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OIG calls out unimplemented recommendations 

OIG calls out unimplemented recommendations 

WASHINGTON – The Office of Inspector General has published its annual “Top Unimplemented Recommendations: Solutions to Reduce Fraud, Waste and Abuse in HHS Programs” and DME makes more than one appearance. 

This year, the OIG’s recommendations focus on the top 25 unimplemented recommendations that, in its view, would most positively affect HHS programs in terms of cost savings, program effectiveness and efficiency, and public health and safety if implemented. 

Recommendations related to DME include: 

CMS should improve and implement system edit processes for its DME Medicare contractors to prevent improper payments for services provided to hospice beneficiaries. 

For 121 of 200 sampled durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items, Medicare improperly paid suppliers for DMEPOS items they provided to hospice beneficiaries. These items were provided to palliate or manage the beneficiaries' terminal illnesses and related conditions and, as such, are considered included in the per diem payments that Medicare pays to hospices. These items should have been provided directly by the hospices or under arrangements between the hospices and the suppliers and not separately paid by Medicare. Medicare improperly paid the suppliers because the system edit processes that should have prevented the improper payments were not effective or did not exist. In some of these cases (67), the suppliers inappropriately used a modifier (GW) to indicate that the items were not related to the beneficiaries’ terminal illness or conditions, but our audit found that these items were related. On the basis of our sample results, we estimated that Medicare could have saved $116.9 million in payments during our audit period from January 1, 2015, through April 30, 2019, and beneficiaries could have saved $29.8 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf. 

CMS should require MAOs to submit and encourage MAOs to provide program oversight based on an ordering provider’s national provider identifier (NPI) on encounter records for DME, prosthetics, orthotics and supplies, as well as for laboratory, imaging and home health services. 

Ordering and referring provider identifiers are not required in, and were frequently absent from, Medicare Advantage encounter data for records of DME, prosthetics, orthotics, and supplies, clinical laboratory, imaging, and home health services. The lack of ordering and referring provider identifiers limits the use of these data for vital program oversight and enforcement activities. For example, these provider identifiers are critical for identifying questionable billing patterns and pursuing fraud investigations for ordering and referring providers. In an OIG survey conducted in 2020, almost half of the MAOs that lacked ordering NPIs on at least some MA encounter records raised concerns that this hindered their data analysis for program integrity. An NPI is an important tool for assessing whether ordering or referring providers have determined that services were appropriate for patients. 

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