Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare of claims for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) billed on dates of service from January 1, 2017, through December 31, 2017. Below are the review results:

 Background

Medicare covers replacement supplies for positive airway pressure (PAP) devices only when suppliers document that the supplies remain reasonable and necessary. Previous Office of Inspector General (OIG) reviews found that Medicare allowed replacement of PAP device supplies more frequently than was reasonable and necessary and that durable medical equipment (DME) suppliers often did not have the documentation required to support the need for replacement supplies.

According to OIG report A-04-17-04056: “Most Medicare Claims for Replacement Positive Airway Pressure Device Supplies Did Not Comply with Medicare Requirements” dated June of 2018, of the 110 claims in the stratified random sample, 86 did not comply with Medicare requirements. Based on these results, the OIG estimated that Medicare made overpayments of an estimated $631.3 million for replacement PAP device supply claims that did not comply with Medicare requirements.

Reason for Review

In response to the OIG report, the CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review.  Noridian completed medical record review to determine if suppliers billed in accordance with statutory, regulatory and subregulatory guidance.

Common Reasons for Denial

• No Response to the Documentation Request
  • The documentation was not submitted or not submitted timely. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request.
• Assessment of Functional Condition
  • The refill documentation does not indicate the supplier has assessed the functional condition of the supplies being refilled. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 requires suppliers to contact the beneficiary prior to dispensing a refill. Local Coverage Article A55426 requires to assess the functional condition of non-consumable supplies being refilled, to support need for replacement/refill.
• Invalid Refill Request
  • Documentation does not include a valid refill request. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 requires suppliers to contact the beneficiary, prior to dispensing a refill, to ensure the requested items remain reasonable and necessary, confirm any changes to the order and assess need for a replacement.
• Detailed Written Order
  • The documentation does not include a detailed written orde CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3 requires that all durable medical equipment items require a detailed written order prior to billing.
• Continued Need
  • The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. Local Coverage Article A55426 requires, for ongoing supplies and accessories, documentation in the medical record must support that the item(s) remain reasonable and necessary and that timely documentation “is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.”

References/Resources

• Title XVIII of the Social Security Act, §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
• Title XVIII of the Social Security Act, §1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
• 42 CFR 424.57(c)(12). Supplier Must Maintain Proof of Delivery.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section26. Supplier Proof of Delivery Documentation Requirements.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26.1. Proof of Delivery and Delivery Methods.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26.3. Proof of Delivery Requirements for Recently Eligible Medicare FFS Beneficiaries.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.1. Physician Orders.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.2. Verbal and Preliminary Written Orders.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section2.3. Detailed Written Orders.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4. Written Orders Prior to Delivery.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.7. Requirement of New Orders.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.8. Refills of DMEPOS items provided on a Recurring Basis.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.7. Documentation in the Patient’s Medical Record.
• Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 8. Supplier documentation and Proof of delivery.
• Local Coverage Determination (LCD) L33800: Respiratory Assist Devices. Effective 10/01/2015-present.
• Local Coverage Determination (LCD) L33718: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. Effective 10/01/2015-present.
• Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs. Effective 01/01/2017-present.
• Local Coverage Article A52467: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. Effective 10/01/2015-present.
• Local Coverage Article A52517: Respiratory Assist Devices. Effective 10/01/2015-present.

Last Updated Jan 28, 2022