Stakeholders slam self-audits

Friday, October 12, 2018

WASHINGTON – A recent request by the DME MAC contractors for certain CPAP providers to audit themselves is setting them up to fail, say industry stakeholders.

Noridian and CGS recently sent letters to about 82 providers, asking them to do one of two things: audit 100% of their claims for CPAP supplies going back six years; or pull a statistically valid random sample and extrapolate the results.

The first request is unreasonable due to the number of claims it would involve, and the second is “ludicrous” because it requires a skillset most providers don’t have, say stakeholders.

“What it’s doing is putting a significant burden and a significant responsibility on the supplier to do something that they are probably not used to doing at all,” said Wayne van Halem, president of The van Halem Group. “What if it’s not done properly? What if the supplier determines something shouldn’t be refunded and, a year down the road, the government says it wasn’t done properly?”

The affected providers are those associated with overpayments that were identified in a recent Office of Inspector General report. The report found that, of 110 sample claims that Medicare paid in 2014 and 2015, only 24 complied with Medicare requirements.

”These people haven’t even been through the appeals process for anything the OIG has found,” said Kim Brummett, vice president of regulatory affairs for AAHomecare. “The claims haven’t even been recouped yet.”

Members of AAHomecare’s Regulatory Council plan to hold a strategy call after Medtrade to determine next steps, Brummett said.

“We will see if we can get to somebody at OIG after we regroup and say, this is pretty unrealistic and really sets suppliers up to fail,” she said. “It’s ludicrous.”


Pulling a statistically valid random sample and extrapolating the results is relatively easy.  I'm just curious how many samples would be deemed acceptable.

The word gives me goose bumps. 47 claims turned into a 3 year nightmare ending in relatively nothing for CMS.  Reading this article just scares me, I do not want to deal with this again, ever!