Category: Audits

UPDATE: Targeted Probe and Educate (TPE) Pilot

UPDATED: October 6, 2017 In October 2017, the TPE Pilot is now open to all four DME MAC Jurisdictions. Suppliers will be chosen based on the following criteria: Items that pose the greatest financial risk to the Medicare Trust Fund – HCPCS with high national error rates, high dollar equipment, etc. Individual suppliers with high

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Audit Alert: AFO & KAFO Orthoses

On July 5, 2017, Performant Recovery, the National DMEPOS RAC, added AFO and KAFO orthoses to their approved issues list. According to their website, Performant Recovery will perform complex reviews of these claims to determine if basic coverage criteria outlined in the Local Coverage Determination (LCD) for AFO/KAFO Orthoses was met. Performant will review medical

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Improvements to the Adjudication Process of Serial Claims

A major win for DME Suppliers was announced yesterday, as CMS released information regarding improvements to the adjudication process of serial claims. Effective April 7, 2017, CMS has implemented changes to improve the processing and adjudication of recurring (monthly) claims for capped rental and certain inexpensive and routinely purchased (IRP) items. Prior to April 2017,

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Audit Alerts

DME contractors perform pre- and post-payment reviews on a continual basis. Through data analysis, the medical review department determines the codes they will review and then sends Additional Documentation Request (ADR) letters to suppliers that bill those codes. The following list includes those codes currently being reviewed amongst all four DME jurisdictions. Positive Airway Pressure

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OIG Report Identifies Common Characteristics in OIG Home Health Fraud Cases

Home health has long been recognized as a program area vulnerable to fraud, waste, and abuse. In 2015, Medicare reimbursed more than 11,000 home health agencies (HHAs) for almost 7 million episodes of home health care, totaling approximately $18.4 billion. From 2011–2015, OIG home health investigations resulted in more than 350 criminal and civil actions

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2017 OIG Work Plan for Home Health Agencies

The OIG has published their Work Plan for 2017, which summarizes new and ongoing projects the OIG plans to pursue with respect to HHS programs and operations. Why is that important to you? Because once the OIG identifies their areas of focus, audit contractors such as the Home Health and Hospice Medicare Administrative Contractors (HHH

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Audit Alerts – Jurisdiction D (Noridian)

Noridian Jurisdiction D recently announced the results of service specific prepayment reviews. Please see the list below to determine if the services you provide to beneficiaries’ in Jurisdiction D could be at risk for an audit. Codes that will remain on prepayment review due to recently published improper payment rates: • Therapeutic Shoes (A5500) •

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