Afternoon television used to be a place where a person like me could go to satisfy a fix for classic situation comedies. On days when I find myself eating a vacation day in my living room, I now spend much less time in front of the television, mostly because of the incredibly low quality of advertisers on at that time of the day. What I see is commercials for assorted trade schools, many of which in the modern flat job market are for medical coding careers (which encourage me not so gently to get back to work or else be replaced). These are followed by the ever-popular “Have you been hurt in an accident/worked around asbestos/had a medical crisis due to drug X being prescribed for you” ads from the many now-familiar ambulance-chasing law firms across the country. The third set of ads are usually for power scooters for the elderly. In addition to being amazed at how much thinner the scooter drivers in the commercial are to their real world, 2-miles-per-hour counterparts that I see at my local Target, my thoughts turn, as they are wont to do for a compliance officer, to the world of durable medical equipment fraud.
In my weekly review of health care fraud’s many police blotters, rarely is there a week of reading that does not include at lease one durable medical equipment supplier. In the past 2 years, literally hundreds of millions of dollars in Medicare fraud has been unearthed by OIG and Department of Justice investigations, with the states of California and Florida providing a target-rich environment for DMEPOS fraud investigations.
With the number of issues related to inpatient hospital reimbursement currently outpacing those of other health care providers, it is easy to overlook the fact that a few DME issues have been approved for investigation by the RAC’s. A quick glance at the active issues lists for the 4 recovery audit contractors indicates that there are currently different levels of engagement in DME audits. CGI, the Region B contractor, has only 5 current approved issues related to DME claims. HealthDataInsights, the Region D contractor, currently leads the pack with 17 active issues. With these facts in mind, I’d like to spend some time today looking at what currently exists on the approved issues lists.
There are 2 specific issues for DME that currently find themselves on the lists of all of the contractors, the most prominent of these being identifying claims for durable medical equipment dispensed after the date of death of the beneficiary. This is an easy issue, as most funeral directors agree that cremation rarely requires a wheelchair. This leads me to the second issue that appears on all lists, which is the unbundling of claims for wheelchair bases and additional options and accessories, with DCS, the Region A contractor, paying particularly acute attention to this issue.
Issues related to the bundling of supplies appear on multiple issue lists, but not all, including the billing of additions or substitutions to different types of knee orthoses, which are not billed separately. Currently only Connolly Consulting, the Region C contractor, is not reviewing these claims. All contractors but CGI are looking at the billing patterns of urological supplies for bundling issues. Two contractors are currently looking at claims for parenteral nutrition solutions, with HDI looking at daily over-utilization and DCS focusing on the improper separate billing of additives to the solutions.
The dispensing of drugs is slowly becoming an audit focus of the contractors. Connolly, along with CGI, is looking at the unit billing for the asthma drug budesonide, with CGI focusing on the maximum units allowed in a three-month period, and Connolly reviewing the per vial billing. Connolly is also focusing on the unit billing on claims for the inhalation drugs Perforomist and Brovana. Aside from the drugs themselves, DCS and Connolly are also looking at the billing of pharmacy supply and dispensing fees to verify that these fees are only being reimbursed when accompanied by claims for oral anti-cancer drugs, oral anti-emetics, immunosuppressive drugs or inhalation drugs.
An assortment of other issues exist under the carriers, but it is worth noting that all review issues related to DMEPOS are currently of the automated variety, which is an indicator that DME issues are currently below the radar. Given the scope of the fraud found in this portion of Medicare billing, to say nothing of the fact that not one RAC is currently looking at power scooters for billing irregularities, it appears that the RAC’s have a long way to go, with a number of potential issues still to be considered. It looks like the aisles of my local Target will be clogged with scooters for the time being.