Pre-Election News Round Up — Audits, Waivers, New Requirements

For those of you lucky enough to not be inundated by hundreds of millions of dollars in political advertising, there is an election tomorrow that will have a major impact on the future of our health care system and, more specifically, the future of orthotic and prosthetic providers and reimbursement. There have also been a few things happening over the past few weeks that could have been lost in the shuffle as the Presidential election has sucked up the oxygen the past few weeks. Please take a look at the stories below.

Bill Regulating Audit Contractors Introduced in House — Congressman Sam Graves (R-MO) recently introduced HR 6575 which would place new restrictions on CMS audit contractors for RAC, administrative and CERT audits for Part A claims.  The bill would cap the dollar amount of claims that can be identified annually and also cap the amount of additional documentation that can be requested, while creating a new form of oversight for auditors of Part A claims.

As you are surely aware, audits for Part B claims (DMEPOS) are crippling independent orthotic and prosthetic facilities ability to continue operating by withholding and recouping payment dating back several years.  These audits are being overturned at an alarmingly high rate, but that does not help the ability of some O&P professionals from being able to continue serving their patients. Our profession needs to work with congress to either add Part B claims to the bill referenced above, or introduce separate legislation regulating audit contractors for orthotic and prosthetic claims. Read the full text of the legislation here.

CERT Audit Contractor in Northeast Reaches Out — From the O&P Listserv. I was asked by Alina Jimenez, CERT coordinator for Medicare Reg A to give her contact information to all, so that any suppliers who are impacted by the hurricane in their capability to access records and respond to CERT audits may contact her and let her know.  Her contact information is Alina Jimenez, telephone number 323-432-7840 and email alina.jimenez@hp.com<mailto:alina.jimenez@hp.com.  Her contact info is also available on the CERT connection page http://www.medicarenhic.com/dme/dmerc_cert.shtml

Medicare Waivers Available in NY and NJ Hurt by Sandy  – HHS Secretary Kathleen Sebellius has made arrangements to waive or modify requirements for Medicare providers hit by Hurricane Sandy. Declaring a public health emergency under section 1135 of the Social Security Act, Sebellius cleared the way for providers to submit waiver requests to CMS for at least 60 days for claims and other provider requirements. Under section 1135, HHS may permit affected providers to adjust certain operating procedures temporarily while continuing to receive reimbursement under Medicare, Medicaid and CHIP. More from HME News

CMS Final Rule Details Face-to-Face Requirements for Claims — Last last month, CMS released a final rule on face-to-face requirements to justify medical necessity of DMEPOS claims.  The final rule will require, as a condition of payment for certain DMEPOS, that a physician, physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist has had a face-to-face encounter with the beneficiary. The meeting must be documented by the physician or specialist and communicated to the DMEPOS provider. The face-to-face encounter must occur within six months before the written order. The full final rule can be found here.

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