Regulatory review: Suspensions, overpayments and exemptions

Friday, April 15, 2016

WASHINGTON – From a regulatory perspective, the first several months of 2016 have brought pain, and a little bit of relief, to HME providers.

Among the pain points, says Wayne van Halem, is the new level of aggressiveness in the actions taken by the ZPICs. The contractors are handing out payment suspensions where, previously, they may have handed out overpayment demands, he says.

“Some of the reasons for suspensions are ridiculous,” said van Halem, president of The van Halem Group. “Because CMS is reorganizing their contracts, I have a sneaking suspicion the ZPICs are trying to show CMS that they meet all of the contract requirements.”

An example of a reason for suspension, van Halem says: allegedly leading a physician on an order by using a form titled “Power Mobility Device Order,” even though the form came from the DME MAC.

Another pain point is a new rule that went into effect in March that requires providers to disclose overpayments within 60 days, something that has been an expectation in the past but is now in writing.

“It depends on your volume of claims, but this is a pretty common occurrence,” van Halem says.

Additionally, there’s a new batch of SMRC audits, this time focusing on oxygen equipment, nebulizers and CPAP devices.

The SMRC audits, which involve submitting additional documentation, are straightforward but time consuming, especially for larger providers, says Stephanie Morgan Greene, a healthcare attorney who’s executive vice president of business development for ACU-Serve.

“Our larger clients that have multiple locations are getting SMRC audits for each location for each of the product categories,” she said. “One client has received its 10th audit at 40 claims a piece. It’s a lot of work.”

On the other side of the spectrum: The RACs have started rewarding providers with low error rates by exempting them from certain audits. Three hundred and thirty PTANs have received exemption letters in one or more categories in Jurisdiction C, says Andrea Stark.

“We’ve also seen letters in Jurisdiction D,” said Stark, a reimbursement consultant with MiraVista. “We’re definitely seeing that in action.”