earlier this year that it had added 10 new competitive bidding areas for the CPAP product category. In five of those CBAs, payment for CPAP devices, related accessories and services will be made on a bundled, non-capped monthly rental basis, while payment in the other five CBAs will be made on a capped monthly rental basis like other existing CBAs.

The sign-on letter is being spearheaded by Reps. Tim Walberg, R-Minn., Debbie Dingell, D-Mich., Cathy McMorris Rodgers, R-Wash., Scott Peters, D-Calif., and Michael Bishop, R-Mich.