Tag: Audits

YARMOUTH, Maine – After lying largely dormant during the public health emergency, audits are on the rise, including for respiratory claims, say industry consultants.  While audits never stopped completely during the PHE, waivers of certain coverage criteria, including for oxygen equipment and CGMs, helped lessen the burden on providers. But UPIC auditors are now increasingly targeting claims covered by those waivers, says Kelly Grahovac.   “It’s almost like they...

WASHINGTON – CMS plans to primarily focus MAC, RAC and SMRC medical reviews on claims with dates of service outside of the public health emergency, the agency stated in a recent clarification.  CMS stated:  “During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once...

WASHINGTON – CMS plans to primarily focus MAC, RAC and SMRC medical reviews on claims with dates of service outside of the public health emergency, the agency stated in a recent clarification.  CMS stated:  “During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once...

ATLANTA – The government has gotten much better at analyzing data for evidence of fraud, so HME providers need to be sure they are maintaining a culture of compliance.  That was a main takeaway during “Understanding How the Government Uses Audits to Bring Fraud Investigations” at Medtrade on Monday.  “(The Center for Program Integrity) is currently tracking all claims,” said Josh Skora, a partner with the law firm K&L Gates. “Once they have aberrant...

ATLANTA - As the HME industry ventures further into a post-pandemic landscape, providers should move away from reliance on audit waivers and flexibilities, Medtrade East speakers say.  While audits never stopped completely during the throes of COVID-19, federally sanctioned waivers helped staunch the burden to providers while the pandemic raged. Yet, now with the viral threat easing up, so are the audit breaks.  “I strongly encourage any suppliers who are relying on waivers...

AMARILLO, Texas – With the roller coaster of vaccine mandates and the uptick in audits, legal issues are keeping HME providers on their toes, say Jeff Baird and Denise Leard. Baird and Leard, both health care attorneys with Brown & Fortunato, gave HME News a look into the latest developments on these two topics.  Vaccine variables The long story short, Baird says, is if you’re an HME company, you have to worry about whether or not your employees are visiting a health care facility...

ATLANTA – The Office of Medicare Hearings and Appeals should be caught up on a years-long backlog of appeals at the administrative law judge (ALJ) level sometime this summer, predicts Wayne van Halem, president of the van Halem Group.   That means OMHA should be back to holding hearings at the ALJ level within 90 days as required by law, he says.  “The appeals process has to be timely,” he said. “If the appeals process is timely and Medicare has to hold off...

WASHINGTON – Noridian Healthcare Solutions, the Supplemental Medical Review Contractor for CMS, is conducting post-payment reviews for orthopedic footwear claims from Jan. 1, 2019, through Dec. 31, 2019. Orthopedic footwear is covered under the “leg, arm, back and neck braces, and artificial legs, arms and eyes” benefit. Coverage is provided when coverage, coding and documentation requirements are met. The reviews will include base and accessory codes. Noridian noted that this service...

WASHINGTON – The DME MACs are moving forward with audits for claims filed after March 2020, when COVID-19 hit the U.S. and certain waivers went into effect, but audit experts don’t anticipate any widespread problems.  Early in the pandemic, CMS temporarily waived several requirements, including coverage criteria, face-to-face requirements and delivery signatures for respiratory equipment.   “The MACs have been easing into audits since last August, even though...

NASHVILLE, Tenn. – CGS will be conducting complex post-pay, service-specific medical review of lower limb prostheses, L5700 and L5701, the contractor announced on March 19. “This review will be conducted because data analysis revealed that Jurisdiction C’s allowed dollars for L5700 and L5701 were significantly above expected amounts,” CGS stated. “Additionally, the orthotics policy group ranked No. 1 in total comprehensive error rate testing (CERT) errors.”...