Medicare Contractors looking for O&P supplier violations on posted business hours and physical facility standards


Wanted to pass along this article to OPGA membership; recently OPGA was contacted by several members who have had site visits from CMS contractors looking to verify that the O&P facility is adhering to Medicare DMEPOS supplier standards. This is consistent with CMS increased focus on DMEPOS supplier standard violations. If an O&P facility is found not to be adhering to the posted business hours, or is found not to be open during those posted business hours, it could mean a revocation of your Medicare provider billing number for up to 2 years. Please take the time to read the article below and reach out to OPGA with any questions you may have.

Medicare Contractors looking for O&P supplier violations on posted business hours and physical facility standards

Medicare suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) should be on the alert for enhanced Medicare supplier standard compliance monitoring by CMS, the National Supplier Clearinghouse (NSC), and their agents. Recently, these entities have taken draconian actions to revoke the enrollment of a number of suppliers who failed to be present during indicated hours of operation. Recent Administrative Law Judge (ALJ) decisions have upheld such revocations for technical violation of the Medicare supplier standard, even in the face of extenuating circumstances, reinforcing the need for suppliers to review their practices and policies to ensure full compliance.

Medicare supplier standard number 7 requires suppliers to appropriately maintain their physical facilities, including being accessible and staffed during posted hours of operation, maintaining a permanent visible sign in plain view, and posting hours of operation. In addition, supplier standard 7 requires the supplier’s business location to be accessible to the public, Medicare beneficiaries, CMS, NSC, and their agents (although there is an exception for “closed door” businesses, such as a pharmacy or supplier providing services only to beneficiaries residing in a nursing home, under certain circumstances).

Since compliance with all Medicare supplier standards is a condition of Medicare participation, suppliers must be present during published business hours or face revocation of their supplier number. This includes having staff present during lunch, unless the posted hours of operation specifically exclude certain lunch hours, and during holidays unless otherwise posted. We have observed a trend in deficiencies relating to supplier standard 7 being found during CMS and/or NSC supplier site visits resulting in supplier number revocations. For instance, suppliers have been found in violation when staff are out to lunch during a site visit or when an inspector uses the wrong set of elevators in a multi-use office building and is therefore unable to find the supplier’s office.

Recent ALJ decisions Continue reading

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House Subcommittee Focuses on RAC’s in hearing, Duckworth stands up for small providers

Two major subcommittee meetings were held in the House of Representatives today on Medicare waste, fraud and abuse. One of the issues hightlighted in both hearings was the conduct of RAC auditors and the impact they are having on providers large and small. The House Government Oversight and Government Reform Health Subcommittee heard testimony from The Center for Program Integrity, the GAO and the HHS OIG on efforts to control waste fraud and abuse within the Medicare program.

Subcommittee member Congresswoman Tammy Duckworth, herself a double amputee veteran, questioned the CMS witnesses on the impact of these RAC policies on small medical providers, specifically the orthotic and prosthetic providers that have worked to bring her back to a sense of normalcy in her life. Take a look at the link to video of the testimony to see members of congress putting the words of small orthotic and prosthetic providers into action. OPGA, our network of independent O&P facilities and the entire O&P profession have worked hard over the past several years to engage Congresswoman Duckworth on the audit issue and that work seems to be paying off in 2014.

Congresswoman Tammy Duckworth (D-IL) said “It seems blaintly unfair and unAmerican to take these folks money and not give them the right to due process.” She then addressed the panel asking if CMS has any plans to restore fairness to our providers.

View the video here: Congresswoman Duckworth begins at the 1:06:44 mark. Continue reading

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Region D Custom AFO’s Audit Results

From time to time I like to present additional resources for OPGA members to review. The following post is from Ossur’s R&R blog and authored by Linda Collins, one of the leading audit experts in the O&P profession. The full post can be found at the link below.

Posted by Linda Collins | May 16, 2014

Medicare continues to audit Ankle-Foot Orthoses. Last week Jurisdiction D announced the results of a widespread pre-payment review of HCPCS codes L4360, L1970 and L1960. There was an overall 80% plus denial rate for these claims. The main reasons for denial include:

  • The treating physician’s records did not provide detailed documentation to support medical necessity of a custom orthosis rather than a prefabricated orthosis.
  • Documentation submitted was insufficient to support custom coverage criteria.
  • Documentation submitted was insufficient to support basic coverage criteria
  • There was no detailed written order or dispensing order provided

What does this mean for you?

First, Medicare expects that the beneficiary’s medical records will reflect the need for the care provided. This documentation must be available upon request.

In the case of custom-fabricated AFOs, Continue reading

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Michigan BCBS adds certification requirement to bill O&P

Blue Cross Blue Shield of Michigan recently announced their plan to reject DMEPOS claims submitted for orthotics and prosthetics if the submitting provider has not provided certifying documentation proving they are certified to provide orthotics and prosthetics. Providers will be required to bill with their appropriate provider ID #, connecting the complexity of the claim with the certification of the provider.

This language should sound familiar, because it is exactly what the orthotic and prosthetic profession has been banging on CMS’ door to implement on a federal level for nearly a decade. Way back in 2001, Congress passed the Benefits Improvement and Protection Act (BIPA), which included Section 427, requiring CMS to only reimburse licensed or otherwise qualified providers for custom orthotics and prosthetics. Unfortunately, CMS has chosen not to implement this important provision, leading to the reimbursement of thousands of providers that are not qualified to provide orthotic and prosthetic care.

The O&P profession over the past several years has worked with members of congress to create an additional piece of legislation, known as the Medicare O&P  Improvement Act, to again instruct CMS to implement BIPA Section 427 and only reimburse those qualified to provide O&P. This bill would also provide a link between the qualification of the provider and the complexity of care/device that is being provided to the patient.

Slowly, too slowly, payers are beginning to pick up the pieces of BIPA Section 427 because it is smart policy that would actually prevent fraudulent payments from being paid out to providers in the first place — novel concept! With the current audit system, perhaps it would behoove CMS to implement policies to prevent fraudulent claims from being paid in the first place, rather than spending hundreds of millions of dollars trying to track those payments down after the fact and punishing honest providers in process! Continue reading

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House Subcommittee to hold hearing on Medicare fraud policies, RAC audits key topic

House Ways and Means Health Subcommittee Chairman Kevin Brady (R-TX) announced yesterday that the Subcommittee on Health will hold a hearing on Medicare waste, fraud, and abuse, with a focus on the policies that address these problems.  Chairman Brady recently spoke at the AOPA Policy Forum in Washington DC and is very aware of the problems with the current RAC program and the plight of orthotists and prosthetists relating to RAC audits.

This hearing will allow the Subcommittee to hear directly from the U.S. Office of the Inspector General at the Department of Health and Human Services (OIG-HHS), the U.S. Government Accountability Office (GAO), and the Centers for Medicare and Medicaid Services’ Center for Program Integrity (CPI) about the different recommendations and approaches to curb abuses within Medicare.  

One section of the hearing will be denoted to RAC audits:

Recovery Audit Contractors (RACs) aim to reduce Medicare improper payments through the detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments.  Many of these activities involve data-mining activities based on billing information.  Most of the data analysis is done after Medicare has made payment, but some work is now also being done before on a pre-payment basis.  The Affordable Care Act established RACs for Medicare Part C and Part D and for Medicaid. 

The Subcommittee will hear testimony from Gloria Jarmon, Deputy Inspector General for Audit Services at OIG-HHS; Kathleen King, Director, Health Care at GAO; and Dr. Shantanu Agrawal, Deputy Administrator Director of CPI.  The hearing will take place on Wednesday, April 30, 2014, in 1100 Longworth House Office Building, beginning at 2:00 P.M.

Click here for the full release from the House Committee on Ways and Means.

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CMS begins rollout of fingerprint analysis for new DMEPOS providers

CMS recently released guidance on the rollout of their new fingerprint background check requirement for certain DMEPOS providers. It has been more than three years since CMS released their final rule on developing a fingerprint background check process for new DMEPOS and home health suppliers that was created as part of the Affordable Care Act. 

The final rule created three groups of DMEPOS and home health suppliers and their potential risk level for fraud and abusive billing. The group classifications are “limited risk”, “moderate risk” and “high risk”.  At this point, this initiative is limited to those suppliers designated as “high risk” will be subject to the fingerprint background check.

According to the final rule, currently enrolled DMEPOS suppliers (which includes orthotists and prosthetists) who are subject to revalidation prior to 2015 will be classified as “moderate risk” and will not be subject to the fingerprint background check. However, newly enrolling DMEPOS suppliers  will be classified as “high risk”, meaning they will be subject the fingerprint analysis and background check.

Additionally, as you will see below, there are other ways a supplier can be moved into the “high risk” category that include CMS payment suspensions going back 10 years and several other similar distinctions that would require an existing O&P practitioner to be subject to the new fingerprint rules.

The “moderate” and “high” risk classification screening requirements and actions are listed below. Continue reading

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OTS Orthotics Defined… AGAIN!

When CMS released the 2014 HCPCS update codes late last year, they also provided guidance on how they would define “off the shelf” orthotics, for the purpose of identifying what type of provider could provide certain noncustomized devices to beneficiaries. After debate, CMS recalled their original definitions of “off the shelf”, creating more confusion in the O&P profession.  Some of the codes listed in the off-the-shelf category are also parallel codes that can apply to custom fit versions of the same device.  The full updated 2014 DMEPOS fee schedule can be found here.  The new definitions from Medicare contractor CGS for what qualifies as off-the-shelf are below.

When providing these items suppliers must:

  • Provide the product that is specified by the ordering physician, i.e. (1) type of orthosis and (2) method of fitting (OTS or custom fitted)
  • Be sure that the medical record justifies the need for the type of product and method of fitting
  • Be sure only to use the code that accurately reflects both the type of orthosis and the appropriate level of fitting
  • Have detailed documentation that justifies the code selected for custom fitted versus OTS codes)

The following definitions will be used for correct coding of these items.

Off-the-shelf (OTS) orthotics are:

  • Items that are prefabricated
  • They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted
  • OTS items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit an individual
  • This fitting does not require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthoses to fit the item to the individual beneficiary

The term “minimal self-adjustment” is defined Continue reading

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